Medical Council of Canada Qualifying Examination

Part I

Medical Expert Objectives

Émilie Parent – FMEQ internal affairs delegate

Maxime Morin-Lavoie – FMEQ, president & MCC, student member

February 2020
Disclaimer
This document is a non-official studying tool put together by medical students, for medical students.
The following content is based on the studying objectives provided by the Medical Council of Canada
(MCC) on their website. It is not and official document provider by the Medical Council of Canada. In
the event of any discrepancy between the content of this document and the MCC’s official website, the
MCC’s official website prevails.

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INTRODUCTION................................................................................................................................................... 9
MULTIPLE CHOICE QUESTIONS .................................................................................................................................................................................. 9
CLINICAL DECISION-MAKING....................................................................................................................................................................................10
1 – ABDOMINAL DISTENSION............................................................................................................................. 11
2 – ABDOMINAL / PELVIC MASS ......................................................................................................................... 12
2.4 HERNIA (ABDOMINAL WALL AND GROIN) ................................................................................................................. 13
3 – ABDOMINAL PAIN........................................................................................................................................ 14
3.1 ABDOMINAL PAIN (CHILDREN) ............................................................................................................................... 14
3.2 ACUTE ABDOMINAL PAIN ........................................................................................................................................................................16
3.3 CHRONIC ABDOMINAL PAIN ....................................................................................................................................................................18
3.4 ANORECTAL PAIN .....................................................................................................................................................................................19
4 – ALLERGIC REACTIONS AND ATOPY ................................................................................................................ 20
5 – ATTENTION, LEARNING, AND SCHOOL PROBLEMS ......................................................................................... 21
6 – GASTROINTESTINAL BLEEDING ..................................................................................................................... 22
6.1 UPPER GASTROINTESTINAL BLEEDING ....................................................................................................................................................22
6.2 LOWER GASTROINTESTINAL BLEEDING ...................................................................................................................................................23
7 – BLOOD IN SPUTUM (HEMOPTYSIS) ............................................................................................................... 24
8 – BLOOD IN URINE / HEMATURIA .................................................................................................................... 25
9 – ABNORMAL BLOOD PRESSURE ..................................................................................................................... 26
9.1 HYPERTENSION ........................................................................................................................................................................................26
9.1.1 HYPERTENSION IN CHILDHOOD ...............................................................................................................................................................28
9.1.4 HYPERTENSIVE DISORDERS OF PREGNANCY ...........................................................................................................................................29
9.2 HYPOTENSION / SHOCK ..........................................................................................................................................................................30
10 – BREAST DISORDERS.................................................................................................................................... 31
10.1 BREAST MASSES AND ENLARGEMENT.....................................................................................................................................................31
10.2 BREAST DISCHARGE .................................................................................................................................................................................32
11 – BURNS ....................................................................................................................................................... 33
12 – CALCIUM / PHOSPHATE CONCENTRATION ABNORMAL, SERUM................................................................... 34
12.2 CALCIUM DISORDERS ...............................................................................................................................................................................34
13 – CARDIAC ARREST ....................................................................................................................................... 36
14 – CHEST PAIN ............................................................................................................................................... 37
15 – COAGULATION ABNORMALITIES................................................................................................................. 38
15.1 BLEEDING, BRUISING ...............................................................................................................................................................................38
15.2 PREVENTION OF VENOUS THROMBOSIS .................................................................................................................................................39
16 – CONSTIPATION .......................................................................................................................................... 40
16.1 ADULT CONSTIPATION .............................................................................................................................................................................40
16.2 PEDIATRIC CONSTIPATION .......................................................................................................................................................................41
17 – CONTRACEPTION ....................................................................................................................................... 42
18 – COUGH ...................................................................................................................................................... 43
19 – CYANOSIS / HYPOXIA ................................................................................................................................. 44
20 – LIMP IN CHILDREN ..................................................................................................................................... 45

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21 – DEVELOPMENTAL DELAY ............................................................................................................................ 46
21.1 ADULTS WITH DEVELOPMENTAL DISABILITIES ........................................................................................................................................47
22 – DIARRHEA ................................................................................................................................................. 48
22.1 ACUTE DIARRHEA .....................................................................................................................................................................................48
22.2 CHRONIC DIARRHEA.................................................................................................................................................................................49
22.3 PEDIATRIC DIARRHEA...............................................................................................................................................................................51
23 – DIPLOPIA ................................................................................................................................................... 52
24 – DIZZINESS / VERTIGO ................................................................................................................................. 53
25 – DYING PATIENTS ........................................................................................................................................ 54
26 – DYSPHAGIA ............................................................................................................................................... 55
27 – DYSPNEA ................................................................................................................................................... 56
27.3 PEDIATRIC RESPIRATORY DISTRESS .........................................................................................................................................................57
28 – EAR PAIN ................................................................................................................................................... 59
29 – EDEMA / ANASARCA / ASCITES ................................................................................................................... 60
29.1 GENERALIZED EDEMA ..............................................................................................................................................................................60
29.2 LOCALIZED EDEMA ...................................................................................................................................................................................61
30 – EYE REDNESS ............................................................................................................................................. 62
31 – FAILURE TO THRIVE .................................................................................................................................... 63
31.1 FRAILTY IN THE ELDERLY ..........................................................................................................................................................................63
31.2 FAILURE TO THRIVE (INFANT, CHILD) ....................................................................................................................... 65
32 – FALLS ......................................................................................................................................................... 66
33 – FATIGUE .................................................................................................................................................... 67
35 – ATAXIA (GAIT)............................................................................................................................................ 68
36 – GENETICS CONCERNS ................................................................................................................................. 69
36.2 CONGENITAL ANOMALIES / DYSMORPHIC FEATURES ............................................................................................................................70
37 – GLUCOSE ABNORMAL, SERUM/ DIABETES / POLYDIPSIA ............................................................................. 71
37.1 GLUCOSE ABNORMALITIES ......................................................................................................................................................................71
37.2 DIABETES MELLITUS ................................................................................................................................................................................72
38 – SKIN AND INTEGUMENT CONDITIONS ......................................................................................................... 73
39 – HEADACHE................................................................................................................................................. 75
40 – HEARING LOSS ........................................................................................................................................... 76
41 – CEREBROVASCULAR ACCIDENT AND TRANSIENT ISCHEMIC ATTACK (STROKE) .............................................. 77
42 – HEMOGLOBIN SERUM, ABNORMAL ............................................................................................................ 78
42.1 ANEMIA ....................................................................................................................................................................................................78
42.2 ELEVATED HEMOGLOBIN .........................................................................................................................................................................79
44 – LANGUAGE AND SPEECH DISORDERS .......................................................................................................... 80
45 – ACID-BASE ABNORMALITIES, HYDROGEN .................................................................................................... 81
46 – INFERTILITY ............................................................................................................................................... 83
47 – INCONTINENCE .......................................................................................................................................... 84

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 47.1 FECAL INCONTINENCE..............................................................................................................................................................................84
47.2 URINARY INCONTINENCE, ADULT............................................................................................................................................................85
47.3 URINARY INCONTINENCE, CHILDREN / ENURESIS ..................................................................................................................................86
48 – ERECTILE DYSFONCTION ............................................................................................................................. 87
49 – JAUNDICE .................................................................................................................................................. 88
49.1 NEONATAL JAUNDICE ..............................................................................................................................................................................89
50 – JOINT PAIN ................................................................................................................................................ 90
50.1 OLIGOARTHRALGIA (PAIN IN ONE TO FOUR JOINTS).................................................................................................... 90
50.2 POLYARTHRALGIA (PAIN IN MORE THAN FOUR JOINTS) ............................................................................................... 92
50.3 NON-ARTICULAR MUSCULOSKELETAL PAIN............................................................................................................................................93
50.4 BACK PAIN AND RELATED SYMPTOMS ....................................................................................................................................................94
50.5 NECK PAIN ................................................................................................................................................................................................95
51 – ABNORMAL SERUM LIPIDS ......................................................................................................................... 96
52 – ABNORMAL LIVER FUNCTION TESTS............................................................................................................ 98
53 – LUMP / MASS (MUSCULOSKELETAL) ........................................................................................................... 99
54 – LYMPHADENOPATHY ............................................................................................................................... 100
54.1 MEDIASTINAL MASS ............................................................................................................................................................................. 101
56 – MENSTRUAL CYCLE, ABNORMAL ............................................................................................................... 102
56.1 AMENORRHEA / OLIGOMENORRHEA................................................................................................................................................... 102
56.2 DYSMENORRHEA .................................................................................................................................................................................. 103
56.3 PREMENSTRUAL DYSPHORIC DISORDER (PMS) ....................................................................................................... 104
57 – MENOPAUSE............................................................................................................................................ 105
58 – MENTAL STATUS, ALTERED ....................................................................................................................... 106
58.1 COMA .................................................................................................................................................................................................... 106
58.2 DELIRIUM .............................................................................................................................................................................................. 107
58.3 MAJOR / MILD NEUROCOGNITIVE DISORDERS (DEMENTIA)....................................................................................... 108
59 – MOOD DISORDERS ................................................................................................................................... 109
59.1 DEPRESSED MOOD ................................................................................................................................................................................ 109
59.2 MANIA / HYPOMANIA ......................................................................................................................................................................... 110
60 – ORAL CONDITIONS ................................................................................................................................... 111
61 – MOVEMENT DISORDERS / TIC DISORDERS ................................................................................................ 112
62 – ABNORMAL HEART SOUNDS AND MURMURS ........................................................................................... 114
63 – NECK MASS / GOITER / THYROID DISEASE ................................................................................................. 115
64 – NEONATAL DISTRESS ................................................................................................................................ 116
66 – NUMBNESS / TINGLING / ALTERED SENSATION ......................................................................................... 117
67 – PAIN ........................................................................................................................................................ 118
67.1.2.1 GENERALIZED PAIN DISORDERS................................................................................................................................................. 118
67.2.2 CENTRAL / PERIPHERAL NEUROPATHIC PAIN ............................................................................................................................... 119
68 – PALPITATIONS ......................................................................................................................................... 120
69 – ANXIETY .................................................................................................................................................. 121
71 – PEDIATRIC EMERGENCIES ......................................................................................................................... 122

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 71.1 CRYING OR FUSSING CHILD ................................................................................................................................................................... 122
71.2 HYPOTONIC INFANT .............................................................................................................................................................................. 123
73 – PELVIC PAIN............................................................................................................................................. 124
74 – PERIOD HEALTH ENCOUNTER/PREVENTIVE HEALTH ADVICE ...................................................................... 125
74.1 NEWBORN ASSESSMENT ...................................................................................................................................................................... 127
74.2 IMMUNIZATION .................................................................................................................................................................................... 128
74.3 PRE-OPERATIVE MEDICAL EVALUATION .............................................................................................................................................. 129
74.5 THE WELL CHILD AND ADOLESCENT ..................................................................................................................................................... 130
75 – PERSONNALITY DISORDERS ...................................................................................................................... 132
76 – PLEURAL EFFUSION .................................................................................................................................. 133
77 – POISONING .............................................................................................................................................. 134
78 – POPULATION HEALTH AND ITS DETERMINANTS ........................................................................................ 135
78.1 CONCEPTS OF HEALTH AND ITS DETERMINANTS ................................................................................................................................. 135
78.2 ASSESSING AND MEASURING HEALTH STATUS AT THE POPULATION LEVEL....................................................................................... 136
78.3 INTERVENTIONS AT THE POPULATION LEVEL ....................................................................................................................................... 137
78.4 ADMINISTRATION OF EFFECTIVE HEALTH PROGRAMS AT THE POPULATION LEVEL ........................................................................... 138
78.5 OUTBREAK MANAGEMENT................................................................................................................................................................... 139
78.6 ENVIRONMENT ..................................................................................................................................................................................... 140
78.7 HEALTH OF SPECIAL POPULATIONS ...................................................................................................................................................... 141
78.8 WORK-RELATED HEALTH ISSUES .......................................................................................................................................................... 143
79 – POTASSIUM CONCENTRATION, ABNORMAL .............................................................................................. 144
79.1 HYPERKALIEMIA .................................................................................................................................................................................... 144
79.2 HYPOKALEMIA....................................................................................................................................................................................... 145
80 – PREGNANCY ............................................................................................................................................ 146
80.1 PRENATAL CARE .................................................................................................................................................................................... 146
80.2 INTRAPARTUM AND POST-PARTUM CARE ........................................................................................................................................... 148
81 – EARLY PREGNANCY LOSS / SPONTANEOUS ABORTION .............................................................................. 150
82 – PRETERM LABOUR ................................................................................................................................... 151
83 – UTERINE PROLAPSE / PELVIC RELAXATION ................................................................................................ 152
84 – PROTEINURIA .......................................................................................................................................... 153
85 – PRURITUS ................................................................................................................................................ 154
86 – PSYCHOSIS ............................................................................................................................................... 155
89 – RENAL FAILURE ........................................................................................................................................ 156
89.1 ACUTE KIDNEY DISEASE ........................................................................................................................................................................ 156
89.2 CHRONIC KIDNEY DISEASE .................................................................................................................................................................... 157
90 – SCROTAL MASS ........................................................................................................................................ 158
91 – SCROTAL PAIN ......................................................................................................................................... 159
92 – SEIZURES / EPILEPSY ................................................................................................................................ 160
93 – SEXUAL MATURATION ............................................................................................................................. 161
93.1 ABNORMAL PUBERTAL DEVELOPMENT................................................................................................................................................ 161
94 – SEXUAL DYSFUNCTIONS AND DISORDERS ................................................................................................. 163
94.1 GENDER AND SEXUALITY ...................................................................................................................................................................... 164

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97 – SKIN RASH / PAPULES............................................................................................................................... 165
97.2 URTICARIA / ANGIOEDEMA ................................................................................................................................................................. 165
98 – SLEEP-WAKE DISORDERS .......................................................................................................................... 166
99 – SODIUM CONCENTRATION SERUM, ABNORMAL ....................................................................................... 167
99.1 HYPERNATREMIA .................................................................................................................................................................................. 167
99.2 HYPONATREMIA.................................................................................................................................................................................... 168
100 – SORE THROAT / RHINORRHEA ................................................................................................................ 169
101 – STATURE ABNORMAL (TALL STATURE / SHORT STATURE) ........................................................................ 170
102 – STRABISMUS / AMBLYOPIA .................................................................................................................... 171
103 – SUBSTANCE USE OR ADDICTIVE DISORDERS ............................................................................................ 172
103.1 SUBSTANCE WITHDRAWAL ............................................................................................................................................................. 174
104 – SUDDEN INFANT DEATH SYNDROME (SIDS) ............................................................................................. 175
104.1 BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) .................................................................................................. 177
105 – SUICIDAL BEHAVIOUR ............................................................................................................................ 178
106 – SYNCOPE AND PRE-SYNCOPE .................................................................................................................. 179
107 – TEMPERATURE, ABNORMAL / FEVER AND/OR CHILLS .............................................................................. 180
107.1 FEVER AND HYPERTHERMIA ........................................................................................................................................................... 180
107.4 FEVER IN THE IMMUNE COMPROMISED HOST / RECURRENT FEVER............................................................................................ 182
107.5 HYPOTHERMIA ................................................................................................................................................................................ 183
108 – TINNITUS ............................................................................................................................................... 184
109 – TRAUMA................................................................................................................................................ 185
109.1 ABDOMINAL INJURIES ..................................................................................................................................................................... 186
109.3 BONE OR JOINT INJURY ................................................................................................................................................................... 187
109.4 CHEST INJURIES ............................................................................................................................................................................... 189
109.6 DROWNING (NEAR-DROWNING)...................................................................................................................... 190
109.8 FACIAL INJURIES............................................................................................................................................................................... 191
109.9 HAND / WRIST INJURIES................................................................................................................................................................. 192
109.10 HEAD TRAUMA / BRAIN DEATH / TRANSPLANT DONATIONS ....................................................................................................... 193
109.11 NERVE INJURY.................................................................................................................................................................................. 194
109.12 SKIN WOUNDS ................................................................................................................................................................................ 195
109.13 SPINAL TRAUMA ............................................................................................................................................................................. 196
109.14 URINARY TRACT INJURIES .............................................................................................................................................................. 197
109.15 VASCULAR INJURY .......................................................................................................................................................................... 198
110 – URINARY FREQUENCY ............................................................................................................................ 199
110.1 DYSURIA / URINARY FREQUENCY AND URGENCY / PYURIA ......................................................................................................... 199
110.2 POLYURIA / POLYDIPSIA ................................................................................................................................................................. 200
111 – URINARY TRACT OBSTRUCTION .............................................................................................................. 201
112 – VAGINAL BLEEDING EXCESSIVE / IRREGULAR / ABNORMAL...................................................................... 202
113 – VAGINAL DISCHARGE / VULVAR PRURITUS.............................................................................................. 204
114 – VIOLENCE, FAMILY ................................................................................................................................. 205
114.1 CHILD ABUSE.................................................................................................................................................................................... 205
114.2 ELDER ABUSE ................................................................................................................................................................................... 207
114.3 ADULT ABUSE / INTIMATE PARTNER ABUSE .................................................................................................................................. 208

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115 – VISUAL DISTURBANCE / LOSS.................................................................................................................. 209
115.1 ACUTE VISUAL DISTURBANCE / LOSS .............................................................................................................................................. 209
115.2 CHRONIC VISUAL DISTURBANCE / LOSS.......................................................................................................................................... 210
116 – VOMITING / NAUSEA ............................................................................................................................. 211
117 – WEAKNESS (NOT CAUSED BY CEREBROVASCULAR ACCIDENT) .................................................................. 213
118 – WEIGHT ABNORMAL .............................................................................................................................. 215
118.1 WEIGHT GAIN / OBESITY ................................................................................................................................................................ 215
118.2 WEIGHT LOSS / EATING DISORDERS/ ANOREXIA .......................................................................................................................... 216
118.3 INTRAUTERINE GROWTH RESTRICTION........................................................................................................................................... 217
120 – WHITE BLOOD CELLS, ABNORMALITIES ................................................................................................... 218
121 – LEGAL, ETHICAL AND ORGANIZATIONAL ASPECTS OF MEDICINE ............................................................... 219
121.1 CONSENT ......................................................................................................................................................................................... 219
121.2 TRUTH TELLING................................................................................................................................................................................ 220
121.3 NEGLIGENCE .................................................................................................................................................................................... 221
121.4 CONFIDENTIALITY ............................................................................................................................................................................ 222
121.5 LEGAL SYSTEM ................................................................................................................................................................................. 223
123 – OBSESSIVE COMPULSIVE DISORDER (OCD) AND RELATED DISORDER ........................................................ 224
REFERENCES.................................................................................................................................................... 225

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INTRODUCTION
The following information regarding the MCCQE part I can be found on the MCC website:

The MCCQE Part I is a summative examination that assesses the critical medical knowledge and clinical
decision-making ability of a candidate at a level expected of a medical student who is completing his or her
medical degree in Canada. The examination is based on the MCC Objectives, which are organized under the
CanMEDS roles. Candidates graduating and completing the MCCQE Part I normally enter supervised practice.
Aside from formal accreditation processes of the undergraduate and postgraduate education programs, the
MCCQE Part I is the only national standard for medical schools across Canada and, therefore, is administered
at the end of medical school.

The MCCQE Part I is a one-day, computer-based test. You are allowed up to four hours in the morning
session to complete 210 Multiple-Choice Questions. You are allowed up to three and a half hours in the
afternoon session for the Clinical Decision-Making component, which consists of 38 cases with short-menu
and short-answer write-in questions.

The exam is based on a Blueprint that assesses your performance across two broad categories:

Dimensions of care, covering the spectrum of medical care;

Physician activities, reflecting a physician’s scope of practice and behaviours.

Each category has four domains, and each is assigned a specific content weighting on the exam:

Multiple choice questions

The Multiple-Choice Questions (MCQ) component of the MCCQE Part I consists of 210 questions, of which
35 are pilot questions that do not count towards your total score. While the pilot questions are not scored, they
are not identified as pilots in the exam. We encourage you to do as well as you can on every question. Each
MCQ has a stem and five options, of which only one is correct. You can select only one answer. The maximum
time allotted for this component is four hours.

9
All of the MCQ questions are presented in a single block. MCQ example
You may navigate freely between all MCQ. You can flag An otherwise healthy 36-year old man presents to your office with a 4-
questions and return to those questions at any point during week history of a generalized, intensely pruritic papular rash. On
examination, he has excoriated papules and vesicles on wrists, sides of
the MCQ portion of the exam. Certain test items will have fingers, arms, and buttocks. No other abnormalities are noted. His 9-
pictorial material, such as photographs, diagrams, x rays, year-old son also has had itching on fingers and wrists. Which one of
electrocardiograms, and graphic or tabulated material. If the following is the most likely diagnosis?
relevant to a question, you will be presented with the normal • Neurodermatitis
lab values directly in the question. • Impetigo
• Pityriasis rosea

To select an option, click on the text of that option. You can • Shingles

change your answer by simply clicking on a different option. • Scabies

There is no penalty for incorrect answers, so you should

always answer a question, even when you are unsure.

You are only required to submit the MCQ portion of the exam once, when you have completed the MCQ
component and are ready to submit, or when your allotted time expires. Once you have submitted your exam,
you may not go back to change your answers.

Clinical decision-making
The Clinical Decision-Making (CDM) component of the exam consists of 38 case descriptions, followed by
one or more questions, which assess problem-solving and decision-making skills in the resolution of a clinical
case. You may be asked to:

Elicit clinical information;

Order diagnostic procedures;
Make diagnoses; or
Prescribe therapy.

Your decisions should reflect the management of an actual patient.

In total, you will be presented with 60 to 70 questions related to the 38 CDM cases. Questions are either in a
short-menu or write-in format. The maximum time allotted for the CDM component of the exam is
3 1/2 hours.
All the cases and questions are presented in a single block. You may navigate freely between all questions.
Certain test items will have pictorial material, such as photographs, diagrams, x-rays, electrocardiograms, and
graphic or tabulated material. If relevant to the case or question, you will be presented with the normal lab
values directly in the CDM question.

Points are not deducted for incorrect answers. However, you will receive a score of zero on a question if you
exceed the maximum number of allowable responses or select a response that is considered harmful or
dangerous to the patient. See below for advice on how to answer CDM questions.
Of the 38 CDM cases, eight are pilot cases that do not count towards your total score. While the pilot cases and
questions are not scored, they are not identified as pilot cases in the exam. We encourage you to do as well as
you can on every case and question.

You are only required to submit the examination once, when you have completed your CDM component and
are ready to submit, or when your allotted time expires. Once you have submitted your examination, you may
not go back to change your answers.

10
1 – ABDOMINAL DISTENSION
Rationale

Abdominal distension may indicate the presence of serious intra-abdominal or systemic disease, but it is also a
common symptom of benign disease, such as irritable bowel syndrome.

Causal conditions (list not exhaustive)

1) Ascites
a. Exudative: Low serum-to-ascites albumin gradient (e.g., peritoneal carcinomatosis)
b. Transudative: High serum-to-ascites albumin gradient (e.g., portal hypertension)
2) Bowel dilatation
a. Mechanical obstruction (e.g., adhesions, volvulus)
b. Paralytic (e.g., toxic megacolon, neuropathy)
3) Other
a. Abdominal mass
b. Irritable bowel syndrome
c. Organomegaly (e.g., hepatomegaly)
d. Pelvic mass (e.g., ovarian cancer) (see ABDOMINAL MASS)

Key objectives

Given a patient with abdominal distension, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, the candidate should be able to differentiate
ascites from bowel obstruction.

Enabling objectives

Given a patient with abdominal distention, the candidate will

1) List and interpret critical clinical findings, including

a. Perform an appropriate history and physical examination to differentiate ascites from
distended bowel or mass;
b. Identify the underlying cause of the ascites or bowel distention (e.g., cirrhosis, colon cancer);
2) List and interpret critical investigations, including
a. Laboratory investigations and imaging (e.g., liver enzymes, abdominal imaging including three
views of the abdomen, ultrasound; paracentesis);
3) Construct an effective plan of management, including
a. Initiate specific therapy in case of ascites (e.g., dietary, therapeutic paracentesis);
b. Initiate specific therapy in case of mechanical or paralytic bowel obstruction;
c. Determine if the patient requires specialized care.

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2 – ABDOMINAL / PELVIC MASS
Rationale

Abdominal or pelvic masses may be found on physical examination or incidentally on imaging. It is important
to determine which masses require immediate investigation or can be safely monitored.

Causal conditions (list not exhaustive)

1) Organomegaly
a. Hepatomegaly
b. Splenomegaly
c. Enlarged kidneys (e.g., cysts, hydronephrosis)
2) Neoplasms (benign/malignant)
a. Lymphoma/Sarcoma
b. Gastrointestinal tumors (e.g., gastric, colon, pancreas, hepatoma, gastrointestinal stromal
tumor)
c. Gynecologic tumors (e.g., ovarian, uterine)
d. Renal/adrenal
e. Neuroblastoma
3) Gynecologic
a. Ovary (e.g., benign or malignant)
b. Tube (e.g., ectopic pregnancy)
c. Uterus (e.g., leiomyoma, pregnancy)
4) Bladder/prostate (e.g., urinary retention, cancer)
5) Other
a. Pancreatic pseudocyst
b. Vascular (abdominal aortic aneurysm)
c. Abdominal wall masses

Key objectives

Given a patient with an abdominal or a pelvic mass, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan. In particular, the candidate should recognize
those features of a mass that indicate the need for immediate intervention.

Enabling objectives

Given a patient with an abdominal or a pelvic mass, the candidate will

1) List and interpret critical clinical findings, including

a. Identify systemic symptoms and signs related to the mass (e.g., weight loss, hypertension,
menstrual irregularity);
b. Perform an appropriate physical examination to determine the likely cause of the mass;
2) List and interpret critical investigations, including
a. Laboratory and imaging tests (e.g., ultrasonography, computed tomography abdomen/pelvis
scan, tumor markers);
3) Construct an effective initial management plan, including
a. Determine whether the patient requires immediate intervention or referral for specialized care
(e.g., abdominal aortic aneurysm);
b. Determine if the patient requires serial monitoring (e.g., renal cyst).

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2.4 Hernia (abdominal wall and groin)

Rationale

A hernia is an abnormal protrusion of part of a viscus through its containing wall. Hernias, in particular
inguinal hernias, are very common, and thus, herniorrhaphy is a common surgical intervention.

Causal conditions (list not exhaustive)

1) Congenital hernia
a. Infantile inguinal hernia
b. Umbilical
2) Acquired hernia
a. Inguinal hernia
i. Indirect
ii. Direct
b. Femoral hernia
c. Umbilical hernia
d. Ventral (incisional) hernia

Key objectives

Particular attention should be paid to the physical examination and identification of the type of hernia. Non-
reducible (incarcerated) hernia are at increased risk for strangulation and requires emergent, rather than elective,
repair.

Enabling objectives

Given a patient with a hernia, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate the various types of hernias on the basis of physical exam;
b. Differentiate hernias from other causes of a groin masses;
c. Identify hernias needing emergent surgical repair;
2) List and interpret critical investigations of a patient who may have strangulation, ischemia, or bowel
obstruction;
3) Construct an effective management plan, including
a. Select patients in need of surgical consultation;
b. Counsel and educate patients on the risks associated with uncorrected hernias as well as
strategies to reduce post-operative recurrence (especially with ventral hernias).

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3 – ABDOMINAL PAIN
3.1 Abdominal pain (children)

Rationale

Abdominal pain is a common complaint in children. While the symptoms may result from serious abdominal
pathology, in a large proportion of cases, an identifiable organic cause is not found. The causes are often age
dependent.

Causal conditions (list not exhaustive)

1) Lower abdominal
a. Appendicitis
b. Constipation
c. Gastroenteritis
d. Mesenteric lymphadenitis
e. Inflammatory bowel disease
f. Inguinal hernia (incarcerated)
g. Urinary tract infection
h. Gynecological cause in pubertal children
2) Generalized pain
a. Peritoneal inflammation
b. Bowel
i. Infantile colic
ii. Obstruction
c. Malabsorption
d. Irritable bowel syndrome
3) Flank pain
a. Pyelonephritis
b. Kidney stones
4) Periumbilical recurrent abdominal pain
5) Epigastric pain
a. Gastroesophageal reflux
b. Peptic ulcer
c. Biliary tract disease
d. Pancreatitis

Key objectives

In particular, the candidate will distinguish those patients requiring emergency medical and/or surgical
treatment, recognizing that a non-organic cause is the most common etiology for the symptoms.

Enabling objectives

Given a pediatric patient with abdominal pain, the candidate will

1) List and interpret critical findings, including those derived from

a. The identification of causes of abdominal pain requiring surgery (this requires particular
attention to a thorough physical examination aimed at findings suggestive of peritonitis);
b. The differentiation of all possible psychological causes or psychosocial circumstances in case
of chronic abdominal pain;

14
 c. The differentiation between organic pain and infantile colic;
2) List and interpret critical investigations, including
a. Laboratory investigations and diagnostic imaging;
3) Construct an effective initial management plan, including
a. Determining whether emergency surgical or medical care is required;
b. Outlining the initial plan of management in case of acute intestinal obstruction;
c. Outlining a plan of management for common causes of abdominal pain based on age;
d. Determining whether specialized care and/or further investigations are required.
e. Determining whether psychosocial issues need to be addressed.

15
3.2 Acute abdominal pain

Rationale

Acute abdominal pain is a common complaint in adults, leading to frequent physician visits both in the
Emergency Department and office setting. Acute abdominal pain may result from serious intra-abdominal,
intrathoracic, or retroperitoneal processes.

Causal conditions (list not exhaustive)

1) Localized pain
a. Upper abdominal region
i. Biliary tract disease
ii. Pancreatitis
iii. Peptic ulcer disease, gastritis
iv. Gastroesophageal reflux disease
v. Acute hepatitis, hepatic abscess
vi. Splenic infarct, splenic abscess
vii. Referred cardiothoracic pain
viii. Musculoskeletal pain
b. Lower abdominal region
i. Appendicitis
ii. Mesenteric lymphadenitis
iii. Diverticulitis
iv. Incarcerated hernia
v. Pelvic inflammatory disease
vi. Ectopic pregnancy
vii. Ovarian (e.g., torsion or ruptured cyst)
viii. Urinary tract infection
ix. Renal colic
x. Inflammatory bowel disease
xi. Bowel obstruction
2) Diffuse pain
a. Generalized peritonitis
b. Ruptured abdominal aortic aneurysm
c. Ischemic bowel disease
d. Gastroenteritis
e. Irritable bowel syndrome

Key objectives

Given a patient with acute abdominal pain, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, the candidate will identify those patients
requiring emergency medical or surgical treatment.

Enabling objectives

Given a patient with acute abdominal pain, the candidate will

1) List and interpret critical clinical findings, including

a. Historical features
i. The onset, frequency, duration, location, radiation, quality, and severity of pain;
ii. Identify aggravating and alleviating factors;

16
 b. Appropriate physical examination
i. Recognize features of peritonitis;
ii. Perform rectal and genitourinary examinations when appropriate;
2) List and interpret the critical investigations, including
a. Order and interpret appropriate laboratory and diagnostic imaging;
3) Construct an effective management plan, including
a. Select patients that require emergency surgery or emergency medical care;
b. Outline a plan of management for non-emergency conditions;
c. Select patients in need of specialized care and/or further investigation.

17
3.3 Chronic abdominal pain

Rationale

Chronic or recurrent abdominal pain is a common symptom with an extensive differential diagnosis and
heterogeneous pathophysiology. The history and physical examination frequently differentiate amongst the
causative disorders.

Causal conditions (list not exhaustive)

1) Upper abdominal region

a. Gastric cancer
b. Ulcer and non-ulcer dyspepsia (e.g., heartburn)
c. Biliary disease
d. Pancreatic disease
e. Hepatic disease
f. Referred cardiothoracic pain
2) Lower abdominal region
a. Bowel disease
i. Inflammatory bowel disease
ii. Diverticular disease
iii. Irritable bowel syndrome
b. Genitourinary disease
i. Endometriosis
ii. Benign or malignant tumors
iii. Urinary tract disease
iv. Pelvic inflammatory disease

Key objectives

Given a patient with chronic abdominal pain, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan.

Enabling objectives

Given a patient with chronic abdominal pain, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A detailed history and an appropriate physical examination;
2) List and interpret critical investigations, including
a. Laboratory investigations, advanced imaging, and endoscopic evaluation;
3) Construct an effective initial management plan, including
a. Appropriate medical, surgical, and non-pharmacologic management;
b. Recognition of situations where patients need long-term follow-up due to the risk of later
complications (e.g., Barrett's esophagitis);
c. Recognition of possible underlying psychosocial issues leading to abdominal pain (e.g., spousal
abuse).

18
3.4 Anorectal pain

Rationale

Most causes of anal pain are treatable, and early identification and treatment will reduce morbidity.

Causal conditions (list not exhaustive)

1) Anorectal disease
a. Inflammatory bowel disease
b. Fissures, fistulas
c. Hemorrhoids
2) Dermatologic disease
a. Psoriasis
b. Contact dermatitis or atopic dermatitis
3) Malignancy (dermatologic or other)
4) Infections
a. Sexually transmitted
b. Bacterial, fungal, or parasitic
5) Trauma
6) Coccygeal pain

Key objectives

Given a patient with anorectal pain, the candidate will diagnose the cause, severity and complications, and will
initiate an appropriate management plan. In particular, the candidate will inquire about risk factors or
symptoms suggestive of underlying disease.

Enabling objectives

Given a patient with anorectal pain, the candidate will

1) List and interpret critical clinical findings, including

a. History of rectal pain and bleeding, disturbed bowel function, and anal trauma;
b. Results of an appropriate examination, including digital rectal examination;
2) List and interpret critical investigations, including
a. Laboratory investigations;
b. Endoscopic examination;
3) Construct an effective initial management plan, including
a. Determine whether the patient requires urgent surgical treatment;
b. Counsel the patient about conservative treatment options in case of hemorrhoids and anal
fissures;
c. Counsel the patient about future preventative measures (e.g., condom use for anal
intercourse);
d. Refer the patient for specialized care, if necessary.

19
4 – ALLERGIC REACTIONS AND ATOPY
Rationale

Allergic conditions are common and may be life-threatening. Many patients may have multiple manifestations
of an atopic disorder.

Causal conditions (list not exhaustive)

Allergic reactions may be present with the following clinical manifestations:

1) Anaphylaxis
a. Drugs, food allergens, insect stings, idiopathic
2) Urticaria or angioedema
a. Drugs, food, physical stressors (e.g., cold, exercise) or congenital causes
3) Atopic dermatitis
4) Respiratory allergy (e.g., pollen, dust mites)

Key objectives

Given a patient with an allergic reaction, the candidate will determine the cause and severity, and will initiate an
appropriate management plan. Particular attention should be paid to findings suggestive of anaphylaxis and its
management.

Enabling objectives

Given a patient with an allergic reaction, the candidate will

1) List and interpret critical clinical findings, including

a. History of drug ingestion, food ingestion, stings, environmental and occupational exposures,
exercise, or family history;
b. Results of an appropriate physical examination;
2) List and interpret critical investigations, including
a. Appropriate use of tests designed to identify allergens;
3) Construct an effective management plan, including
a. Emergency management of anaphylaxis with appropriate measures;
b. Long-term management including patient education counseling (e.g., reassignment or removal
from work, avoidance of triggers).

20
5 – ATTENTION, LEARNING, AND SCHOOL PROBLEMS
Rationale

School and learning problems are among the most common reasons for children to present to primary care
clinicians. Difficulties at school can be caused by treatable medical and developmental conditions which, if
unaddressed, can lead to long-term psychosocial dysfunction and chronic health problems.

Causal conditions (list not exhaustive)

1) Developmental disorders (e.g., attention deficit hyperactivity disorder [ADHD], specific learning
disorder, autism spectrum disorder)
2) Sensory impairment (e.g., hearing or vision impairment)
3) Neurological disorders (e.g., seizure disorder, fetal alcohol spectrum disorder)
4) Mental health disorders
5) Psychosocial stressors (e.g., hunger, adverse childhood experience)
6) Chronic medical disease (e.g., obstructive sleep apnea)
7) Substance abuse-related and addictive disorders

Key objectives

Given a child or youth with learning or school problems, the candidate will assess for potential causal
conditions, which often co-occur, and will initiate an appropriate management plan. Particular emphasis should
be placed on early involvement of interdisciplinary resources and longitudinal supportive care.

Enabling objectives

Given a child or youth with learning or school problems, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A thorough medical and developmental history, with a focus on potential causal conditions;
b. An educational history from school staff;
c. A physical examination, with particular attention to signs of neurologic or genetic causal
conditions;
2) List and interpret critical investigations, including
a. Systematic hearing and vision screening;
b. Relevant laboratory tests (e.g., thyrotrophin-stimulating hormone, lead level);
c. Psychological (cognitive) testing or behavioral checklists (e.g., ADHD screening tools);
3) Construct an effective management plan, including
a. Supporting family advocacy for academic and/or behavioral interventions at school;
b. Referring for interdisciplinary intervention, if necessary (e.g., behavior management);
c. Ensuring medical management of causal conditions when required (e.g., long-acting stimulant
medications);
d. Providing counseling and longitudinal family support;
e. Referring for specialized care, if necessary.

21
6 – GASTROINTESTINAL BLEEDING
6.1 Upper gastrointestinal bleeding

Rationale

Upper gastrointestinal bleeding can manifest either as hematemesis or melena. It always warrants careful and
urgent evaluation, investigation, and treatment. The management depends on the amount of blood loss, the
likely cause of the bleeding, and the underlying health of the patient.

Causal conditions (list not exhaustive)

1) Ulcerative or erosive processes

a. Peptic ulcer disease
b. Esophagitis
c. Gastritis
2) Portal hypertension
3) Trauma (e.g., Mallory-Weiss tear)
4) Tumors

Key objectives

Given a patient with hematemesis or melena, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, the candidate will determine and manage the
hemodynamic status of the patient and resuscitate if necessary.

Enabling objectives

Given a patient with upper gastrointestinal bleeding, the candidate will

1) List and interpret critical clinical findings, including

a. The cause of the bleeding, as determined by clinical history;
b. The results of an appropriate physical examination notably aimed at assessing the patient's
hemodynamic stability;
c. Indications of a high likelihood of rebleeding;
2) List and interpret critical clinical investigations, including
a. Endoscopy;
b. Laboratory and diagnostic imaging as appropriate;
3) Construct an effective management plan, including
a. Resuscitation of the hemodynamically unstable patient;
b. Medical treatment as appropriate;
c. Employment of endoscopic procedures as needed;
d. Determining whether the patient needs immediate specialized care (gastroenterology, general
surgery, or intensive care unit).
e. Instituting preventive measures or treatments to avoid rebleeding (e.g. treatment of H. pylori)

22
6.2 Lower gastrointestinal bleeding

Rationale

Lower gastrointestinal bleeding is defined as blood originating distal to the ligament of Treitz. It can present as
frank bleeding (hematochezia) or as occult blood loss. Although commonly seen in benign conditions, it may
be the first presentation of malignancy.

Causal conditions (list not exhaustive)

1) Colorectal cancer or polyps

2) Diverticulosis
3) Angiodysplasia
4) Anorectal disease
5) Enterocolitis
6) Brisk bleeding from the upper gastrointestinal tract
7) Rectal trauma

Key objectives

Particular attention should be given to the hemodynamic status of the patient and the need for immediate
specialized care. The candidate should also identify patients at high risk of colorectal cancer for screening
colonoscopy.

Enabling objectives

Given a patient with lower gastrointestinal tract bleeding, the candidate will

1) List and interpret critical clinical findings, including

a. Assess through history and physical examination, including a rectal examination as part of the
initial assessment;
b. Assess the hemodynamic status;
2) List and interpret critical clinical investigations, including
a. Perform colonoscopy as appropriate;
b. Select additional investigations as appropriate;
3) Construct an effective initial management plan, including
a. Identify patients in need of immediate resuscitation and referral for specialized care.

23
7 – BLOOD IN SPUTUM (HEMOPTYSIS)
Rationale

Expectoration of blood can range from blood streaking of sputum to massive hemoptysis (greater than 200
ml/d) that may be acutely life-threatening. Bleeding usually starts and stops unpredictably, but under certain
circumstances may require immediate establishment of an airway and control of the bleeding.

Causal conditions (list not exhaustive)

1) Airway disease
a. Inflammatory (e.g., bronchiectasis, bronchitis)
b. Neoplasms (e.g., bronchogenic carcinoma)
c. Other (e.g., foreign body, trauma)
2) Pulmonary parenchymal disease
a. Infectious (e.g., tuberculosis, necrotizing pneumonia)
b. Inflammatory/Immune (e.g., vasculitis)
c. Other (e.g., coagulopathy)
3) Cardiac/Vascular
a. Pulmonary embolus with infarction
b. Elevated capillary pressure (e.g., mitral stenosis, left ventricular failure)
c. Arteriovenous malformation

Key objectives

Given a patient with hemoptysis, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate must determine if the patient requires
urgent intervention and stabilization, or if he needs further investigation to rule out serious underlying disease.

Enabling objectives

Given a patient with hemoptysis, the candidate will

1) List and interpret critical clinical findings, including

a. Potential risk factors for causes of hemoptysis (e.g., smoking, asbestos exposure, anti-
coagulants);
b. Results of an appropriate history and physical examination aimed at determining the stability
of the patient and the underlying cause;
2) List and interpret critical investigations, including
a. Chest x-ray and other imaging, including computed chest tomography;
b. Complete blood count and coagulation screen;
c. Tests for systemic disease;
3) Construct an effective initial plan of management, including
a. Resuscitate and stabilize the patient in case of massive hemoptysis;
b. Outline the treatment of causes that are not life-threatening and do not require immediate
referral to a specialist;
c. Determine if the patient requires specialized care;
d. Determine if there is an underlying trigger (e.g., smoking. Work-related exposure) and outline
preventive measures.

24
8 – BLOOD IN URINE / HEMATURIA
Rationale

Hematuria can be gross or microscopic. Although gross hematuria is often caused by a significant underlying
pathology, both microscopic and gross hematuria require investigation.

Causal conditions (list not exhaustive)

1) Renal
2) Glomerular disease (e.g. systemic lupus erythematosus, hemolytic uremic syndrome, vasculitis)
3) Non-glomerular (e.g. Acute interstitial nephritis, renal tumor, exercise)
4) Post renal (e.g. stones, bladder tumor, benign prostatic hyperplasia, cystitis)
5) Hematologic (e.g. coagulopathy, sickle hemoglobinopathy)

Key objectives

Interpret a urinalysis, paying attention to differentiating glomerular from non-glomerular causes and construct
an initial management plan.

Enabling objectives

Given a patient with hematuria, the candidate will

1) List and interpret clinical findings, including results of a detailed history and of an appropriate physical
examination;
2) List and interpret investigations, including a urinalysis as well as further laboratory and imaging studies,
as appropriate;
3) Construct an appropriate initial management plan, including appropriate follow up and referral for
specialized procedures, as required (e.g., renal biopsy, cystoscopy).

25
9 – ABNORMAL BLOOD PRESSURE
9.1 Hypertension

Rationale

Hypertension is a common condition that presents with elevation in either systolic or diastolic blood pressure,
and represents a major risk factor for morbidity and mortality in Canada. In some cases, it can constitute a
medical emergency with life-threatening consequences. Appropriate investigation and management of
hypertension are expected to improve health outcomes.

Causal conditions (list not exhaustive)

1) Primary
2) Secondary
a. Renal parenchymal disease (e.g., kidney injury, polycystic kidney disease)
b. Metabolic or endocrine (e.g., adrenal adenoma/hyperplasia, thyroid)
c. Vascular (e.g., unilateral renal artery stenosis, coarctation of the aorta)
d. Catecholamine excess (e.g., pheochromocytoma, drugs)
e. Obstructive sleep apnea

Key objectives

Given a patient with hypertension, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to other cardiac risk factors,
existing target organ damage and the identification of patients with hypertensive urgencies and emergencies.

Enabling objectives

Given a patient with hypertension, the candidate will

1) List and interpret key clinical findings, including

a. Accurate measurements taken to appropriately assess blood pressure, correctly diagnose
hypertension, and determine its severity;
b. Results of an appropriate history and physical examination aimed at eliciting risk factors,
evidence of acute and chronic target organ damage and secondary causes;
2) List and interpret critical investigations, including
a. Baseline investigations (e.g., creatinine, electrolytes, urinalysis);
b. Tests for risk factors (e.g., fasting lipids and glucose);
c. Tests for secondary causes, where indicated (e.g., urinary catecholamines, thyroid-stimulating
hormone);
d. Tests for end organ damage (microalbuminuria, electrocardiography);
3) Construct an effective initial management plan, including
a. Recommending non-pharmacological management strategies (e.g., sodium reduction, weight
loss, stress reduction);
b. Selecting appropriate anti-hypertensive medication taking into consideration concomitant
conditions (e.g., diabetes mellitus, asthma);
c. Selecting appropriate anti-hypertensive medication, dose, and dosage schedule taking into
consideration individual characteristics (e.g., elderly), compliance, and potential for adverse
reactions;
d. Selecting appropriate parenteral agents for hypertensive emergencies and ensure appropriate
titration and monitoring;

26
e. Implementing strategies for the prevention of complications;
f. Discussing psychosocial aspects of taking lifelong medications (e.g., cost, adherence).

27
9.1.1 Hypertension in childhood

Rationale

Hypertension, although uncommon in children, is usually due to an identifiable secondary cause. Essential
hypertension is more common in adolescence.

Causal conditions (list not exhaustive)

1) Neonates and young infants

a. Renal artery thrombosis after umbilical artery (UA) catheter
b. Coarctation of the aorta
c. Congenital renal disease
d. Renal artery stenosis
2) Children aged 1-10 year
a. Renal disease
b. Coarctation of the aorta
3) Over 10 years of age
a. Essential hypertension
b. Renal disease
c. As with 1-10 years (less common)

Key objectives

Given a child with hypertension, the candidate will diagnose the cause, severity and associated complications,
and will initiate an appropriate management plan. Particular attention should be paid to distinguishing primary
from secondary hypertension.

Enabling objectives

Given a child with hypertension, the candidate will

1) List and interpret critical clinical findings, including

a. Accurate measurement of hypertension, and classification using blood pressure tables for
children;
b. Signs of secondary hypertension (e.g., coarctation of the aorta, renal disease)
c. Obtain height, weight, body mass index, and relevant family history;
d. Diagnose renal parenchymal disease;
2) List and interpret critical investigations, including
a. Primary diagnostic screen for renal disease;
b. Diagnostic imaging to rule out renovascular disease and coarctation, if indicated;
c. Endocrinological studies (e.g., thyroid function), if indicated;
3) Construct an effective initial management plan, including
a. Lifestyle approaches for an obese patient (weight loss, exercise, salt restrictions, dietary
counseling);
b. Selection of appropriate anti-hypertensive medication;
c. Determination as to whether the patient needs specialized care.

28
9.1.4 Hypertensive disorders of pregnancy

Rationale

Pregnancy may be complicated by pre-existent chronic hypertension, the onset of preeclampsia, eclampsia, or
gestational hypertension. Hypertension in pregnancy may be life-threatening for both mother and baby.

Causal conditions (list not exhaustive)

1) Chronic hypertension with or without preeclampsia or eclampsia

2) Gestational hypertension with or without preeclampsia or eclampsia
3)
Key objectives

Given a pregnant patient with hypertension and/or proteinuria, the candidate will diagnose hypertensive
disorders of pregnancy, as well as their causes, severity, and complications, and will initiate an appropriate
management plan. In particular, the candidate will identify and take urgent action in cases of preeclampsia or
eclampsia.

Enabling objectives

Given a pregnant patient with a hypertensive disorder, the candidate will

1) List and interpret critical clinical findings, including

a. Diagnose the presence of preeclampsia or eclampsia;
2) List and interpret critical clinical and laboratory findings, including
a. Appropriate urine and hematologic investigations;
3) Construct an effective plan of management, including
a. Urgent measures for the treatment of preeclampsia and eclampsia;
b. Refer the patient for specialized care if necessary.

29
9.2 Hypotension / Shock

Rationale

Hypotension/shock is a frequently encountered, life-threatening emergency. Regardless of the underlying

cause, certain general measures are usually indicated that can be life-saving.

Causal conditions (list not exhaustive)

1) Cardiac output diminished

a. Hypovolemia
i. Hemorrhage
ii. Third space loss
iii. Other loss
b. Cardiac dysfunction
i. Intrinsic
1. Myopathy (e.g., ischemic)
2. Rhythm abnormalities
3. Mechanical (e.g., valvular disease)
ii. Extrinsic or Obstructive
1. Pulmonary embolus
2. Pulmonary hypertension
3. Tension pneumothorax
4. Pericardial disease
5. Aortic dissection
6. Venacaval obstruction
2) Distributive (diminished systemic vascular resistance)
a. Sepsis
b. Anaphylaxis
c. Inadequate tissue oxygenation
i. Neurogenic, autonomic blockade
ii. Drugs
iii. Spinal shock
iv. Addisonian crisis

Key objectives

Given a patient with hypotension, the candidate will diagnose the cause and urgency, paying particular attention
to the presence or absence of shock. The candidate will initiate an appropriate and timely management plan.

Enabling objectives

Given a patient with hypotension, the candidate will

1) List and interpret critical findings, including

a. Symptoms and signs that indicate shock;
b. Information necessary to diagnose the underlying cause of hypotension;
2) List and interpret critical clinical investigations, including
a. Tests to confirm the presence of shock as well as the underlying cause;
3) Construct an effective initial management plan, including
a. Restore tissue perfusion depending on the underlying cause;
b. Initiate specific therapeutic interventions for the underlying cause of shock.

30
10 – BREAST DISORDERS
10.1 Breast masses and enlargement

Rationale

While breast masses are common and considering the prevalence of breast cancer in women, it is important to
note that not all breast masses are cancerous. Breast cancer screening is an important tool for the detection of
the disease in its early stages. Breast enlargement may be due to physiological causes or an underlying mass
effect.

Causal conditions (list not exhaustive)

1) Malignant breast masses

2) Non-malignant breast masses
a. Fibrocystic change
b. Breast infections
c. Associated with lactation
3) Gynecomastia
a. Physiological (newborn, adolescence, elderly)
b. Pathological (e.g., testosterone deficiency or increased estrogen production, medications)

Key objectives

Given a patient with a breast mass or gynecomastia, the candidate will diagnose the cause, severity and urgency,
and will initiate an appropriate management plan.

Enabling objectives

Given a patient with a breast mass or gynecomastia, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history and physical examination (e.g., drug use);
b. Identified risk factors for malignancy;
2) List and interpret critical investigations (e.g., imaging, biopsy);
3) Construct an effective management and prevention plan, including
a. Screening;
b. Treatment;
c. Referral, if necessary;
d. Follow-up assessment and support (e.g., genetic testing).
e.

31
10.2 Breast discharge

Rationale

Although noticeable breast secretions are normal in most reproductive-aged women, spontaneous persistent
discharge may reflect underlying disease and requires investigation.

Causal conditions (list not exhaustive)

1) Galactorrhea
a. Idiopathic
b. Hyperprolactinemia
i. Physiologic
ii. Drugs, including herbal remedies
iii. Pituitary tumors
2) Breast neoplasm
3)
Key objectives

Given a patient with breast discharge, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan, with emphasis on differentiating between galactorrhea and other
causes of breast discharge.

Enabling objectives

Given a patient with breast discharge, the candidate will

1) List and interpret critical clinical findings, including

a. Examination of breasts for skin lesions;
b. Characteristics of discharge;
c. Breast mass;
2) List and interpret critical investigations and laboratory findings, including
a. Diagnostic cytology;
b. Diagnostic imaging;
3) Construct an effective management plan and determine appropriate follow-up, including
a. Counsel/educate the patient (e.g., possible fear of cancer);
b. Determine if the patient requires specialized care.
c.

32
11 – BURNS
Rationale

Burns are relatively common and, depending upon severity, may be life-threatening or fatal.

Causal conditions (list not exhaustive)

1) Thermal
2) Electrical
3) Chemical
4) Radiation

Key objectives

Given a patient who presents with burns, the candidate will diagnose the severity and manage any
complications. In particular, the candidate will institute initial management of major thermal trauma.

Enabling objectives

Given the patient with burns, the candidate will

1) List and interpret critical clinical findings, including

a. Severity and extent of the burn;
b. Risk of associated inhalation injury or other associated clinical problems;
c. Patient's tetanus immunization status;
2) List and interpret critical investigations, including
a. Laboratory and imaging studies;
3) Construct an effective initial management plan, including
a. Resuscitating and stabilizing the patient, including the use of appropriate intravenous fluids;
b. Providing physiologic monitoring and pain control;
c. Identifying patients requiring special care;
d. Anticipating medium- and long-term complications (e.g., psychosocial impact).

33
12 – CALCIUM / PHOSPHATE CONCENTRATION
ABNORMAL, SERUM
12.2 Calcium disorders

Rationale

Patients who develop hypocalcemia, particularly if the onset is acute, may develop tetany and/or seizures.
Severe or prolonged hypercalcemia may cause irreversible end-organ damage and may be life-threatening.

Causal conditions (list not exhaustive)

1) Hypocalcemia
a. Loss of calcium from the circulation
i. Hyperphosphatemia (e.g., renal insufficiency)
ii. Pancreatitis
iii. Osteoblastic metastases
iv. Drugs (e.g., EDTA)
v. Rhabdomyolysis
b. Decreased vitamin D production or action
i. kidney injury
ii. Rickets
iii. Malabsorption
iv. Neonatal
c. Decreased parathyroid hormone production or action
i. Postoperative
ii. Autoimmune
iii. Diminished response
iv. Post parathyroidectomy
d. Low magnesium
2) Hypercalcemia
a. Increased intestinal absorption
i. Increased intake (e.g., milk-alkali syndrome)
ii. Vitamin D mediated (e.g., sarcoidosis)
b. Increased bone resorption
i. Malignancy
ii. Hyperparathyroidism
iii. Hyperthyroidism
iv. Immobilization
c. Diminished excretion (e.g., diuretics)

Key objectives

Given the patient with either hypo- or hypercalcemia, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with hypocalcemia, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate the hypocalcemia related to renal disease from that due to other causes;

34
 b. Recognize features of tetany;
2) List and interpret critical clinical investigations, including
a. Assess severity utilizing ionized calcium and/or total calcium corrected for albumin level;
b. Interpret phosphate, magnesium, parathyroid hormone, and vitamin d levels, and renal
function;
3) Construct an effective initial management plan, including
a. Administer intravenous calcium in patients with symptomatic hypocalcemia;
b. Select patients in need of specialized care.

Given the patient with hypercalcemia, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate the hypercalcemia caused by malignancy from that due to other causes;
b. Determine the volume status of the patient;
2) List and interpret critical clinical investigations, including
a. Assess severity utilizing ionized calcium and/or total calcium corrected for albumin level;
b. Determine causal condition(s) using laboratory testing and imaging;
3) Construct an effective initial management plan, including
a. Administer fluid resuscitation with or without medications in patients with severe
hypercalcemia;
b. Select patients in need of specialized care.

35
13 – CARDIAC ARREST
Rationale

Cardiac arrest is life threatening and relatively common, particularly in the hospital setting. Timely basic and
advanced cardiac life support improves patient survival.

Causal conditions (list not exhaustive)

1) Coronary artery disease

2) Cardiac conduction abnormalities
3) Myocardial abnormalities
4) Non-cardiac causes (e.g., pulmonary embolus)

Key objectives

Given a patient who presents with cardiac arrest, the candidate will be able to initiate immediate acute cardiac
life support, and construct an appropriate subsequent management plan.

Enabling objectives

Given the patient with cardiac arrest, the candidate will

1) List and interpret critical clinical findings, including

a. Pulseless circulatory state;
b. Features that may help determine the cause of the arrest;
2) List and interpret critical investigations
3) Construct an effective management plan, including
a. Initiation of basic life support (bls) and advanced cardiovascular life support (ACLS)
protocols;
b. Communication with family members concerning the event, including
i. Outcome
ii. Breaking bad news
iii. Organ donation
iv. Autopsy request.

36
14 – CHEST PAIN
Rationale

Chest pain is a very common clinical presentation with a spectrum of underlying causes ranging from benign to
life-threatening.

Causal conditions (list not exhaustive)

1) Cardiovascular
a. Ischemic
i. Acute coronary syndromes
ii. Stable angina pectoris
b. Non-ischemic
i. Aortic aneurysm
ii. Pericarditis
2) Pulmonary or mediastinal
a. Pulmonary embolus or pulmonary infarct
b. Pleuritis
c. Pneumothorax
d. Malignancy
3) Gastro-intestinal
a. Esophageal spasm or esophagitis
b. Peptic ulcer disease
c. Mallory-Weiss syndrome
d. Biliary disease or pancreatitis
4) Anxiety disorders
5) Chest wall pain (e.g., costochondritis)

Key objectives

Given a patient who presents with chest pain, the candidate will diagnose the cause and severity, with particular
attention to excluding life-threatening diagnoses.

Enabling objectives

Given the patient with chest pain, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate cardiac from non-cardiac pain;
b. Determine the presence of cardiac risk factors;
c. Recognize that serious cardiovascular disease may present atypically;
d. Perform and interpret an appropriate physical examination;
2) List and interpret critical investigations, including
a. Interpret electrocardiogram (ECG) and appropriate laboratory tests;
b. Select, as appropriate, patients for additional investigations (e.g., stress testing, imaging);
3) Construct an effective initial management plan, including
a. Determine urgency of clinical condition;
b. Initiate appropriate therapies in urgent situations (e.g., acute coronary syndrome, aortic
dissection);
c. Refer for urgent specialized care, as required;
d. Initiate secondary preventive strategies as indicated.

37
15 – COAGULATION ABNORMALITIES
15.1 Bleeding, bruising
Rationale

Some bleeding or bruising, although common, is idiopathic and/or self-limiting (e.g., epistaxis, post-traumatic
bruising). However, excessive or spontaneous bleeding/bruising may point to a serious underlying disease, in
which case urgent management may be required. Note that bleeding related to major organ systems is covered
under other objectives.

Causal conditions (list not exhaustive)

1) Localized bleeding (e.g., epistaxis, laceration)

2) Hemostasis disorders
a. Platelet or blood vessels disorders (e.g., von Willebrand disease, collagen disorder, medication-
induced)
b. Coagulation disorders (e.g., factor VIII or vitamin K deficiency, fibrinolysis)

Key objectives

Given a patient with a bleeding tendency or bruising, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan, recognizing that some presentations are self-
limited.

Enabling objectives

Given a patient with a localized or other bleeding/bruising, the candidate will

1) List and interpret critical clinical findings, including results of an appropriate history and physical
examination performed with a particular attention to
a. Airway and hemodynamic status;
b. Differentiation between various disorders of hemostasis and self-limited and/or idiopathic
bleeding (e.g., epistaxis);
2) List and interpret relevant investigations (e.g., complete blood count, coagulation studies);
3) Construct an effective initial management plan, including
a. Initiating immediate management of bleeding (e.g., nasal packing, IV resuscitation if
hemodynamically unstable);
b. Providing counselling/education on how to prevent future episodes;
c. Making a determination as to whether specialized care is required.

38
15.2 Prevention of venous thrombosis

Rationale

Venous thrombosis is a major cause of morbidity and mortality. Physicians should use best evidence to lower
the risk of this disease.

Causal conditions (list not exhaustive)

1) Stasis (e.g., hospitalization, travel)

2) Endothelial injury (e.g., previous thrombosis)
3) Hypercoagulability (e.g., drugs, cancer, inherited or acquired conditions)

Key objectives

Given a patient who may be at risk of venous thrombosis, the candidate will recognize the risk, take further
measures to assess the likelihood of occurrence and use best evidence to intervene.

Enabling objectives

Given a patient at possible risk of thrombosis, the candidate will

1) Take an appropriate history and perform a physical examination to confirm the need for concern;
2) List and interpret the appropriate investigations indicated for that patient including
a. Hematologic or coagulation tests;
b. Investigations for other underlying conditions;
3) Construct an effective initial management plan, including
a. Non-pharmacologic measures (e.g., anti-embolic stockings);
b. Anti-coagulation;
4) Promote systemic measures for consistent prevention of thrombosis in a clinical setting.

39
16 – CONSTIPATION
16.1 Adult constipation

Rationale

Constipation is a common presenting complaint and can be attributed to a number of possible functional and
organic causes. It may have a significant effect on quality of life and may be the presenting feature of significant
pathology.

Causal conditions (list not exhaustive)

1) Diet, lifestyle
2) Irritable bowel syndrome
3) Drugs
4) Neurogenic (central or peripheral)
5) Myopathic
6) Metabolic
7) Pregnancy
8) Obstructive lesions
9) Anorectal disease

Key objectives

Given an adult patient with constipation, the candidate will diagnose the cause and severity, and will initiate an
appropriate management plan.

Enabling objectives

Given an adult patient with constipation, the candidate will

1) List and interpret critical clinical findings, including

a. The features of the patient's history and physical examination that distinguish functional from
organic causes;
2) List and interpret critical investigations, including
a. Investigations required to determine whether the patient needs endoscopic examination or
diagnostic imaging;
3) Construct an effective initial management plan, including
a. Putting in place a conservative plan of symptom management (e.g., dietary and lifestyle
changes, appropriate laxative use);
b. Outlining a plan for managing constipation that is secondary to medications;
c. Determining whether the patient requires specialized care;
d. Implementing prevention strategies (e.g., dietary changes, behaviour modification).

40
16.2 Pediatric constipation

Rationale

Constipation is a common problem in children. It is important to differentiate functional from organic causes,
recognizing that the vast majority of children do not have an organic cause for constipation.

Causal conditions (list not exhaustive)

1) Neonate and Infant

a. Dietary
b. Anatomic (e.g., Hirschsprung disease)
2) Older child
a. Dietary
b. Psychologic
c. Anatomic (e.g., bowel obstruction)
d. Neurologic
e. Endocrine/metabolic
f. Other (e.g., celiac disease, cystic fibrosis)

Key objectives

Given a child who presents with constipation, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan

Enabling objectives

Given a child who presents with constipation, the candidate will

1) List and interpret critical clinical findings, including

a. Clinical features that help to distinguish functional from organic;
b. The social and psychological effects of chronic constipation;
2) List and interpret critical clinical investigations, including:
a. The possibility that no investigation may be necessary;
3) Construct an effective initial management plan, including
a. Initial and long-term therapy including laxatives, diet, and education;
b. Multidisciplinary approach as needed;

41
17 – CONTRACEPTION
Rationale

Contraception can be accomplished through a variety of methods. Ideally, the prevention of pregnancy should
be directed at education of both partners.

Causal conditions (list not exhaustive)

1) Non-permanent contraception
a. Hormonal contraception
b. Barrier methods
c. Intrauterine devices
d. Other (e.g., abstinence)
2) Permanent contraception
a. Male sterilization
b. Female sterilization

Key objectives

Given a patient who presents with a need or request for contraception, the candidate will discuss the treatment
available options and initiate an appropriate management plan.

Enabling objectives

1) Given the patient requesting or requiring contraception, the candidate will

2) list and interpret critical clinical findings, including
a. obtain a general and sexual history including risk factors for complications;
b. perform an appropriate physical examination;
3) list and interpret critical clinical investigations, including
a. perform cultures, Papanicolaou smear, and pregnancy test;
4) construct an effective initial management and prevention plan, including
a. discuss the various contraception options with the patient, including
i. risks of failure;
ii. potential complications;
iii. protection against sexually transmitted infections;
iv. drug interactions associated with each method;
b. discuss emergency contraceptives as back-up when needed.

42
18 – COUGH
Rationale

Cough is a common problem for which patients seek medical advice. Assessment of cough is important in
order to distinguish benign from serious causes.

Causal conditions (list not exhaustive)

1) Acute cough
a. Infectious
b. Irritant
c. Other (e.g., cardiac)
2) Chronic cough (lasting 3 weeks or longer)
a. Upper respiratory tract
b. Pulmonary
c. Gastrointestinal (e.g., gastroesophageal reflux)
d. Cardiac
e. Other (e.g., medications, work-related exposure)

Key objectives

Given a patient with a cough, the candidate will diagnose the cause, severity, and complications, and will initiate
an appropriate management plan. Particular attention should be paid to differentiating benign from more
serious causes requiring full investigation and further management.

Enabling objectives

Given a patient with a cough, the candidate will

1) List and interpret critical clinical findings, including

a. Discrimination between acute and chronic cough;
b. Differentiation of benign from more serious causes;
c. Triggers and aggravating factors;
2) List and interpret critical investigations, including
a. Appropriate imaging investigations;
b. Pulmonary function testing;
3) Construct an initial management plan, including
a. Determining if the patient requires specialized care;
b. Prescribing appropriate medication;
c. Counseling and educating the patient with chronic cough
d. Reassuring the patient if he does not require further investigation.
e. Advising the patient on work-related issues, if necessary.
f.

43
19 – CYANOSIS / HYPOXIA
Rationale

Cyanosis is the bluish discoloration of the tissues that results from increased concentration of reduced
hemoglobin. Hypoxia is defined as insufficient levels of oxygen in tissues to maintain cell function. These
findings could indicate a serious underlying condition, and may require urgent management.

Causal conditions (list not exhaustive)

1) Central cyanosis or hypoxemia

a. High alveolar-arterial (A-a) gradient
i. Shunting (e.g., tetralogy of Fallot, acute respiratory distress syndrome)
ii. V/Q (ventilation-perfusion) mismatch (e.g., cystic fibrosis, pulmonary embolus)
iii. Diffusion impairment (e.g., restrictive lung disease)
b. Normal A-a gradient
i. Hypoventilation (e.g., opioid overdose)
ii. High altitude
2) Peripheral (e.g., low cardiac output, cold exposure)

Key objectives

Given a patient with cyanosis, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to determining if hypoxemia or
hypoxia is present.

Enabling objectives

Given a patient with cyanosis, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. An appropriate history and physical examination in order to distinguish central from
peripheral cyanosis and to determine severity and complications;
2) List and interpret critical investigations (e.g., calculation of a-a gradient)
3) Construct an effective initial plan of management, including
a. Initiating resuscitation if the patient is critically ill;
b. Initiating treatment of the underlying cause;
c. Referring the patient to specialized care, if indicated;
d. Counselling and educating the patient about preventive measures, if applicable.
e.

44
20 – LIMP IN CHILDREN
Rationale

Limp is a labored, jerky or strenuous way of walking, usually caused by weakness, pain, or deformity. Although
usually caused by benign conditions, at times it may be life or limb threatening.

Causal conditions (list not exhaustive)

1) Congenital (lower limb, spine)

2) Acquired (lower limb, spine)
a. Infection
b. Inflammation
c. Tumors
i. Benign
ii. Malignant
3) Other
a. Growing pains
b. Pain amplification syndromes

Key objectives

Given a child with a limp, the candidate will identify the most likely cause, in particular ruling out the most
serious possible diagnoses. Note, in particular, that the most serious diseases causing a limp or leg pain in
children are usually unilateral.

Enabling objectives

Given a child with a limp, the candidate will

4) Acquire and interpret critical clinical findings, including

a. Determining whether the pain originates in bone, joint, or soft tissue.
b. Localizing the site of pain (e.g., unilateral or bilateral) and the site of pathology (e.g., referred
pain).
c. Recognizing signs and symptoms suggestive of serious disease;
d. Calculating leg length discrepancies;
e. Describing stance and gait;
5) List and interpret critical investigations, including
a. Appropriate diagnostic imaging modalities (e.g., x-ray, nuclear scan);
6) Constructing an effective initial management plan, including
a. Determining if the patient requires specialized care, including referral to other health care
professionals;
b. In the case of a child persistent pain or limp, determining if further assessment is needed.

45
21 – DEVELOPMENTAL DELAY
Rationale

Primary care physicians are often the first clinicians to assess development in an infant, and to recognize
delayed or atypical development. Early intervention can have a significant positive impact on outcomes in
children with many developmental disorders, so systematic developmental surveillance is an integral part of
primary health care for children.

Causal conditions (list not exhaustive)

1) Global developmental delay

a. Neurological disorders (e.g., fetal alcohol spectrum disorder, cerebral dysgenesis)
b. Genetic and metabolic disorders (e.g., trisomy 21, congenital hypothyroidism)
c. Toxic exposures (e.g., lead)
d. Severe psychosocial deprivation
2) Speech and language delay
a. Hearing impairment
b. Developmental language disorder
c. Autism spectrum disorders (when associated with atypical social and behavioral features)
3) Motor delay
a. Cerebral palsy
b. Muscular dystrophies
c. Developmental coordination disorder

Key objectives

Using a validated developmental screening tool, the candidate will identify children with delayed or atypical
development in one or more domains. Children for whom developmental concern has been raised will be
referred to early developmental intervention services, which can become involved prior to specialized
developmental assessment.

Enabling objectives

Given a young patient with developmental delay, the candidate will

1) List and interpret critical clinical findings, including

a. Use of validated developmental screening tool to identify domains of developmental delay;
b. Thorough relevant history and physical examination, with particular attention to identification
of immediately modifiable causal conditions (e.g., toxic exposures, severe neglect);
2) List and interpret relevant investigations, including
a. Audiology assessment in case of delayed language development;
b. Diagnostic investigations (e.g., genetic and metabolic tests, neuroimaging) if indicated;
3) Construct an effective plan of management, including
a. Immediate referral for specialized pediatric assessment in case of developmental regression;
b. Referral for early intervention services in case of a delay in any developmental domain;
c. Determination as to whether specialized or multidisciplinary assessment and intervention are
required;
d. Involvement of appropriate community services for family support;
e. Ongoing supportive communication with the family.
f.

46
21.1 Adults with developmental disabilities

Rationale

The need for health care for adults with developmental disabilities is growing as a result of social insertion
measures and of longer life expectancy than in the past. However, they may have complex health problems and
poor health status.

Causal conditions (list not exhaustive)

1) Unknown etiology
2) Known etiology and associated conditions
a. Genetic syndromes (e.g., Down Syndrome)
b. Autism spectrum disorder
c. Fetal alcohol spectrum disorder
d. Brain injury (e.g., cerebral palsy)
e. Central nervous system infection
f. Other

Key objectives

Given an adult with developmental disability, the candidate will identify common physical, mental and
behavioral issues and initiate an appropriate management plan. Particular attention should be paid to the known
disparities in health status and health care for this group, adapting communication to the patient's level of
intellectual and adaptive functioning and to the interdisciplinary coordination of care.

Enabling objectives

Given an adult with developmental disability, the candidate will

3) List and interpret critical clinical findings, including

a. Assessed level of intellectual and adaptive functioning;
b. Assessed atypical presentations of serious illness and/or pain (e.g., infection, trauma);
c. Assessed risk for abuse and neglect;
4) List and interpret critical investigations depending on the disability (e.g., thyroid-stimulating hormone
(TSH) in down syndrome, hearing and vision testing)
5) Construct an effective initial management plan, including
a. Assessing the patient's ability to give voluntary and informed consent;
b. Obtaining input and assistance from caregivers;
c. Initiating interdisciplinary care, if necessary;
d. Performing appropriate screening and preventive measures (e.g., for infectious diseases and
cancer);
e. Ensuring appropriate use of psychotropic medication (e.g., antipsychotics), including
discussion of risks/benefits;
f. Anticipating medium-and long-term complications (e.g., psychosocial impact, safety).

47
22 – DIARRHEA
22.1 Acute diarrhea

Rationale

Acute diarrhea is defined as a disturbance of stool frequency and/or consistency. Diarrheal diseases are
extremely common worldwide. Even in North America, morbidity and mortality are significant.

Causal conditions (list not exhaustive)

1) Infection
a. Viruses
b. Bacteria
c. Parasites
2) Drugs or toxins
3) Ischemic
4) Inflammatory bowel disease
5) Metabolic disease (e.g., hyperthyroidism)

Key objectives

Given a patient with acute diarrhea, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to the history of risk factors
associated with specific causes and the assessment for such complications as volume loss or electrolyte
abnormalities.

Enabling objectives

Given a patient with acute diarrhea, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate small from large bowel diarrhea;
b. Identify potential risk factors for specific infections (e.g., travel);
c. Perform an appropriate history and physical examination to determine severity and
complications (e.g., volume depletion, co-morbidities);
2) List and interpret critical investigations, including
a. Perform appropriate laboratory investigations and other tests (e.g., stool cultures, electrolytes);
3) Construct an effective initial management plan, including
a. Initiate dietary interventions where appropriate;
b. Initiate rehydration where appropriate;
c. Initiate specific therapy only when indicated;
d. Refer to specialized care when indicated by the possible diagnosis or by the case severity;
e. Alert the public health authorities when required.
f.

48
22.2 Chronic diarrhea

Rationale

Chronic diarrhea is defined as a disturbance of stool frequency and/or consistency of greater than four weeks'
duration.

Causal conditions (list not exhaustive)

1) Steatorrhea
a. Luminal
i. Pancreatic insufficiency
ii. Cholestasis
iii. Ileal disease or resection
iv. Bacterial overgrowth
b. Mucosal
i. Lactase deficiency
ii. Celiac disease
2) Large bowel
a. Secretory diarrhea (e.g., villous adenoma)
b. Inflammatory diarrhea
i. Inflammatory bowel disease
ii. Infection
iii. Other (e.g., radiation, ischemic colitis)
c. Motility disorder (e.g., irritable bowel syndrome)
3) Small bowel
a. Osmotic diarrhea
b. Secretory diarrhea
i. Tumors
1. Neuroendocrine (e.g., carcinoid)
2. Neoplasia (e.g., lymphoma)
ii. Mucosal
c. Motility disorders (e.g., diabetic neuropathy)

Key objectives

Given a patient with chronic diarrhea, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, the history should focus on contrasting small and
large bowel diarrhea.

Enabling objectives

Given a patient with chronic diarrhea, the candidate will

1) List and interpret clinical findings, including

a. Differentiate pancreatic and biliary causes from small bowel and large bowel causes of
diarrhea;
b. Differentiate osmotic from secretory diarrhea;
c. Differentiate maldigestion from malabsorption;
d. Diagnose irritable bowel syndrome on the basis of history and appropriate exclusion of other
causes;
2) List and interpret critical investigations, including
a. Select and interpret investigations for malabsorption and specific underlying causes;

49
 b. Select and interpret investigations for other causes of chronic diarrhea;
3) Construct an effective initial management plan, including
a. Prevent, recognize, and treat related complications (e.g., other manifestations of inflammatory
bowel disease);
b. Select patients in need of specialized care or consultation;
c. Conduct education and counseling of patients with malabsorption and inflammatory bowel
disease.
d.

50
22.3 Pediatric diarrhea

Rationale

Diarrhea is defined as a disturbance of stool frequency and/or consistency. It is considered acute if the
duration is less than fourteen days. Diarrhea is a common problem in infants and children. In most cases, it is
mild and self-limited, but the potential exists for significant morbidity and mortality from hypovolemia,
dehydration, and electrolyte abnormalities.

Causal conditions (list not exhaustive)

1) Infections
2) Diet-related (e.g., milk protein intolerance)
3) Ischemic intestinal damage (e.g., intussusception)
4) Infections
5) Malabsorption
a. Lactase deficiency
b. Cystic fibrosis
c. Celiac disease
6) Other causes
a. Drugs
b. Laxative abuse
c. Inflammatory bowel disease

Key objectives

Given a child with diarrhea, the candidate will obtain a detailed history of the nature of the diarrhea and
associated symptoms. The candidate will diagnose the cause, severity, and complications, paying particular
attention to signs and symptoms of dehydration or hypovolemia, and will initiate an appropriate management
plan.

Enabling objectives

Given a child with diarrhea, the candidate will

1) List and interpret critical clinical findings, including

a. Given a patient with acute diarrhea, elicit a history for risk factors of infectious causes;
b. Given a patient with chronic diarrhea, elicit a history of infectious, dietary, or systemic
symptoms and/or complications;
c. Conduct a physical examination to assess the etiology, severity, or complications of diarrhea
(e.g., growth delay);
2) List and interpret critical investigations in view of the common etiologies, including
a. Select and interpret the basic investigations for malabsorption;
b. Select and interpret the basic investigations for chronic infections and other causes;
3) Construct an effective management plan, including
a. Provide resuscitation for acutely ill patients;
b. Select patients who require referral to a specialist;
c. Refer to public health authorities if required.
d.

51
23 – DIPLOPIA
Rationale

Diplopia, or double vision, is the major symptom associated with dysfunction of the extraocular muscles or
abnormalities of the motor nerves innervating these muscles.

Causal conditions (list not exhaustive)

1) Monocular diplopia (e.g., refractive error, cataract)

2) Binocular diplopia
a. Oculomotor nerve dysfunction
i. ischemia
ii. diabetes-associated
iii. multiple sclerosis
iv. intercranial mass (e.g., aneurysm)
b. Myasthenia gravis
c. Graves' orbitopathy
d. Orbital inflammation, infection, or tumor
e. Fracture of orbital floor or "blow out"
f. Decompensation of childhood phoria (e.g., squint)

Key objectives

Given a patient with diplopia, the candidate will diagnose the cause and severity of diplopia and will initiate an
appropriate management plan. Of particular importance is the clinical determination of whether true binocular
diplopia is present, which resolves with occlusion of vision to either eye.

Enabling objectives

Given a patient with diplopia, the candidate will

1) List and interpret critical clinical findings, including

a. Indications of the underlying disease process (e.g., pain, features of hyperthyroidism);
b. Establish onset and development;
c. Perform an appropriate physical examination (e.g., eyes, neurologic, thyroid);
2) List and interpret critical investigations, including
a. Identification of underlying medical conditions;
3) Construct an effective initial management plan, including
a. Selection of patients in need of specialized care.
b.

52
24 – DIZZINESS / VERTIGO
Rationale

Dizziness is a common, but imprecise complaint. Physicians need to determine whether it refers to vertigo,
which may be a symptom of significant intracranial disease, or a non-specific symptom that could be related to
non-vestibular causes.

Causal conditions (list not exhaustive)

1) Vertigo
a. Peripheral vestibular dysfunction
i. Benign positional vertigo
ii. Peripheral vestibulopathy
iii. Ménière's disease
iv. Drugs (e.g., aminoglycosides)
v. Acoustic neuroma
2) Central vestibular dysfunction
a. Cerebrovascular
b. Multiple sclerosis
c. Drugs (e.g., anticonvulsants, hypnotics, alcohol)
3) Other dizziness
a. Hyperventilation
b. Disequilibrium (e.g., poor mobility, peripheral neuropathy)
c. Presyncope
d. Anxiety or panic disorder

Key objectives

Given a patient complaining of dizziness, the candidate will discriminate between vertigo and other causes.

Enabling objectives

Given a patient with dizziness or vertigo, the candidate will

1) List and interpret critical clinical findings, including

a. Distinguish clinically between amongst vertigo, gait disturbances, orthostatic light-headedness,
and other disorders;
b. Differentiate patients with central versus peripheral causes of vertigo on the basis of history
and physical examination;
2) List and interpret critical investigations, including
a. Selection of patients requiring specialized testing;
3) Construct an effective initial management plan, including
a. Determine which patients with central vertigo require more urgent management;
b. Describe the symptomatic management of patients with benign causes of vertigo;
c. Counsel and educate patients with benign causes of dizziness or vertigo;
d. Select patients in need of specialized care.
e.

53
25 – DYING PATIENTS
Rationale

Physicians frequently deal with patients dying from incurable or untreatable diseases, many of which cause
significant physical and psychological pain. The physician’s role is to comfort patients and their families and to
address patient pain, including facilitating access to medical assistance in dying.

Causal conditions (list not exhaustive)

None.

Key objectives

Given a dying patient, the candidate will develop an appropriate palliative care plan that optimally controls pain
and other symptoms, maintains human dignity, and recognizes the importance of family and social supports
and of the health care team’s different roles. The candidate must know the provisions in Canada’s law on
medical assistance in dying (MAID; Bill C-14) and must be prepared to discuss these provisions with patients
and to act upon such a request where appropriate.

Enabling objectives

Given a patient approaching end of life, the candidate will

1) Determine patient mental capacity to discuss and provide informed consent regarding end-of-life care.
If the patient does not have the capacity to make such decisions, the candidate will determine whether
the patient has an advance directive or a substitute decision-maker.
2) Develop an appropriate management plan, including
a. Discussing with the patient or substitute decision-maker the patient’s wishes for their care
(e.g., resuscitation) at the appropriate time;
b. Using pharmacologic and nonpharmacologic measures for symptom control (e.g., pain,
respiratory distress, delirium, or agitation) while recognizing appropriate indications, adverse
effects, and possible complications;
c. Determining the patient’s eligibility (e.g., medical indication, provincial, and territorial legal
requirement) for medical assistance in dying if requested and providing access to this
intervention without discrimination;
d. Ensuring a culturally sensitive approach to emotional, physical, and spiritual support for the
patient and their family;
e. Treating the patient, their family, and significant others with dignity and respect throughout
end-of-life care;
f. Referring the patient to other professionals as needed.
g.

54
26 – DYSPHAGIA
Rationale

Dysphagia, defined as difficulty swallowing, is a complaint that should be regarded as a clear signal of
potentially serious organic pathology, which therefore warrants careful and complete evaluation.

Causal conditions (list not exhaustive)

1) Oropharyngeal dysphagia
a. Structural
i. Peritonsillar abscess
ii. Pharyngitis
iii. Tumor
iv. Zenker diverticulum
b. Neuromuscular
i. Central (e.g., cerebrovascular accident (CVA))
ii. Cranial nerves (e.g., amyotrophic lateral sclerosis (ALS))
iii. Systemic myopathies (e.g., dermatomyositis)
c. Xerostomia
2) Esophageal dysphagia
a. Mechanical obstruction
i. Intrinsic
1. Intermittent (e.g., lower esophageal ring, web)
2. Progressive (e.g., carcinoma, peptic stricture)
3. Foreign object
ii. Extrinsic (e.g., mediastinal mass)
b. Neuromuscular disorder
i. Intermittent (e.g., diffuse esophageal spasm)
ii. Progressive (e.g., scleroderma, achalasia)

Key objectives

Given a patient with dysphagia, the candidate will differentiate oropharyngeal from esophageal causes and
initiate a management plan based upon the underlying cause and severity.

Enabling objectives

Given a patient with dysphagia, the candidate will

1) List and interpret critical clinical findings, including

a. Determining from the history whether the problem is most likely oropharyngeal, or upper or
lower esophageal;
b. Identifying the characteristics of the esophageal dysphagia that suggest specific underlying
disorders;
c. Determining complication risk;
2) List and interpret critical investigations, including determining whether specific investigations are
required (e.g., barium swallow, endoscopy);
3) Construct an effective initial management plan, including
a. Determining whether the patient needs specialized care;
b. Anticipating short-, medium- and long-term complications (e.g., aspiration).

55
27 – DYSPNEA
Rationale

Dyspnea, which is a subjective sensation of shortness of breath or difficulty breathing is a common and
distressful symptom. The presence of dyspnea, especially when acute, may indicate serious life-threatening
illness. When chronic, it is a major cause of disability.

Causal conditions (list not exhaustive)

1) Cardiac causes
a. Myocardial dysfunction (e.g., ischemic cardiomyopathy)
b. Valvular heart disease
c. Pericardial disease (e.g., tamponade)
d. Increased cardiac output (e.g., anemia)
e. Arrhythmia
2) Pulmonary causes
a. Upper airway (e.g., foreign body, anaphylaxis)
b. Chest wall and pleura (e.g., pleural effusion)
c. Lower airway (e.g., asthma, chronic obstructive pulmonary disease)
d. Alveolar (e.g., pneumonia)
3) Central causes (e.g., metabolic acidosis, anxiety)

Key objectives

Given a patient with dyspnea, the candidate will diagnose the cause, severity and complications, and will initiate
an appropriate management plan. It is particularly important to identify patients with life-threatening causes of
dyspnea.

Enabling objectives

Given a patient with acute dyspnea, the candidate will

1) List and interpret critical clinical findings, including

a. Current airway, breathing, and circulation status;
b. Determination as to whether the dyspnea is of cardiac, pulmonary or central origin;
c. History of occupational and environmental exposures;
2) List and interpret critical investigations (e.g., electrocardiogram, arterial blood gases, chest X-ray);
3) Construct an effective management plan, including
a. Initiating management if the patient presents with life-threatening dyspnea;
b. Referring the patient for specialized care, if necessary;
c. Planning long-term management in case of chronic dyspnea, including secondary prevention
strategies;
d. Anticipating medium- and long-term complications (e.g., psychosocial impact, safety) in case
of chronic dyspnea.

56
27.3 Pediatric respiratory distress

Rationale

After fever, respiratory distress is one of the most common pediatric emergency complaints, the causes of
which can be life-threatening.

Causal conditions (list not exhaustive)

1) Upper airway problems

a. Croup
b. Foreign body aspiration
c. Laryngeal disorders
d. Epiglottitis
e. Retropharyngeal abscess
f. Choanal atresia
2) Lower airway, pulmonary disorders
a. Tracheitis, bronchiolitis
b. Pneumonia, atelectasis
c. Asthma, bronchospasm
d. Respiratory distress syndrome of the neonate
e. Tracheo-esophageal fistula
f. Pulmonary embolus
3) Pleural disorders
a. Pleural effusion, empyema
b. Pneumothorax
4) Neurologic disorders (e.g., drugs)
5) Other (e.g., extrapulmonary restriction)
6) Cardiac disorders
a. Congestive heart failure (left-to-right shunt, left ventricular failure)
b. Cardiac tamponade

Key objectives

Given a patient with pediatric dyspnea or respiratory distress, the candidate will diagnose the cause, severity,
and complications, and will initiate an appropriate management plan. In particular, for correct assessment, it is
important to consider the respiratory rate in the context of age of the child.

Enabling objectives

Given a patient with pediatric respiratory distress, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate a child who appears well from a child in distress or in critical condition;
b. For the child in distress or critical condition, first evaluate the airway, breathing, and
circulation status, then perform a thorough history and physical examination;
c. Differentiate cardiac from pulmonary, neuromuscular, or other causes;
2) List and interpret critical investigations, including
a. Selection and interpretation of appropriate cardiac and pulmonary investigations (e.g., arterial
blood gases, complete blood count (CBC));
3) Construct an effective plan of management, including
a. Manage patients with life-threatening respiratory distress, including selection of patients
requiring hospitalization and specialized care;

57
b. Plan long-term management of patients with chronic disease, including secondary prevention
strategies.

58
28 – EAR PAIN
Rationale

The cause of ear pain is usually otologic, but it may be referred. In young children who are most frequently
affected by ear infections, a good otologic examination is crucial.

Causal conditions (list not exhaustive)

1) External ear pain

a. Infections
i. Otitis externa (e.g., fungal, bacterial)
ii. Auricular cellulitis
iii. Perichondritis
iv. External canal abscess
b. Trauma (e.g., frostbite, piercings)
c. Other (e.g., foreign body, cerumen impaction)
2) Middle and inner ear pain
a. Infections or inflammation
i. Acute otitis media
ii. Serous otitis media
iii. Mastoiditis
iv. Myringitis
b. Trauma (e.g., perforation, barotrauma)
c. Neoplasms
3) Referred pain
a. Infections (e.g., sinusitis, dental disease)
b. Trigeminal neuralgia
c. Other (e.g., temporomandibular joint dysfunction, thyroiditis)

Key objectives

Given a patient with ear pain, the candidate will diagnose the cause, severity, and complications, and will initiate
an appropriate management plan. In particular, a careful and complete head and neck examination is required,
especially with a normal-appearing ear canal, tympanic membrane, and middle ear.

Enabling objectives

Given a patient with ear pain, the candidate will

1) List and interpret critical clinical findings, including

a. Determine features on history and physical examination suggestive of infection;
b. Perform an examination of the ear, head, and neck area for other causes of pain;
2) List and interpret critical investigations, including
a. Culture and sensitivity of ear canal discharge, if present;
3) Construct an effective initial management plan, including
a. Decide whether supportive measures are all that is required.

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29 – EDEMA / ANASARCA / ASCITES
29.1 Generalized edema

Rationale

Generalized edema is systemic soft tissue swelling produced by expansion of the interstitial fluid volume. This
condition may be caused by serious underlying disease.

Causal conditions (list not exhaustive)

1) Increased capillary hydrostatic pressure

a. Increased plasma volume due to renal sodium retention
i. Heart failure
ii. Reduced systemic vascular resistance (e.g., cirrhosis)
iii. Primary renal sodium retention (e.g., renal disease, drugs)
iv. Pregnancy
v. Premenstrual edema
b. Decreased arteriolar resistance (e.g., calcium channel blockers, idiopathic)
2) Decreased oncotic pressure (hypoalbuminemia)
a. Protein loss (e.g., nephrotic syndrome)
b. Reduced albumin synthesis (e.g., liver disease, malnutrition)
3) Increased capillary permeability (e.g., burns, inflammation)
4) Increased interstitial oncotic pressure (e.g., myxedema)

Key objectives

Given a patient with generalized edema, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, it is important to differentiate systemic edema from
local edema, and categorize the general mechanism of edema, since management may be affected.

Enabling objectives

Given a patient with generalized edema, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination;
2) List and interpret critical investigations (e.g., creatinine, urinalysis, chest X-ray)
3) Construct an effective initial management plan, including
a. Non-pharmacological measures (e.g., dietary salt restriction);
b. Pharmacological measures;
c. Determination as to whether the patient requires specialized care and/or consultation (e.g.,
patient with advanced renal, cardiac, or hepatic disease).
d.

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29.2 Localized edema

Rationale

Localized expansion of interstitial fluid volume can be caused by serious diseases, and is a common cause of
patient concern.

Causal conditions (list not exhaustive)

1) Venous insufficiency (including postphlebitic syndrome)

2) Deep venous thrombosis (DVT)
3) Trauma
4) Lymphedema (e.g., malignancy, primary)
5) Infection (cellulitis/soft tissue/bone)
6) Inflammation (e.g., ruptured Baker cyst, chronic dermatitis)

Key objectives

Given a patient with localized edema, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, diagnosis of proximal deep venous thrombosis must
be considered.

Enabling objectives

Given a patient with localized edema, the candidate will

1) List and interpret critical clinical findings, including

a. Elicit history of risk factors for DVT;
b. Examine extremity for signs associated with specific causes (e.g., palpable clot, tenderness);
c. In the case of suspected DVT, classify the patient into a pretest probability category (e.g., wells
criteria);
2) List and interpret critical investigations (e.g., d-dimer, duplex ultrasonography)
3) Construct an effective initial management plan, including
a. Outline the management of DVT including under circumstances where same-day diagnostic
testing may be unavailable;
b. List indications and complications, and explain management and monitoring of anti-coagulant
therapy;
c. Counsel the patient about anticoagulant therapy (prevention of postphlebitic syndrome);
d. Investigation of causes of DVT, if indicated (e.g., thrombophilic states, underlying cancer);
e. Outline the management of cellulitis;
f. Determine if the patient requires specialized care.

61
30 – EYE REDNESS
Rationale

Eye redness ("red eye") is a very common complaint. Many of the common causes are relatively benign, but
some can lead to significant vision loss and thus require prompt referral.

Causal conditions (list not exhaustive)

1) Lids, lashes, orbits, lachrymal system

a. Congenital
b. Acquired
2) Conjunctiva, sclera
3) Cornea
4) Anterior chamber, iris
5) Trauma

Key objectives

Given a patient with eye redness, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, prompt referral is required for some conditions that
could lead to significant vision loss.

Enabling objectives

Given a patient with eye redness, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate causal conditions that are benign from those that require prompt referral;
b. Determine if vision or visual acuity is affected;
2) List and interpret critical investigations, including
a. A slit lamp examination, as appropriate;
3) Construct an effective initial management plan, including
a. Determine if the patient requires urgent referral.

62
31 – FAILURE TO THRIVE
31.1 Frailty in the elderly

Rationale

Frailty is a term that applies to some older adults who have varying degrees of weight loss and/or malnutrition,
cognitive impairment, multiple medical comorbidities, decreased mobility, and/or psychosocial stressors,
leading to decreased function (e.g., activities of daily living). A multidisciplinary approach in the form of a
comprehensive geriatric assessment has been shown to decrease morbidity and maintain or improve function.

Causal conditions (list not exhaustive)

1) Medications
2) Environmental/Social (e.g., isolation, poverty, elder abuse, neglect)
3) Medical disease
4) Malnutrition (e.g., from poor dentition, malabsorption, dysphagia)
5) Psychiatric (e.g., mild cognitive impairment, dementia, depression, psychosis)
6) Changes in visual acuity
7) Changes in auditory acuity
8) Decreased mobility

Key objectives

Given a frail elderly patient, the candidate will diagnose the cause, severity, and complications, will conduct an
assessment of function and cognition, and will initiate an appropriate management plan that demonstrates an
awareness of the importance of a multidisciplinary approach.

Enabling objectives

Given a frail elderly patient, the candidate will

1) Obtain and interpret critical clinical findings, including

a. Complete psychosocial history (e.g., social supports, financial status);
b. Symptoms of medical disease, weight loss, and malnutrition;
c. Comprehensive medication history;
d. Screen for elder abuse and neglect;
e. Assessment of the impact of symptoms on activities of daily living;
f. Physical examination findings of malnutrition;
g. Mental status examination and cognitive function using a validated scale;
2) Construct an appropriate plan for further investigation that is supported by the history and physical
examination findings
3) Construct an effective initial multifactorial management plan, including but not limited to
a. Consultations (with medical specialists and other health professionals);
b. Non-pharmacological approaches to nutrition;
c. Pharmacological/medical;
i. Recommend interventions to target causes of morbidity;
ii. Outline changes to medications to improve symptoms and minimize adverse effects;
d. Community support services;
i. List services available to support elders in the community (e.g., home care services);

63
ii. Determine if the patient needs to be referred for counseling about financial concerns
or abuse.

64
31.2 Failure to thrive (infant, child)
Rationale

"Failure to thrive" is a term that describes the occurrence of growth failure in either height or weight during
childhood. It is essential to be able to identify different growth patterns and the potential associated causes.

Causal conditions (list not exhaustive)

1) Prenatal
a. Placental insufficiency
b. Intrauterine infections
c. Genetic
d. Maternal
i. Pre-existing conditions (e.g., diabetes, renal disease)
ii. Use of medications, drugs, tobacco, or alcohol
2) Postnatal
a. Inadequate calorie intake
i. Caregiver
1. Inadequate feeding skills
2. Inappropriate food for age
3. Neglect
4. Insufficient lactation
5. Disturbed mother and child relationship
ii. Infant
1. Sucking or swallowing dysfunction (e.g., cleft palate)
2. Chronic disease (e.g., infection, metabolic disorders)
b. Inadequate caloric absorption (e.g., gastroesophageal reflux)
c. Increased caloric requirements (e.g., hyperthyroid, congenital heart disease)
d. Social determinants (e.g., poverty, societal disorder)
e. Adverse childhood experience

Key objectives

Given an infant or child who is failing to thrive, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan. Special attention should be given to
psychosocial and environmental factors as well as disease entities giving rise to poor infant and child
maturation.

Enabling objectives

Given an infant or child with failure to thrive, the candidate will

1) List and interpret critical clinical findings, including

a. Plot growth parameters on a regular basis and recognize when a child or infant has failure to
thrive;
b. Perform a history and physical examination to determine the cause of the failure to thrive;
c. Identify possible social risk factors that may be responsible for failure to thrive;
2) Perform necessary investigations as appropriate
3) Construct an effective initial management plan, including
a. Construct an ongoing program to monitor the progress of such infants or children;
b. If appropriate, construct a counseling and education program for caregivers of infants or
children with poor growth;
c. Appropriately consult with other health professionals and/or community resources.

65
32 – FALLS
Rationale

Falls are common with many possible contributing factors. They can be associated with serious injury.
Multifactorial interventions can prevent falls and their sequelae.

Causal conditions (list not exhaustive)

1) Medical conditions (e.g., vertigo, gait disturbances, syncope)

2) Psychiatric conditions (e.g., cognitive impairment, substance abuse)
3) Medications
4) Environmental or behavioral risk factors (e.g., walking surface, choice of footwear)
5) Other contributors (e.g., decreased vision, urinary urgency)

Key objectives

Given a patient with a presenting complaint of falls, the candidate will identify contributing factors and initiate
an appropriate management and prevention plan. In particular, the candidate will recognize the patient who is
at risk of falling.

Enabling objectives

Given a patient at risk of falling, the candidate will

1) List and interpret critical clinical findings, including

a. A description of current and previous falls;
b. A medical history for risk factors (e.g., medical conditions, medication history, substance
abuse);
c. Environmental hazards;
d. A complete physical and functional evaluation;
2) List and interpret relevant investigations
3) Construct an effective initial management plan, including
a. Managing acute and chronic illness with particular attention to a review of medications;
b. Suggesting specific interventions for preventing further falls (e.g., balance/gait training, muscle
strengthening exercises);
c. Suggesting appropriate home safety interventions (e.g., removing environmental hazards, grab
bars, emergency response systems);
d. Appropriate consultation, including with medical specialists and other health professionals
(e.g., physiotherapist and occupational therapist, social worker, pharmacist).

66
33 – FATIGUE
Rationale

Fatigue is a common presenting complaint, particularly in primary care. However, many patients are not found
to have a specific disease process when fatigue is not accompanied by another more specific symptom.
Therefore, the key to making a diagnosis is taking a careful and detailed history, followed by an appropriate
physical examination and limited laboratory testing.

Although many disease processes may have fatigue as a symptom, the disorders listed here are those
characterized almost exclusively by fatigue as a predominant symptom.

Causal conditions (list not exhaustive)

1) Iatrogenic/pharmacologic
a. Hypnotic
b. Antihypertensives
c. Antidepressants
d. Substance abuse
2) Idiopathic
a. Idiopathic chronic fatigue
b. Chronic fatigue syndrome
c. Fibromyalgia
3) Other disease categories associated with fatigue
a. Psychiatric
b. Endocrine-metabolic
c. Cardiopulmonary
d. Infectious
e. Connective tissue disorders
f. Sleep disturbances (e.g. shift work)
g. Neoplastic-hematologic

Key objectives

Given a patient with fatigue, the candidate will perform a thorough and complete history and physical
examination in order to establish an underlying cause.

Enabling objectives

Given a patient with fatigue, the candidate will

1) List and interpret critical clinical findings, including

a. Features that are more likely associated with either a psychological or iatrogenic cause of
fatigue;
b. Results of a complete physical examination;
2) Critically select and interpret clinical investigations, recognizing that in the absence of localizing
features, tests may be of limited value;
3) Construct an effective initial management plan, including
a. Treating any underlying causes;
b. Outlining a plan of management that will help minimize the impact of fatigue on function and
quality of life if no underlying cause can be identified.

67
35 – ATAXIA (GAIT)
Rationale

Neurologic abnormalities of gait can result from disorders affecting several levels of the nervous system. The
type of abnormality observed clinically often indicates the site affected.

Causal conditions (list not exhaustive)

1) Cerebellar ataxia
a. Tumors
b. Vascular
c. Hereditary
d. Multiple sclerosis
e. Drugs
f. Alcohol
2) Sensory ataxia
a. Vestibular
b. Proprioceptive
c. Visual
3) Other disorders of locomotion
a. Other central nervous system (e.g., cerebral)
b. Parkinson's disease

Key objectives

Given a patient with a gait disturbance, the candidate will distinguish ataxia from other abnormalities. The
candidate will determine a localization, etiology, outcome, and complications, and will initiate an appropriate
management plan.

Enabling objectives

Given a patient with a gait disturbance, the candidate will

1) List and interpret critical findings, including

a. Appropriate history and physical examination to differentiate between ataxia and other causes
of gait abnormality, and to establish the localization and cause;
2) List and interpret critical investigations, including
a. Appropriate laboratory and diagnostic imaging investigations based on clinical findings;
3) Construct an effective initial management plan, including
a. Selection of patients in need of specific management or specialized care.

68
36 – GENETICS CONCERNS
Rationale

An individual's genetic make-up has an impact on their development, as well as their predisposition to disease.
Genetic variation and mutation may cause disease directly, or interact with various experiential and
environmental factors to influence development and medical conditions.

Causal conditions (list not exhaustive)

1) Chromosomal (e.g., aneuploidy, rearrangements)

2) Single-gene
a. Mendelian (e.g., autosomal dominant)
b. Non-Mendelian (e.g., mitochondrial, epigenetic)
3) Prenatal Exposure
a. Drugs or toxins (e.g., fetal alcohol spectrum disorder)
b. Infectious (e.g., congenital rubella)
c. Maternal disease (e.g., maternal diabetes)
4) Multifactorial (e.g., neural tube defects)

Key objectives

The candidate will recognize situations where a person or a population is at risk of a genetic or epigenetic
condition. Given a patient with evidence of, or a family history consistent with, a genetic or congenital
condition, the candidate will diagnose the cause, severity and complications, and will initiate an appropriate
management plan.

Enabling objectives

Recognize where disease in an individual might reflect the existence of risk factors inherent to a given
population (e.g., Tay-Sachs disease).

Given a patient presenting with clinical findings suggestive of a genetic etiology, the candidate will

1) List and interpret relevant clinical findings, including

a. Obstetrical, medical and family history, as well as ethnic or geographic origin and social
determinants of health;
b. Results of a physical examination of the patient and of selected family members, if need be;
2) List and interpret relevant laboratory and diagnostic imaging;
3) Construct an effective initial management plan, including, if required:
a. Genetic counselling;
b. Examination of reproductive options;
c. A referral for specialized evaluation, genetic testing, community resources, social and
psychological support services.

69
36.2 Congenital anomalies / dysmorphic features

Rationale

Congenital anomalies and dysmorphic features are often associated with long-term disability, making early
detection and identification vital. Although early involvement of pediatric or genetic specialists is appropriate,
primary care physicians are often required to contribute immediate care, and subsequently assist with long-term
management.

Causal conditions (list not exhaustive)

1) Teratogenic disorders (e.g., fetal alcohol spectrum disorder, congenital cytomegalovirus infections)
2) Genetic disorders (e.g., Down syndrome, fragile X syndrome)
3) Mechanical forces (e.g., constriction band syndrome)

Key objectives

Given a patient with congenital anomalies or dysmorphic features, the candidate will investigate the cause,
determine the severity of the immediate presentation, and will initiate an appropriate management plan.
Particular attention should be paid to the identification of patients requiring early referral for specialized care,
and to the provision of supportive counseling for parents.

Enabling objectives

Given a patient with congenital anomalies or dysmorphic features, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. An appropriate history with particular attention to any potential teratogenic exposures and
family history;
b. An appropriate physical examination, with particular attention to signs of severe anomalies
(e.g., cardiovascular malformations) to ambiguous genitalia as well as to recognizable
phenotypic patterns (e.g., Down syndrome);
2) List and interpret appropriate investigations (e.g., karyotype, screening for toxoplasmosis, rubella,
cytomegalovirus, herpes simplex, and human immunodeficiency virus [TORCH]);
3) Construct an effective initial management plan, including
a. Stabilization and immediate referral in case of hemodynamic instability;
b. Referral for specialized pediatric or genetic care, if necessary;
c. Referral for therapeutic services, counseling and family support groups, if indicated;
d. Provision of family support and counseling regarding recurrence risk, including discussion of
prenatal strategies for the prevention of recurrence, indications for antenatal screening and
diagnostic prenatal testing, and referral for genetic counseling, if indicated;

70
37 – GLUCOSE ABNORMAL, SERUM/ DIABETES /
POLYDIPSIA
37.1 Glucose abnormalities

Rationale

Maintenance of the blood sugar within normal limits is essential for health. In the short-term, hypoglycemia is
much more dangerous than hyperglycemia. Fortunately, both are uncommon clinical problems outside of
diabetes mellitus.

Causal conditions (list not exhaustive)

1) Hypoglycemia
a. Postprandial
b. Fasting
i. Secondary to overutilization of glucose (e.g., sulfonylureas)
ii. Secondary to impaired glucose production (e.g., adrenal insufficiency)
2) Hyperglycemia
a. Diabetes mellitus
b. Endocrine
c. Drugs

Key objectives

Given a patient with a glucose abnormality, the candidate will diagnose the cause, severity and complications,
and will initiate an appropriate management plan. Particular attention should be paid to management of
emergent situations, to prevention of progression of pre-diabetes, and to prevention of complications.

Enabling objectives

Given a patient with a glucose abnormality, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history and physical examination aimed at determining cause and
complications;
b. Differentiation of true hypoglycemia from pseudohypoglycemia;
2) List and interpret critical investigations, including
a. Laboratory and radiological examinations (e.g., glucose tolerance test);
3) Construct an effective management plan for hyper- or hypoglycemia, including
a. Counselling and educating the patient on preventive measures;
b. Providing emergent treatment;
c. Determining whether the patient requires specialized care;
d. Referring the patient to appropriate support services, including lifestyle and psychosocial
support.

71
37.2 Diabetes Mellitus

Rationale

Diabetes mellitus is an increasingly common multi-system disease associated with a relative or absolute
impairment of insulin secretion together with varying degrees of peripheral resistance to the action of insulin.

Causal conditions (list not exhaustive)

1) Type 1
a. Autoimmunity
b. Idiopathic
2) Type 2
a. Obesity
b. Other (e.g., genetic predisposition, medications)
3) Gestational diabetes mellitus

Key objectives

Given a patient with diabetes mellitus, the candidate will diagnose the cause, severity and complications, and
will initiate an appropriate management plan. Particularly important are early detection of the disease, and
recognition of medical emergencies such as acute hypoglycemia, diabetic ketoacidosis, and hyperosmolar
nonketotic coma.

Enabling objectives

Given a patient with diabetes mellitus, the candidate will

1) List and interpret critical clinical findings, including

a. History and physical examination aimed at identifying
i. long-term complications;
ii. secondary causes;
iii. risk factors;
2) List and interpret critical investigations, including
a. Laboratory and radiological for monitoring and emergent situations;
3) Construct an effective management plan, including
a. Education and counselling (e.g., lifestyle modifications, management of risk factors, intensive
glycemic control);
b. Prevention and management of emergent situations (e.g., hypoglycemia);
c. Prevention and management of complications (e.g., diabetic nephropathy, retinopathy);
d. Determining whether the patient requires specialized care and/or referral to other health care
professionals.

72
38 – SKIN AND INTEGUMENT CONDITIONS
Rationale

Skin disorders (including rashes, tumors and ulcers) are among the most common reasons for seeking medical
attention from primary care physicians and specialists such as dermatologists. Integument conditions (including
hair and nails) are also common. These disorders can be due to local diseases or may indicate an underlying
systemic condition. Patients who are affected can present with psychological distress.

Causal conditions (list not exhaustive)

1) Rashes
a. Macular
b. Papular
c. Vesiculobullous
d. Pustular
2) Tumours
a. Benign
b. Premalignant
c. Malignant (e.g., melanoma)
3) Ulcers
a. Vascular
b. Infectious
c. Autoimmune
d. Pressure ulceration
e. Tumours
f. Toxic
4) Nail presentations
a. Local nail problems
b. Associated with an underlying condition
5) Hair presentations
a. Alopecia
i. Scarring
ii. Non-scarring
b. Hirsutism
c. Hypertrichosis

Key objectives

Given a patient with a skin or an integument condition, the candidate will diagnose the cause, severity and
complications, and will initiate an appropriate management plan. In particular, it is important to determine
whether a condition is benign, malignant or associated with an underlying systemic condition.

Enabling objectives

Given a patient with a skin or an integument condition, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. An appropriate history (e.g., drug and medical history);
b. A general physical examination and an assessment of the skin characteristics (e.g., morphology
and distribution);
2) List and interpret critical investigations, including
a. Those which differentiate benign from more serious disorders (e.g., biopsy, fungal scraping);

73
 b. Further investigations, as required (e.g., diagnostic imaging or laboratory tests);
3) Construct an effective management plan, including
a. Prescribe an appropriate topical and/or systemic therapy;
b. Refer if appropriate;
c. Offer counselling and education, including prevention of future skin conditions (e.g., sun
exposure).

74
39 – HEADACHE
Rationale

Headache is a common clinical presentation. Patients with headaches due to serious or life-threatening
conditions must be differentiated from those with benign primary headache disorders.

Causal conditions (list not exhaustive)

1) Primary headache (e.g., migraine, chronic daily headache with medication overuse)
2) Secondary headache
a. Associated with vascular disorders (e.g., severe arterial hypertension)
b. Associated with non-vascular disorders (e.g., intracranial infection)
c. Other (e.g., systemic viral infection, carbon monoxide exposure)

Key objectives

Given a patient with headaches, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to differentiating benign causes of
headaches from potentially serious causes.

Enabling objectives

Given a patient with headaches, the candidate will:

1) List and interpret critical clinical findings, including

a. Symptoms and signs that indicate a need for urgent brain imaging and/or referral for
specialized care;
b. Symptoms and signs to differentiate amongst the various causes of headaches;
2) List and interpret critical investigations, including
a. Appropriate and cost-effective laboratory and diagnostic imaging tests;
b. Indications and contraindications for lumbar puncture;
3) Construct an effective management plan, including
a. Describing and contrasting symptomatic and prophylactic treatments;
b. Avoiding medication overuse;
c. Determining if the patient needs urgent and/or specialized care;
d. Educating and counseling the patient regarding the causes and management of headaches;
e. Determining if the patient is at risk for narcotic addiction or overuse.

75
40 – HEARING LOSS
Rationale

Hearing loss is common and may often be prevented. The underlying causes may often be treated.

Causal conditions (list not exhaustive)

1) Conductive hearing loss

a. External ear pathology
i. Congenital (e.g., atresia)
ii. Inflammation or infection (e.g., otitis externa)
iii. Obstruction of canal (e.g., wax, foreign body)
b. Middle ear pathology
i. Congenital (e.g., atresia)
ii. Infection (e.g., otitis media)
iii. Ossicular pathology (e.g., otosclerosis)
iv. Trauma (e.g., tympanic membrane perforation)
v. Tumors (e.g., glomus, adenoma)
2) Sensory-neural hearing loss
a. Acquired (e.g., presbycusis, noise-induced hearing loss)
b. Congenital (e.g., Alport syndrome)

Key objectives

Given patients with hearing loss or deafness, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. Particular attention should be paid to differentiating between
conductive and sensory-neural hearing loss. Patients should be educated and counseled regarding prevention of
further hearing loss. Hearing loss in infants must be identified as early as possible to prevent delayed
development.

Enabling objectives

Given patients with hearing loss or deafness, the candidate will

1) List and interpret critical clinical findings, including those based on

a. An evaluation of potential risks for further hearing loss;
b. An early identification of hearing loss or deafness in infants and children;
2) List and interpret critical investigations, including
a. Screening in all neonates;
b. Tests required to differentiate between conductive and sensorineural hearing loss, where
appropriate;
3) Construct an effective initial management plan, including
a. Referring the patient for specialized care, if necessary;
b. Counselling and educating the patient regarding prevention of further hearing loss;
c. Following-up on a patient with otitis media, selecting antibiotics if appropriate;
d. Anticipating psychosocial effects of chronic hearing loss.

76
41 – CEREBROVASCULAR ACCIDENT AND TRANSIENT
ISCHEMIC ATTACK (STROKE)
Rationale

Transient ischemic attack (TIA) and cerebrovascular accident (CVA) consist in the acute loss of arterial blood
flow to a part of the brain or brainstem, resulting in temporary or permanent loss of function.

TIA and CVA are among the most common causes of death and disability in Canada. Lifestyle and risk factor
modifications are ways of preventing these disorders, which can be treated with urgent medical or surgical
intervention in some cases.

Causal conditions (list not exhaustive)

1) Ischemia
a. Thrombotic
b. Embolic
2) Hemorrhage
a. Intracerebral and cerebellar
b. Subarachnoid

Key objectives

Given a patient with acute neurological deficits (e.g., aphasia, amaurosis fugax), the candidate will obtain an
appropriate history and perform a physical examination leading to the possible diagnosis of TIA or CVA, and
take action. The candidate will recognize the need for preventive health care in order to decrease the risk of
TIA or CVA. Enabling Objectives

Enabling objectives

Given a patient with risk factors for a TIA or CVA, the candidate will

1. List and interpret critical clinical findings, including results of a history and physical examination aimed
at detecting an early pathology (e.g., bruits, hypertension) that is treatable or correctable.

Given a patient with acute, intermittent or chronic neurological deficits, the candidate will

1) List and interpret critical clinical findings, including results of a history and physical examination aimed
at determining whether TIA or CVA is a possible cause;
2) List and interpret critical investigations, including
a. Imaging (e.g., computed tomography);
b. Laboratory testing (e.g., lipid profile);
3) Construct an effective management plan, including
a. Proceeding with acute or chronic medical and surgical interventions (e.g., blood pressure
control);
b. Referring for specialized services (e.g., rehabilitation, speech-language therapy);
c. Anticipating medium and long-term complications (e.g., psychosocial impact, safety).

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42 – HEMOGLOBIN SERUM, ABNORMAL
42.1 Anemia

Rationale

Anemia is a common problem; however, making the diagnosis may be complex. Anemia may be the sole
manifestation of serious medical disease.

Causal conditions (list not exhaustive)

1) Normocytic
a. Red blood cell loss
i. Obvious (e.g., trauma, metro/menorrhagia)
ii. Occult
b. Decreased red blood cell production
i. Marrow production (e.g., stem cell disorder, bone marrow replacement)
c. Increased destruction (e.g., sickle cell anemia, immune-mediated, mechanical)
d. Multi-factorial (e.g., anemia of chronic disease)
2) Microcytic (e.g., iron deficiency, hemoglobinopathies)
3) Macrocytic (e.g., vitamin B12 or folate deficiency, alcohol use)

Key objectives

Given a patient with anemia, the candidate will diagnose the cause, severity, and complications, and will initiate
an appropriate management plan. Particular attention should be paid to red cell morphology, identification of
common causes in specific patient populations, and risk factors for serious underlying conditions.

Enabling objectives

Given a patient with anemia, the candidate will

1) List and interpret critical clinical findings, including

a. Common causes in specific patient populations;
b. Risk factors for or features suggestive of serious underlying conditions;
2) List and interpret critical investigations, including
a. Red cell morphology;
b. Specific investigations according to red cell morphology and history and physical findings;
3) Construct an effective initial management plan, including
a. Counselling and educating the patient for prevention of recurrence or further complications;
b. Referral for specialized care (e.g., suspicion of colon cancer), if necessary.

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42.2 Elevated hemoglobin

Rationale

Elevated hemoglobin levels may be a manifestation of polycythemia Vera or secondary erythrocytosis. Elevated
hemoglobin levels may be due to many treatable causes. Unrecognized polycythemia may cause end-organ
damage.

Causal conditions (list not exhaustive)

1) Red cell mass increased

a. Polycythemia Vera - low or normal erythropoietin (EPO)
b. Secondary erythrocytosis - elevated EPO
i. Appropriate EPO elevation (e.g., hypoxemia)
ii. Inappropriate EPO elevation (e.g., EPO secreting tumor)
c. Relative polycythemia (decreased plasma volume)

Key objectives

Given a patient with elevated hemoglobin levels, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan

Enabling objectives

Given a patient with elevated hemoglobin level, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiating between primary and secondary erythrocytosis;
b. Assessing the presence of complications;
2) List and interpret critical investigations, including
a. Appropriate laboratory and diagnostic imaging;
3) Construct an effective initial management plan, including
a. Referring the patient for specialized care, if necessary;
b. Counselling and education (e.g., smoking cessation, work environment).

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44 – LANGUAGE AND SPEECH DISORDERS
Rationale

It is important to differentiate speech from language abnormalities. Patients with impairment in comprehension
and/or use of the form, content, or function of language are said to have a language disorder. Patients with
impaired articulation, fluency and voice are said to have a speech disorder.

Causal conditions (list not exhaustive)

1) Language disorder
a. Delayed and developmental language impairment (e.g., deafness, autism spectrum disorder,
neglect, abuse)
b. Degenerative, vascular, or other central nervous system disorders (e.g., stroke)
c. Head injury
2) Speech disorder
a. Articulation disorder (e.g., dysarthria)
b. Fluency (e.g., stuttering, Parkinson disease)
c. Speech apparatus lesions (e.g., cleft palate, head and neck neoplasm)

Key objectives

Given a patient with a language or speech disorder, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan. Particular attention should be paid to
differentiating language from speech disorders.

Enabling objectives

Given a patient with a language or speech disorder, the candidate will

1) List and interpret critical clinical findings, including

a. Assessment of hearing in a child;
b. Evidence of malignancy;
c. Results of an appropriate neurological examination;
2) List and interpret critical investigations (e.g., hearing tests)
3) Construct an effective initial management plan, including
a. Referring the patient for specialized care with appropriate health care professionals (e.g.,
speech therapist, ear, nose, and throat surgeon), if necessary;
b. Counselling and educating the patient and/or family, particularly regarding the psychosocial
impact on function.

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 45 – ACID-BASE ABNORMALITIES, HYDROGEN
Rationale

Abnormally high or low hydrogen ion concentration - acidemia and alkalemia, respectively - is encountered
relatively frequently, particularly in hospital-based practice. Acidemia, in particular, may be caused by an
underlying life-threatening condition. Several acid-base abnormalities can coexist in a single patient.

Causal conditions (list not exhaustive)

1) Metabolic acidosis
a. High anion gap
i. Increased acid production
1. Exogenous (e.g., methanol)
2. Endogenous acids (e.g., ketoacidosis)
ii. Decreased renal acid excretion (kidney injury)
b. Normal anion gap
i. Gastrointestinal bicarbonate loss (e.g., diarrhea)
ii. Renal bicarbonate loss (e.g., renal tubular acidosis, interstitial nephritis)
2) Metabolic alkalosis
a. Expanded effective arterial blood volume (e.g., mineralocorticoid excess)
b. Contracted effective arterial blood volume
i. Gastrointestinal loss (e.g., vomiting)
ii. Renal loss (e.g., diuretics)
c. Exogenous ingestion
3) Respiratory acidosis
a. Neuromuscular causes (e.g., medications, illicit drugs)
b. Pulmonary causes of decreased alveolar ventilation (e.g., chronic obstructive pulmonary
disease)
c. Kyphoscoliosis
d. Hypoventilation (e.g., due to obesity)
4) Respiratory alkalosis
a. Hypoxemia
b. Metabolic (e.g., hepatic failure)
c. Cardio-pulmonary disorders (e.g., pneumonia, embolism)
d. Central nervous system disorders (e.g., subarachnoid hemorrhage)
e. Drugs (e.g., salicylate)
f. Miscellaneous (e.g., fever, pain, pregnancy)

Key objectives

Given a patient with an acid-base abnormality, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan, particularly when dealing with a high anion
gap metabolic acidosis.

Enabling objectives

Given a patient with an acid-base abnormality, the candidate will

1) Through efficient, focused, data gathering, diagnose cause of acidemia/alkalemia expeditiously

2) List and interpret critical clinical and laboratory findings which were key in the processes of exclusion,
differentiation, and diagnosis:

81
 a.Appropriate investigations for acidemia/alkalemia in order to identify the primary abnormality
and the adequacy of the associated secondary compensation;
3) Construct an effective initial plan of management for acidemia/alkalemia
a. Describe general supportive measures;
b. Describe management for specific acid-base disorders;
c. Determine if the patient needs to be referred for consultation.
d.

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46 – INFERTILITY
Rationale

Infertility is a common condition that is defined as the inability of a couple to conceive after one year of
intercourse without contraception. Both partners must be investigated.

Causal conditions (list not exhaustive)

1) Female
a. Ovulatory dysfunction (e.g., hypogonadotropic hypogonadism, polycystic ovarian syndrome)
b. Tubal and peritoneal abnormalities (e.g., pelvic inflammatory disease [PID])
c. Uterine and cervical factors (e.g., fibroids)
2) Male
a. Testicular dysfunction (e.g., hypogonadotropic hypogonadism, viral orchitis)
b. Post-testicular dysfunction (e.g., abnormal sperm transport)

Key objectives

Given a couple with infertility, the candidate will diagnose the cause and complications, and will explain the
therapeutic options.

Enabling objectives

Given a couple with infertility, the candidate will

1) List and interpret critical clinical findings, including those derived from an appropriate history and
physical examination of both partners;
2) List and interpret critical investigations, including
a. Semen analysis;
b. Tests confirming ovulation;
c. Other laboratory tests (e.g., prolactin, thyroid-stimulating hormone);
3) Construct an effective initial management plan, including
a. Counselling the couple regarding preconceptual use of folic acid;
b. Counselling and educating the couple regarding diagnostic and therapeutic options;
c. Determining whether either patient requires specialized care;
d. Recommending changes to the workplace environment, if indicated;
e. Providing counselling regarding psychosocial stresses, if indicated.

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47 – INCONTINENCE
47.1 Fecal incontinence

Rationale

Fecal incontinence varies from inadvertent soiling with liquid stool to the involuntary excretion of feces. This
disability has a profoundly negative impact on patient quality of life by virtue of diminished patient self-
assuredness and social isolation.

Causal conditions (list not exhaustive)

1) Pelvic floor intact

a. Neurologic conditions
b. Overflow (e.g., impaction)
2) Pelvic floor affected
a. Acquired (e.g., traumatic birth)
b. Congenital

Key objectives

Given a patient with fecal incontinence, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, the candidate will recognize that incontinence can
be multifactorial (for instance patients with significant diarrhea/fecal urgency of any cause with subsequent
incontinence due to a disease affecting cognition or mobility, or due to a relative defect in pelvic floor that is
overwhelmed by the diarrhea).

Enabling objectives

Given a patient with fecal incontinence, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination, including an obstetrical history;
2) List and interpret critical investigations, including
a. Further investigations of the diarrhea, if indicated;
b. Further studies, such as stool analysis, endorectal ultrasound, colonoscopy, sigmoidoscopy,
anoscopy, anorectal manometry, and functional testing, if indicated;
3) Construct an effective management plan, including anticipation of psychosocial impact.

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47.2 Urinary incontinence, adult

Rationale

Incontinence has increased in frequency as our population ages. Incontinence has a detrimental effect on
quality of life and an impact on physical and psychological health.

Causal conditions (list not exhaustive)

1) Transient
a. Polyuria
b. Impaired ability/willingness to reach toilet
c. Medications, alcohol
2) Neurologic (e.g., cauda equina syndrome)
3) Anatomic
a. Stress incontinence
b. Urgency incontinence (e.g., cystitis)
c. Overflow incontinence (e.g., prostate enlargement, multiple sclerosis)

Key objectives

Given a patient with urinary incontinence, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan, in particular addressing the two most common causes (stress
and urgency).

Enabling objectives

Given a patient with urinary incontinence, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination including pelvic, rectal, and neurological
examination;
2) List and interpret critical laboratory investigations, including
a. Urinalysis and culture;
3) Construct an effective initial management plan, including
a. A plan for cystitis and urethritis;
b. Counselling of patients regarding therapeutic and surgical options (e.g., anticholinergic
medication for urgency incontinence), and psychosocial impact;
c. Making an appropriate referral (e.g., for an incontinence program), if need be.

85
47.3 Urinary incontinence, children / Enuresis

Rationale

Enuresis is the involuntary passage of urine in a child. The majority of children with enuresis have primary
nocturnal enuresis. Daytime and secondary enuresis are much less common, but require differentiating between
underlying diseases and stress-related conditions.

Causal conditions (list not exhaustive)

1) Primary enuresis (e.g., family history)

2) Secondary enuresis (e.g., urinary tract infection, vesicoureteral reflux)

Key objectives

In a child five years of age or older, determine whether a physical abnormality is causing the involuntary
passage of urine.

Enabling objectives

Given a patient with enuresis, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination to
i. Determine whether medical reasons underlie the enuresis;
ii. Determine whether a stressful event preceded the occurrence of enuresis (e.g., birth
of a sibling);
2) List and interpret critical clinical and laboratory findings, including
a. Urinalysis and urine culture;
3) Construct an effective management plan, including
a. Counselling, education, and reassurance of the parents of a child with primary nocturnal
enuresis, including treatment options;
b. Counselling and reassurance of the child to improve self-esteem;
c. In the case of secondary enuresis, treatment of the underlying cause;
d. Determining if the patient needs to be referred to a specialist.

86
48 – ERECTILE DYSFONCTION
Rationale

Erectile dysfunction is present when an erection of sufficient rigidity for sexual intercourse cannot be acquired
or sustained more than 75% of the time. It has a major impact on relationships.

Causal conditions (list not exhaustive)

1) Neurologic (e.g., diabetes mellitus)

2) Cardiovascular
3) Pharmacologic (e.g., alcohol)
4) Hormonal (e.g., testosterone deficiency)
5) Psychological or emotional (e.g., performance anxiety)
6) Chronic systemic disease (e.g., kidney injury)

Key objectives

Given a patient with erectile dysfunction, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan.

Enabling objectives

Given a patient with erectile dysfunction, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination, in particular to
i. Determine if there is an organic or psychological cause;
ii. Identify reversible causes (e.g., medications);
2) List and interpret critical investigations, including
a. Laboratory investigations (e.g., testosterone, blood glucose, thyroid hormone);
3) Construct an effective initial management plan, including
a. Determine the therapy based on the underlying cause;
b. Treat associated medical conditions;
c. Suggest lifestyle changes (e.g., weight loss);
d. Describe the indications and contraindications for inhibitors of phosphodiesterase type v and
other drugs and devices;
e. Determine if the patient needs to be referred for specialized care;
f. Counsel and educate the patient (and/or partner, as appropriate).
g.

87
49 – JAUNDICE
Rationale

Jaundice, which has both a biochemical (elevated bilirubin) and clinical (evidence of scleral icterus) definition, is
a common condition with many causes. In some cases, early diagnosis and treatment is important for eventual
desirable outcome. In certain cases, public health issues may need to be addressed.

Causal conditions (list not exhaustive)

1) Unconjugated hyperbilirubinemia (pre-hepatic)

a. Overproduction (e.g., hemolysis)
b. Decreased hepatic uptake (e.g., congestive heart failure)
c. Decreased bilirubin conjugation (e.g., Gilbert syndrome, neonatal jaundice)
2) Conjugated hyperbilirubinemia (hepatic)
a. Intrahepatic cholestasis (e.g., drugs, cirrhosis)
b. Extrahepatic cholestasis (e.g., cholelithiasis)
c. Hepatocellular injury (e.g., sepsis, hypoperfusion)
d. Other (e.g., infiltrative states, fatty liver)

Key objectives

Given a patient with jaundice, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, it is important to identify life-threatening conditions.

Enabling objectives

Given a patient with jaundice, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history and physical examination aimed at determining the
underlying cause, with special attention to the presence of risk factors for infectious disease
and the use of or the exposure to toxic substances;
2) List and interpret critical investigations, including
a. Radiologic and laboratory tests needed to make the diagnosis;
3) Construct an effective initial management plan, including
a. Determining whether the patient requires specialized care or an urgent referral
b. Notifying public health authorities, if necessary.

88
49.1 Neonatal jaundice

Rationale

Jaundice, usually mild unconjugated bilirubinemia, affects many newborns. Although most cases are
physiological, some are indicative of serious underlying disorders.

Causal conditions (list not exhaustive)

1) Unconjugated hyperbilirubinemia
a. Increased bilirubin production
i. Hemolytic causes (e.g., Coombs positive, Coombs negative)
b. Decreased bilirubin conjugation
i. Metabolic or genetic (e.g., Gilbert syndrome, hypothyroidism)
ii. Physiologic (e.g., breast milk jaundice)
c. Gastrointestinal (e.g., sequestered blood)
2) Conjugated hyperbilirubinemia
a. Decreased bilirubin uptake
i. Infections (e.g., sepsis, neonatal hepatitis)
ii. Cholestasis (e.g., total parenteral nutrition)
iii. Metabolic
iv. Genetic
b. Obstructive (e.g., biliary atresia)

Key objectives

Given a patient with neonatal jaundice, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. Particular attention should be paid to jaundice which presents
within the first three days after birth or with a rapid onset.

Enabling objectives

Given a patient with neonatal jaundice, the candidate will

1) List and interpret critical clinical findings, including

a. Determining whether the neonate meets the criteria for treatment of physiologic jaundice;
b. Identifying features of serious underlying disorders;
2) List and interpret critical investigations, including
a. Those investigations which differentiate disorders associated with conjugated or unconjugated
hyperbilirubinemia;
3) Construct an effective initial management plan, including
a. Monitoring and managing physiologic jaundice;
b. Referring the patient to appropriate specialists in the case of non-physiologic jaundice;
c. Counselling and reassuring parents, as appropriate.

89
50 – JOINT PAIN
50.1 Oligoarthralgia (pain in one to four joints)

Rationale

Acute joint pain may reflect an urgent process that needs immediate evaluation and treatment to prevent
permanent damage and loss of function. Chronic pain in a small number of joints is very common, and a very
frequent cause of disability.

Causal conditions (list not exhaustive)

1) Acute joint pain

a. Injury (e.g., meniscal tear)
b. Infection
c. Crystal
d. Hemarthrosis (e.g., clotting disorder)
e. Acute reactive arthritis
2) Chronic joint pain
a. Osteoarthrosis
b. Periarticular disease (e.g., bursitis, tendonosis)
c. Pediatric disorders (e.g., slipped epiphysis, Osgood-Schlatter)
3) Non-articular disease (e.g., bone malignancy, leukemia)

Key objectives

Given a patient with musculoskeletal pain that is localized, the candidate will be able to differentiate joint
disease from other anatomic causes, and through history and physical examination determine the acuity and
severity of the problem. In particular, the candidate will determine if the patient requires immediate, definitive
management, or referral.

Enabling objectives

Given a patient with joint pain, the candidate will

1) List and interpret critical clinical findings, including

a. Whether the joint, or other tissues, is the source of the pain;
b. Whether the underlying cause is traumatic, inflammatory or mechanical;
c. Whether urgent investigation is required;
d. Impact on function;
e. An occupational and recreational history;
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations and other tests;
b. Determination as to when joint aspiration is required, and prescription of the appropriate
investigations (e.g., culture, cell count, crystals);
c. Determination as to when appropriate radiologic investigations are required;
d. Determination as to when other investigations are indicated (other cultures, magnetic
resonance imaging);
3) Construct an effective management plan, including
a. Initial management of common inflammatory conditions (e.g., gout, infection);
b. Initial management of common injuries (e.g., sprains);
c. Referral for specialized care, if indicated (e.g., orthopedic surgery);

90
d. counselling regarding appropriate return to activities and recognition of the potential for long-
term impact on function.

91
50.2 Polyarthralgia (pain in more than four joints)

Rationale

Chronic pain in or around multiple joints is often the presenting symptom of common, disabling diseases,
responsible for a great burden of suffering, loss of function and morbidity. Many of these patients may benefit
from early diagnosis and treatment.

Causal conditions (list not exhaustive)

1) Inflammatory joint pain (e.g., rheumatoid arthritis, juvenile polyarthritis)

2) Mechanical joint pain (e.g., osteoarthritis)
3) Non-articular disease (e.g., fibromyalgia, polymyalgia rheumatica)

Key objectives

Given a patient with widespread musculoskeletal pain, the candidate will be able to differentiate true joint
disease from other causes, and through history and physical exam determine the acuity and severity of the
problem. In particular, the candidate will determine if the disease is inflammatory or not, and initiate
appropriate treatment or referral.

Enabling objectives

Given a patient with joint pain, the candidate will

1. List and interpret critical clinical findings, including

1. Determining, based on the history and physical examination, whether it is an articular problem
and, if so, if it is inflammatory or mechanical;
2. Determining, based on the history and physical examination, whether there are other features
that help make a more definitive diagnosis (e.g., rheumatoid nodules);
3. Impact on function;
2. List and interpret critical investigations, including
1. Appropriate laboratory investigations and other tests (e.g., radiology, erythrocyte
sedimentation rate, anti-CCP [anti-cyclic citrullinated peptide]);
3. Construct an effective management plan, including
1. Immediate treatment of urgent conditions (e.g., polymyalgia rheumatica);
2. Immediate symptomatic and supportive treatment (e.g., anti-inflammatories);
3. Appropriate referral for more specialized care (e.g., rheumatology, physiotherapy), if
indicated;
4. Counseling regarding appropriate return to activities.

92
 50.3 Non-articular musculoskeletal pain
Rationale

Non-articular musculoskeletal pain, though common, is rarely due to life-threatening or damaging conditions.
Often referred to as "soft tissue" pain, it is a common cause for concern, which frequently prompts those
affected to seek medical advice.

Causal conditions (list not exhaustive)

1) Generalized Pain
a. Acute pain (e.g., viral infections)
b. Chronic pain (e.g., fibromyalgia, polymyalgia rheumatica)
2) Localized Pain
a. Acute
i. Trauma (see also Fractures and Dislocations)
ii. Infection (e.g., osteomyelitis, necrotizing fasciitis)
iii. Vascular (e.g., compartment syndrome, sickle cell disease)
b. Chronic
i. Mechanical (e.g., tendonopathy, bursitis)
ii. Vascular (e.g., intermittent claudication)
iii. Neoplastic
iv. Neuropathic
v. Complex regional pain syndrome

Key objectives

Given a patient with musculoskeletal pain, the candidate will be able to differentiate symptoms arising from
bone, joint, muscle, nerve or vascular causes. The candidate will be able to further classify the likely underlying
pathology and determine if urgent action is required.

Enabling objectives

Given a patient with musculoskeletal pain, the candidate will

1) list and interpret critical clinical findings, including
a. likely anatomic and pathogenic pain mechanisms;
b. determining whether the pain represents a problem requiring urgent or immediate
investigation;
c. trigger, if any;
d. impact on function;
e. occupational and recreational history;
2) list and interpret critical investigations, including appropriate laboratory investigations and other tests
a. initial investigations (e.g., radiographs);
b. further or specialized investigations (e.g., Doppler ultrasound, magnetic resonance imaging,
nerve conduction studies), if indicated;
3) construct an effective management plan, including
a. beginning urgent or acute management of serious problems;
b. providing patient education and counselling regarding self-limited or benign conditions;
c. providing counselling regarding appropriate return to activities;
d. referring for specialized care, if necessary.

93
50.4 Back pain and related symptoms

Rationale

Lower back pain is extremely common, and, in most cases, does not require investigation. However, there are
patients presenting with back pain, or signs of nerve compression due to back pathology, who require specific
diagnosis and management to ensure good outcome.

Causal conditions (list not exhaustive)

1) Mechanical back problems

a. Common back pain
b. Acute, discogenic nerve root entrapment
c. Spinal Stenosis and/or cauda equina syndrome
2) Inflammatory arthritis (e.g., ankylosing spondylitis)
3) Infections
4) Fracture
5) Neoplasm
6) Others (e.g., referred pain)

Key objectives

Given a patient with back pain, the candidate will be able to determine whether the patient must undergo
further tests and specific management. In particular, the candidate will determine if the patient requires urgent
intervention.

Enabling objectives

Given a patient with back pain, the candidate will

1) List and interpret critical clinical findings, including

a. Features from the history and the physical examination that suggest the need for urgent
investigation or management (e.g., urinary incontinence, fever);
b. Impact on function;
c. An occupational and recreational history;
d. Determination as to whether the patient requires further investigation or not;
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations and other tests (e.g., computerized tomography or
magnetic resonance imaging, if indicated);
3) Construct an effective management plan, including
a. Ensuring initial management of urgent problems, including appropriate referral for specialized
care;
b. Counseling and educating the patient about appropriate exercise and return to work;
c. Recognizing the potential for long-term impact on function;
d. Prescribing medications in a safe and effective manner, if necessary (e.g., nonsteroidal anti-
inflammatory drugs, opiates).

94
50.5 Neck pain

Rationale

Neck pain is extremely common, and, in most cases, does not require investigation. However, there are patients
presenting with pain, or signs of nerve compression, who require specific diagnosis and management to ensure
good outcome. Neck pain may also be due to non-musculoskeletal causes.

Causal conditions (list not exhaustive)

1) Mechanical problems
a. Neck strain
b. Spondylosis
c. Acute, discogenic nerve root entrapment
d. Spinal stenosis and/or cord compression
2) Inflammatory arthritis (e.g., ankylosing spondylitis)
3) Infections
4) Fracture
5) Neoplasm
6) Pain from soft tissue structures (e.g., thyroid, pharynx)

Key objectives

Given a patient with neck pain, the candidate will be able to determine whether the patient must undergo
further tests and specific management. In particular, the candidate will determine if the patient requires urgent
intervention.

Enabling objectives

Given a patient with neck pain, the candidate will

1) List and interpret critical clinical findings, including

a. Features on history and physical examination that suggest the need for urgent investigation or
management (e.g., in case of neurologic abnormalities or fever);
b. Data from a patient-centered pain history, including the impact on function;
c. Occupational and recreational history;
d. Determination as to whether any further investigation is required or not;
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations and other tests (e.g., computed tomography or magnetic
resonance imaging, if indicated)
3) Construct an effective management plan, including
a. Ensuring initial management of urgent problems, including appropriate referral for specialized
care
b. Counseling and educating the patient about appropriate exercise and return to work.
c. Recognizing the potential for long-term impact on function;
d. Prescribing medications in a safe and effective manner, if necessary (e.g., nonsteroidal anti-
inflammatory drugs, opiates).

95
51 – ABNORMAL SERUM LIPIDS
Rationale

Hypercholesterolemia is a common and important modifiable risk factor for ischemic heart disease,
cerebrovascular disease and peripheral vascular disease. Determination of levels is usually based upon
concomitant risk factors.

Causal conditions (list not exhaustive)

1) Hypercholesteremia (elevated low-density lipoprotein, lipoprotein (a))

a. Primary causes
i. Familial combined hyperlipidemia
ii. Polygenic
iii. Familial hypercholesterolemia
b. Secondary causes
i. Endocrine (e.g., diabetes mellitus, hypothyroidism)
ii. Cholestatic liver disease
iii. Nephrotic syndrome, chronic kidney injury
iv. Other
1. Cigarettes
2. Obesity
3. Drugs (e.g., steroids)
2) Hypertriglyceridemia
a. Primary causes (familial hypertriglyceridemia)
b. Secondary causes
i. Obesity
ii. Diabetes mellitus
iii. Nephrotic syndrome, chronic kidney injury
iv. Drugs (e.g., estrogen)
v. Alcohol
3) Low high-density lipoprotein
a. Primary
b. Secondary
i. Obesity
ii. Drugs (e.g., anabolic steroids)
iii. Metabolic syndrome

Key objectives

Given a patient with abnormal serum lipids, the candidate will diagnose the cause, severity, and complications.
In particular, the candidate will identify those patients who will benefit from serum cholesterol reduction, as
well as both primary and secondary prevention.

Enabling objectives

Given a patient with abnormal serum lipids, the candidate will

1) list and interpret critical clinical findings, including

a. perform a history and physical examination to identify patients with remediable causes for
their lipid abnormalities (e.g., hypothyroidism);
b. select patients at highest risk for subsequent development of ischemic heart disease for drug
therapy (e.g., Framingham risk calculation);

96
2) list and interpret critical investigations, including
a. further laboratory testing to identify patients with remediable causes for their lipid
abnormalities;
3) construct an effective initial management plan, including
a. recommend lifestyle modification and pharmacologic therapy as appropriate;
b. discuss risks and benefits of primary versus secondary prophylaxis with lipid-lowering drugs;
c. select patients in need of specialized care.

97
52 – ABNORMAL LIVER FUNCTION TESTS
Rationale

Abnormal liver function tests are common in clinical practice. Appropriate investigation can distinguish benign
reversible liver disease from potentially life-threatening conditions.

Causal conditions (list not exhaustive)

1) Hepatocellular
a. Acute (e.g., infection, medication)
b. Chronic (e.g., infection, medication)
2) Cholestatic
a. Intrahepatic (e.g., pregnancy)
b. Extrahepatic (e.g., gallstones)
3) Congenital abnormalities (e.g., Gilbert disease)
4) Other (e.g., celiac disease)

Key objectives

Given a patient with abnormal liver function tests, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan, in particular, assessing for any potential
underlying liver disorder or systemic disease.

Enabling objectives

Given a patient with abnormal liver function tests, the candidate will

1) List and interpret critical clinical findings, including

a. Differentiate between abnormal liver function tests due to disease that require treatment from
those that do not;
b. Differentiate primary hepatic disease from systemic disease;
c. Identify complications related to the presence of liver disease (e.g., bleeding, ascites);
2) List and interpret critical investigations, including
a. Laboratory tests appropriate for the identification of specific acute and chronic liver diseases
(e.g., viral serology);
b. Diagnostic imaging (e.g., ultrasound);
3) Construct an effective initial management plan, including
a. Determining if the patient requires urgent referral or hospitalization;
b. Referring the patient for specialized care (e.g., non-urgent), if necessary;
c. Counseling and educating the patient to prevent further hepatic insult (e.g., primary and
secondary prevention strategies for viral hepatitis);
d. Communicating with the public health authorities, if applicable.
e.

98
53 – LUMP / MASS (MUSCULOSKELETAL)
Rationale

Lumps or masses are a common cause for consultation with a physician. Musculoskeletal lumps or masses
represent an important cause of morbidity and mortality.

Causal conditions (list not exhaustive)

1) Neoplastic
a. Soft tissue
i. Benign (e.g., lipoma)
ii. Malignant (e.g., leiomyosarcoma)
b. Bone (e.g., cyst)
i. Benign (e.g., cyst)
ii. Malignant (e.g., Ewing sarcoma)
2) Non-neoplastic
a. Infectious (e.g., osteomyelitis)
b. Traumatic (e.g., hematoma)
c. Inflammatory (e.g., rheumatoid nodules, tendonitis)

Key objectives

Given a patient with a musculoskeletal lump or mass, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan, in particular to distinguish benign from
malignant.

Enabling objectives

Given a patient with a musculoskeletal lump or mass, the candidate will

1) List and interpret clinical findings, including

a. An appropriate history and physical examination with particular attention to features
suggestive of sarcoma;
2) List and interpret key investigations, including
a. Laboratory and radiological studies, if indicated, and in particular determining if the patient
requires a biopsy;
3) Construct an effective initial management plan, including
a. Determination as to whether the patient requires specialized or urgent diagnosis and
treatment.

99
54 – LYMPHADENOPATHY
Rationale

Lymphadenopathy can be localized or diffuse, and benign or malignant. Patients frequently present when they
find a palpable lymph node.

Causal conditions (list not exhaustive)

1) Localized
a. Reactive (e.g., tonsillitis)
b. Neoplastic (e.g., metastatic cancer)
2) Diffuse
a. Infectious (e.g., viral)
b. Inflammatory (e.g., sarcoidosis)
c. Neoplastic (e.g., lymphoma)

Key objectives

Given a patient with lymphadenopathy, the candidate will diagnose the cause, severity, and complications, will
initiate an appropriate management plan, and in particular, determine the need for a biopsy.

Enabling objectives

Given a patient with lymphadenopathy, the candidate will

1) List and interpret relevant clinical findings, including

a. An appropriate history and physical examination;
2) List and interpret relevant investigations, including
a. Laboratory and radiological studies;
b. Indications for a biopsy;
3) Construct an effective management plan, including:
a. Determining whether basic observation and/or treatment is indicated, or if the patient requires
urgent referral;
b. Determining if the patient requires non-urgent referral (e.g., serum sickness);
c. Counselling and education of the patient regarding the nature and scope of needed
investigations.

100
54.1 Mediastinal mass

Rationale

Mediastinal masses that are found on X-ray are classified according to location. Location within the
mediastinum is important for identifying the cause.

Causal conditions (list not exhaustive)

1) Anterior
a. Tumors (e.g., thymoma, lymphoma)
b. Other (e.g., aneurysm)
2) Middle
a. Tumors (e.g., bronchogenic cancer)
b. Other (e.g., sarcoidosis)
3) Posterior
a. Tumors (e.g., esophageal cancer)
b. Other (e.g., hiatal hernia)

Key objectives

Given a patient with a mediastinal mass, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan, in particular, differentiate between causes based on compartment
location.

Enabling objectives

Given a patient with mediastinal mass, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination to help determine the most likely cause;
2) List and interpret relevant investigations, including
a. Laboratory and radiological investigations;
3) Construct an effective initial management plan, including:
a. Determining if the patient requires further investigation;
b. Referral of the patient for specialized diagnostic tests and treatment, if necessary;
c. Counselling and education of the patient regarding the nature and scope of needed
investigations.

101
56 – MENSTRUAL CYCLE, ABNORMAL
56.1 Amenorrhea / oligomenorrhea

Rationale

Amenorrhea and oligomenorrhea are common patient concerns and can be associated with serious underlying
pathology. Primary amenorrhea is the absence of menarche by the age of 15. Secondary amenorrhea is the
absence of menses for more than 3 cycles or 6 months in women who previously had menses. Absence of
menstruation in these circumstances is a reason for investigation and management.

Causal conditions (list not exhaustive)

1) Primary
a. Central
i. Hypothalamus (e.g., functional)
ii. Pituitary
b. Ovary (e.g., ovarian dysgenesis, polycystic ovarian disease)
c. Vaginal, outflow tract (e.g., imperforate hymen)
2) Secondary
a. Pregnancy
b. Central
i. Hypothalamus (e.g., functional, exogenous hormones)
ii. Pituitary (e.g., prolactinoma)
c. Other endocrine (e.g., thyroid disorders)
d. Ovary (e.g., oophorectomy, chemotherapy)
e. Uterus (e.g., Asherman syndrome)

Key objectives

Given a patient with oligomenorrhea or amenorrhea, the candidate will first rule out pregnancy. In amenorrhea,
the candidate will then differentiate between primary and secondary. The candidate will diagnose the cause,
severity, and complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with amenorrhea or oligomenorrhea, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history and physical examination, including a pelvic examination;
2) List and interpret critical investigations, including
a. Appropriate laboratory and radiologic studies, in particular, first rule out pregnancy;
3) Construct an effective initial management plan, including
a. In case of pregnancy;
b. In case of primary amenorrhea;
c. In case of secondary amenorrhea, other than pregnancy;
d. Determining whether the patient requires specialized care;
e. Counseling and education, as appropriate.

102
56.2 Dysmenorrhea

Rationale

Painful menstruation is a very common symptom, and in some this pain can be incapacitating. Dysmenorrhea is
a significant cause of absence from work or school.

Causal conditions (list not exhaustive)

1) Primary/Idiopathic (no pelvic abnormality)

2) Secondary (acquired) (e.g., infections, endometriosis, adnexal abnormalities)

Key objectives

Given a patient with dysmenorrhea, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Specifically, will differentiate primary from secondary dysmenorrhea.

Enabling objectives

Given a patient with dysmenorrhea, the candidate will

1) List and interpret critical clinical findings, including

a. A history of the quality and timing of pain, as related to bleeding;
b. Differentiating primary from secondary dysmenorrhea;
c. Performing a pelvic examination to exclude possible causes of secondary dysmenorrhea;
2) List and interpret critical investigations, including
a. Papanicolaou smear, if indicated;
b. Screening test for infection (e.g., vaginal and cervical cultures);
c. Determination of indications for imaging studies (e.g., ultrasound);
3) Construct an effective initial management plan, including
a. Outlining treatment options including symptomatic control;
b. Determining whether the patient needs to be referred for investigation (examination under
anesthesia, laparoscopy);
c. Determining whether the patient requires specialized care.

103
56.3 Premenstrual dysphoric disorder (PMS)

Rationale

Premenstrual dysphoric disorder (premenstrual syndrome or PMS) is a combination of physical, emotional, or

behavioral symptoms that occur prior to the menstrual cycle and are absent during the rest of the cycle. The
symptoms, on occasion, are severe enough to interfere significantly with work and/or home activities.

Causal conditions (list not exhaustive)

While the cause of premenstrual dysphoric disorder (PMS) is unknown, there are many theories as to the
pathogenesis of this condition.

Key objectives

Given a patient with premenstrual dysphoric disorder (PMS), the candidate will assess the severity and
complications, and will initiate an appropriate management plan. Specifically, the candidate will differentiate
PMS from normal premenstrual symptoms or from other causes of physical and mood changes, and will
explore the psychosocial impact of the condition.

Enabling objectives

Given a patient with premenstrual dysphoric disorder (PMS), the candidate will

1) List and interpret critical clinical findings, including

a. Determining if the symptoms are cyclical (e.g., by use of a symptom diary);
b. Ensuring that symptoms are not related to another chronic condition (e.g., major depressive
disorder);
c. Evaluating the severity of mood and physical symptoms, as well as their psychosocial impact;
2) List and interpret critical investigations, including
a. Consideration and exclusion of conditions with similar symptomatology (e.g., hypothyroidism,
anemia);
b. Recognition of the fact that, in the majority of cases, there is no need for further
investigation;
3) Construct an effective initial management plan, including
a. Outlining initial management including supportive therapy and counselling on life-style issues
(e.g., diet, exercise, stress reduction);
b. Considering the use of hormonal therapy for ovulation suppression (e.g., oral contraceptive);
c. Outlining indications for selective serotonin reuptake inhibitors in the management of
premenstrual dysphoric disorder (PMS).

104
57 – MENOPAUSE
Rationale

Menopause is defined as 12 months of amenorrhea after the final menstrual period, reflecting complete, or near
complete, cessation of ovarian function. Promotion of health maintenance in this group of women will enhance
physical, emotional, and sexual quality of life.

Causal conditions (list not exhaustive)

This Objective relates solely to physiological menopause.

Key objectives

Given a patient with physiological menopause, the candidate will be able to explain and prevent the undesirable
effects of menopause.

Enabling objectives

Given a patient with physiological menopause, the candidate will

1) List and interpret relevant clinical findings, including

a. An appropriate history and physical examination, in particular, looking for atypical findings or
risk factors for complications of menopause;
2) List and interpret investigations, including
a. Those required for well-woman examination;
3) Construct an effective initial management plan, including:
a. Counselling and education of the patient on the normal changes during menopause;
b. Exploration of and reassurance about psychosocial concerns regarding aging and sexuality;
c. Counselling and education of the patient regarding prevention of osteoporosis and
cardiovascular disease;
d. Discussing risks, benefits, and guidelines for hormone replacement therapy, including topical
estrogen therapy;
e. Discussing alternatives to estrogen therapy for some of the symptoms of menopause.

105
58 – MENTAL STATUS, ALTERED
58.1 Coma

Rationale

Coma, whether transient or persistent, is a state of pathologic unconsciousness. Coma requires urgent
evaluation to avoid permanent brain injury or death.

Causal conditions (list not exhaustive)

1) Focal disease (e.g., tumor, stroke)

2) Diffuse disease
a. Vascular (e.g., hypertensive encephalopathy, syncope)
b. Infectious (e.g., meningitis, encephalitis)
c. Trauma
d. Metabolic (e.g., uremia, hypercalcemia, hypoglycemia)
e. Substance use and overdose
3) Seizures

Key objectives

Given a patient in coma, the candidate will diagnose the cause, severity, and complications, and will initiate an
appropriate management plan. Particular attention should be paid to urgent and emergent conditions.

Enabling objectives

Given a patient in coma, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A complete history and corroboration of information from appropriate sources;
b. The identification of most likely causes of coma by means of a complete physical examination
including appropriate neurological examination;
c. The determination of level of consciousness using an appropriate assessment tool (e.g.,
Glasgow coma scale);
2) List and interpret critical investigations, including
a. Laboratory investigations (e.g., toxin screen, glucose), diagnostic imaging (e.g., computerized
tomography, magnetic resonance imaging) and others (e.g., lumbar puncture,
electroencephalography);
3) Construct an effective initial management plan, including
a. Initiating urgent care (e.g., airway, breathing, circulation) and appropriate empiric treatment as
indicated (narcotic/benzodiazepine reversal, glucose);
b. Instituting immediate treatment as required (e.g., antibiotics, anticonvulsants);
c. Referring the patient for specialized care (e.g., neurosurgery), if necessary;
d. Seeking clarification of proxy decision-making while the patient is incapacitated.

106
58.2 Delirium

Rationale

Delirium is a disturbance of cerebral function secondary to an underlying medical condition. Delirium is

extremely common in hospitalized patients. The presenting syndrome is altered level of consciousness,
impaired cognition and reality testing with a fluctuating course. Delirium is associated with increased risk of
death, prolonged hospitalization and institutionalization.

Causal conditions (list not exhaustive)

1) Medications (e.g., sedative, anti-cholinergic)

2) Metabolic (e.g., fluid and electrolyte disturbance)
3) Hypoxia (e.g., anemia, hypoperfusion)
4) Infection
5) Endocrine (e.g., hypothyroidism)
6) Neurological (e.g., stroke, neurocognitive disorder (dementia), infection)
7) Post-surgical
8) Withdrawal (e.g., alcohol, benzodiazepines)
9) Trauma

Key objectives

Given a patient with delirium, a candidate will recognize the syndrome, diagnose the cause(s), and will initiate
an appropriate management plan. Particular attention should be paid to the urgent/emergent nature of the
condition.

Enabling objectives

Given a patient with delirium, a candidate will

1) List and interpret critical clinical findings, including those derived from
a. The identification of susceptibility factors for delirium (e.g., age, alcohol dependence,
neurocognitive disorder [dementia]);
b. The use of appropriate diagnostic clinical tools (e.g., mini-mental state examination);
c. An appropriate history and physical examination, including collateral history from family and
caregivers, aimed at eliciting the cause of delirium;
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations and diagnostic imaging (e.g., blood gases, blood culture,
computerized tomography scan);
3) Construct an effective initial management plan, including
a. Instituting acute management of underlying conditions, as appropriate;
b. Ensuring appropriate treatment of agitation and sleep disturbance;
c. Managing the environment of the patient to assist in re-orientation and settling;
d. Seeking clarification of proxy decision making while the patient is incapacitated.

107
58.3 Major / Mild Neurocognitive disorders (dementia)

Rationale

Neurocognitive disorder (dementia) is a diminution in cognition in the setting of a stable level of consciousness.
It is a major issue for families and caregivers, and is increasing in prevalence with the aging population.
Alzheimer's disease is by far the most common form of neurocognitive disorder (dementia) in the elderly.
Preventive screening of the elderly for risk factors and possible reversible disorders should be routinely done.

See also Objective 31-1, and Objective 74.

Causal conditions (list not exhaustive)

1) Alzheimer's disease
2) Vascular dementia (e.g., multi-infarct, lacunar infarcts)
3) Brain trauma (e.g., postconcussive, anoxia)
4) Drugs (e.g., alcohol, substance abuse)
5) Toxins (e.g., heavy metals, organic toxins)
6) Neurodegenerative disorders (e.g., Parkinson disease, Lewy Body, Huntington disease)
7) Normal pressure hydrocephalus
8) Intracranial masses (e.g., tumours, subdural masses, brain abscesses)
9) Infections (e.g., human immunodeficiency virus, neurosyphilis)
10) Endocrine, metabolic, and nutritional disorders (e.g., hypothyroid, vitamin B12 deficiency)

Key objectives

Given a patient with neurocognitive disorder (dementia), the candidate will identify potential causes, severity,
and complications, and will initiate an appropriate management plan. In particular, the candidate will identify a
deterioration in cognitive function and look for reversible risk factors. The candidate will differentiate early
Alzheimer disease from other causes.

Enabling objectives

Given a patient with neurocognitive disorder (dementia), the candidate will

1) List and interpret critical clinical findings, including those based on

a. A history from the patient and on other collateral information to determine whether cognitive
decline has occurred, the time course, and possible risk factors (e.g., drugs, toxins);
b. A differentiation of true neurocognitive disorder (dementia) from psychiatric disorders (e.g.,
depression);
c. The determination of the patient's mental status as well as the results of the mini-mental state
examination;
2) List and interpret critical investigations (e.g., thyroid-stimulating hormone, vitamin b12, venereal
disease research laboratory);
3) Construct an effective initial management plan, including
a. Treatment of reversible underlying conditions;
b. Initiation of appropriate pharmacotherapy (e.g., cholinesterase inhibitors);
c. Patient and family counseling (e.g., prognosis, alternate decision-making and support
services);
d. Determination as to whether a referral to specialized services (e.g., occupational therapy,
addictions treatment) is required.

108
59 – MOOD DISORDERS
59.1 Depressed mood

Rationale

Symptoms of depression and/or mood dysregulation are common. Depressed mood can lead to significant
social, functional and physical impairment or death.

Causal conditions (list not exhaustive)

1) Major depressive disorder

2) Bipolar disorder (type I, type II)
3) Persistent depressive disorder (dysthymia)
4) Cyclothymic disorder
5) Normal grief
6) Substance-induced mood disorder
7) Mood disorder secondary to a general medical condition
8) Adjustment disorder

Key objectives

Given a patient with depressed mood, the candidate will diagnose the cause, severity and complications, and
will initiate an appropriate management plan. The candidate should pay particular attention to assessment of
suicide risk and the potential need for urgent care.

Enabling objectives

Given a patient suspected of depressed mood, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history, physical examination and assessment of the patient's mental
state;
b. A differential diagnosis based upon differentiation of clinical syndromes presenting with mood
dysregulation;
c. Specific risk factors that warrant immediate intervention (e.g., suicide ideation);
2) List and interpret appropriate investigations, including appropriate laboratory investigations (e.g.,
toxicology screen, thyroid stimulating hormone);
3) Construct an initial management plan including
a. An assessment of safety (e.g., suicide risk, risk of harm to others);
b. Counselling of patient and family regarding psychosocial issues and prevention of further
impairment;
c. Initiation of appropriate pharmacotherapy, if indicated;
d. Appropriate involvement of family and supportive resources;
e. Determination as to whether a referral for specialized care or support services is required.

109
59.2 Mania / Hypomania

Rationale

Mania/Hypomania is an extremely disabling and potentially harmful behavioral syndrome that indicates an
underlying central nervous system disorder. Mania can lead to harm to self or others, and may be accompanied
by features of psychosis.

Causal conditions (list not exhaustive)

1) Bipolar disorder (type I, type II)

2) Substance-induced mood disorder
3) Mood disorder due to a medical condition
4) Cyclothymic disorder

Key objectives

Given a patient presenting with mania/hypomania, the candidate will diagnose the cause, severity and
complications, and will initiate an appropriate management plan. The candidate should pay particular attention
to assessment of risk and the potential need for urgent care.

Enabling objectives

Given a patient with symptoms of mania/hypomania, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history, physical examination and assessment of the patient's mental
state;
b. Collateral information, as appropriate (e.g., information from family, friends, previous
assessments);
c. A differential diagnosis based upon differentiation of clinical syndromes presenting with
mania/hypomania;
d. Specific risk factors that warrant immediate intervention;
2) List and interpret appropriate investigations, including appropriate laboratory investigations (e.g.,
toxicology screen, thyroid stimulating hormone);
3) Construct an initial management plan including
a. An assessment of safety (e.g., suicide risk, risk to others);
b. Initiation of appropriate pharmacotherapy if indicated;
c. Appropriate involvement of family and supportive resources;
d. Determination as to whether a referral for specialized care is required (e.g., involuntary
admission).

110
60 – ORAL CONDITIONS
Rationale

Although many diseases can affect the oral cavity, odontogenic infection (dental caries and periodontal
infections) is the most common one. Apart from discomfort, infections may result in serious complications.
Ruling out oral carcinoma is important.

Causal conditions (list not exhaustive)

1) Congenital (e.g., cleft palate)

2) Acquired
a. Infection (e.g., candidiasis, gonococcal infection)
b. Malignancy (e.g., adenocarcinoma, leukoplakia)
c. Poor oral hygiene (e.g., caries, periodontal disease)
d. Trauma (e.g., abuse)
e. Toxic ingestion
f. Xerostomia (e.g., age, medications)
g. Systemic diseases (e.g., lichen planus, Behçet's disease)

Key objectives

Given a patient with an oral condition, the candidate will diagnose the likely cause, severity and complications,
and will initiate an appropriate management plan. In particular, the candidate will determine whether the patient
requires specialized care.

Enabling objectives

Given a patient with an oral condition, the candidate will

1) List and interpret critical clinical findings, including

a. Signs of potential malignancy;
b. Signs of infection;
2) List and interpret critical investigations, including those required to exclude suspected systemic disease;
3) Construct an effective initial management plan, including
a. Counselling and educating the patient and/or the caregivers regarding oral hygiene and/or diet
(e.g., sugar-containing drinks for children);
b. Counselling on smoking cessation and alcohol abuse;
c. Referring for specialized care, if necessary.

111
61 – MOVEMENT DISORDERS / TIC DISORDERS
Rationale

Movement disorders are classified as excessive (hyperkinetic) or reduced (bradykinetic) activity. Diagnosis
depends primarily on careful observation of the clinical features.

Causal conditions (list not exhaustive)

1) Hyperkinetic
a. Tics
i. Primary (sporadic and inherited)
1. Tourette syndrome
2. Huntington disease
ii. Secondary
1. Infections (e.g., encephalitis, Creutzfeldt-Jakob)
2. Drugs (e.g., stimulants, levodopa)
b. Dystonia
i. Primary (sporadic and inherited)
ii. Dystonia plus syndromes (e.g., medication)
c. Stereotypies (typically with mental retardation or autism)
d. Chorea/Athetosis/Ballism
e. Essential tremor
f. Myoclonus
2) Bradykinetic
a. Parkinson disease
b. Wilson disease
c. Huntington disease
3) Tremor
a. Resting (e.g., Parkinson, severe essential)
b. Intention (e.g., cerebellar disease, multiple sclerosis)
c. Postural/Action (e.g., enhanced physiologic, essential)

Key objectives

Given a patient with a movement disorder, the candidate will diagnose the cause, severity and complications,
and will initiate an appropriate management plan.

Enabling objectives

Given a patient with a movement disorder, the candidate will

1) List and interpret critical clinical findings, including

a. Describing the abnormal movement accurately after careful observation (at rest and in action)
to differentiate between various types and causes of movement disorders;
b. Performing a history and physical examination to look for reversible causes (e.g., medications,
Wilson disease);
c. Identifying key physical findings characteristic of Parkinson disease (e.g., rigidity, akinesia);
2) List and interpret critical investigations including
a. Testing for Wilson disease, if indicated;
b. Imaging studies or other tests, as appropriate;
3) Construct an effective initial management plan, including
a. Initiating medications for common conditions (e.g., essential tremor);

112
b. Recognizing side effects of medication and modifying as necessary (e.g., dystonia, "on/off"
phenomenon);
c. Determining if the patient requires specialized care for diagnosis or management (e.g., genetic
testing);
d. Counselling about the psychosocial impact of the disorder.

113
62 – ABNORMAL HEART SOUNDS AND MURMURS.
Rationale

Murmurs and abnormal heart sounds may be detected on physical examination. Although systolic murmurs are
often "innocent" or physiological, diastolic murmurs are virtually always pathologic. A thorough history and
physical examination almost always identifies which patients require further investigation and management.

Causal conditions (list not exhaustive)

1) Abnormal heart sounds

a. S1 (e.g., mitral stenosis, atrial fibrillation)
b. S2 (e.g., hypertension, aortic stenosis)
c. S3 (e.g., congestive heart failure)
d. S4 (e.g., hypertension)
e. Abnormal splitting (e.g., atrial septal defect)
2) Systolic murmurs
a. Ejection murmurs (e.g., physiologic, aortic stenosis)
b. Pansystolic murmurs (e.g. mitral regurgitation)
3) Diastolic murmurs
a. Early (e.g., aortic regurgitation)
b. Mid-diastolic (e.g., mitral stenosis)
4) Pericardial friction rubs

Key objectives

Given a patient with a murmur or abnormal heart sound(s), the candidate will differentiate innocent from
pathological conditions, diagnose the cause, severity and complications, and will initiate an appropriate
management plan.

Enabling objectives

Given a patient with a diastolic murmur, the candidate will

1) List and interpret critical clinical findings, including

a. The origin of the abnormal sound and/or murmur;
b. An appropriate history and physical exam aimed at determining the underlying pathological
condition, including severity and complications (e.g. Congestive heart failure, endocarditis);
2) List and interpret critical investigations, including
a. Diagnose abnormal heart rhythm by means of clinical findings and electrocardiogram;
b. Select diagnostic imaging, including echocardiography, for further investigation of the diastolic
murmur;
3) Construct an effective initial management plan, including
a. Initiate management for the underlying condition and its complications (e.g., congestive heart
failure, atrial fibrillation, endocarditis);
b. Recommend endocarditis prophylaxis, if indicated;
c. Determine if the patient requires specialized care.

114
63 – NECK MASS / GOITER / THYROID DISEASE
Rationale

The majority of neck masses are benign, but it is important to distinguish those rare ones which are malignant.

Causal conditions (list not exhaustive)

1) Benign
a. Congenital (e.g., thyroglossal duct cyst)
b. Inflammatory (e.g., reactive lymph nodes)
c. Neoplasms (e.g., lipomas)
2) Malignant
a. Thyroid
b. Non-thyroid head and neck cancers
c. Lymphoma

Key objectives

Given a patient with a neck mass, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to excluding malignancy.

Enabling objectives

Given a patient with a neck mass, the candidate will

1) List and interpret critical clinical findings, including

a. An appropriate history and physical examination, paying particular attention to;
i. Risk factors predisposing to malignancy (e.g., smoking);
ii. Time course;
iii. Presence of pain, swallowing or systemic symptoms;
iv. Signs or symptoms of thyroid dysfunction;
2) List and interpret critical investigations, including
a. Recognition that no investigation may be necessary;
b. Investigation of thyroid function;
c. Diagnostic imaging;
3) Construct an effective initial management plan, including
a. Reassurance and appropriate follow-up for a suspected benign lesion;
b. Appropriate medical management (e.g., thyroid supplementation, antibiotics;
c. Referral for specialized care (e.g., fine needle aspiration), if necessary.

115
64 – NEONATAL DISTRESS
Rationale

Neonatal distress is a relatively common occurrence. Failure to identify and appropriately manage an infant in
distress in a timely manner can potentially lead to significant morbidity and mortality.

Causal conditions (list not exhaustive)

1) Prematurity
2) Pulmonary (e.g., meconium aspiration, pneumothorax)
3) Decreased respiratory drive (e.g., maternal medications, asphyxia)
4) Cardiovascular (e.g., anemia, congenital heart disease)
5) Infection

Key objectives

In cases of a neonatal distress, the candidate will be able to assess the need for and initiate resuscitation, identify
causal and ongoing pathologies, and determine ongoing needs, including whether the infant requires level 2 or
level 3 neonatal intensive care.

Enabling objectives

In cases of neonatal distress, the candidate will

1) List and interpret critical clinical findings, including

a. Physical signs and symptoms that necessitate immediate resuscitation;
b. Maternal and perinatal history;
c. Physical examination findings relevant to formulating a differential diagnosis;
2) List and interpret critical initial investigations targeted towards identifying an underlying cause (e.g.,
cord blood gas, blood glucose)
3) Construct an effective initial management plan, including
a. Neonatal resuscitation;
b. Elements of ongoing supportive care, including;
i. Thermoregulation;
ii. Fluid and electrolyte balance;
iii. Sepsis management;
iv. Cardiorespiratory support;
c. Appropriate communication with caregiver(s);
d. Appropriate consultation or referral.

116
66 – NUMBNESS / TINGLING / ALTERED SENSATION
Rationale

Patients will often present complaining only of altered sensation. There are varying underlying causes, some of
which are serious.

Causal conditions (list not exhaustive)

1) Peripheral neuropathy (e.g., diabetic neuropathy, carpal tunnel syndrome, radiculopathy)

2) Central nervous system (e.g., multiple sclerosis)
3) Dermatological (e.g., herpes zoster, angioedema)
4) Mental disorders (e.g., panic attacks)

Key objectives

Given a patient presenting with isolated numbness/tingling/altered sensation, the candidate will diagnose the
cause, severity, and complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with numbness/tingling/altered sensation, the candidate will

1) List and interpret critical clinical findings, including

a. History data relevant to potential underlying causes (e.g., diabetic risk factors, workplace risk
factors, distribution of symptoms);
b. Results of a physical examination including a thorough neurological examination;
2) List and interpret appropriate investigations (e.g., fasting glucose, nerve conduction studies)
a. Recognize the fact that in many such cases investigations may not be required;
3) Construct an effective initial management plan based on the working diagnosis, including
a. Providing appropriate continuing assessment and ongoing care;
b. Determining if the patient requires specialized care;
c. Advising the patient, if necessary, on work-related issues.

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67 – PAIN
67.1.2.1 Generalized pain disorders

Rationale

Complaints of non-articular generalized pain are common, often chronic and can be difficult to manage.

Causal conditions (list not exhaustive)

1) Fibromyalgia / Chronic fatigue syndrome

2) Polymyalgia rheumatica (PMR)
3) Mental health disorders (e.g., depression, somatic symptom disorders)

Key objectives

Given a patient with a generalized pain disorder, the candidate will differentiate articular from non-articular
pain, diagnose the cause, severity, and complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with generalized pain disorder, the candidate will

1) List and interpret critical clinical findings, including

a. Findings on history and physical examination which
i. Differentiate fibromyalgia from other generalized pain syndromes and specific
articular disease;
ii. Suggest other pain syndromes which may be associated with serious complications;
1. PMR and temporal arteritis;
2. Depression and suicide;
2) List and interpret appropriate investigations (e.g., erythrocyte sedimentation rate, temporal artery
biopsy), including
a. Recognizing that many generalized pain disorders are associated with normal investigations;
3) Construct an effective initial management plan appropriate for the working diagnosis, including
a. When appropriate, take a multidisciplinary approach (e.g., physiotherapy, psychosocial
support);
b. Determine if the patient requires specialized care.

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67.2.2 Central / Peripheral neuropathic pain

Rationale

Neuropathic pain is a common and often disabling symptom with many underlying causes. Various treatment
options exist. Failure to diagnose and treat early may result in greater disability. It may be the initial presentation
of a potentially serious underlying medical condition

Causal conditions (list not exhaustive)

1) Metabolic (e.g., diabetic neuropathy)

2) Nerve entrapment (e.g., carpal tunnel syndrome, lymphoma, trigeminal neuralgia)
3) Infectious (e.g., post-herpetic neuralgia)
4) Central (e.g., phantom limb pain, spinal cord injuries)
5) Sympathetic (e.g., reflex sympathetic dystrophy)

Key objectives

Given a patient with neuropathic pain, the candidate will diagnose the cause, severity and complications, and
will initiate appropriate management.

Enabling objectives

Given a patient with neuropathic pain, the candidate will

1) List and interpret critical clinical findings, including a thorough history and physical examination
including:
a. A thorough review of the pain history (including past treatments), and psychosocial and
functional impairment;
b. Identify signs of neurological impairment and other causes of pain or numbness (e.g., vascular
insufficiency);
2) List and interpret possible appropriate investigations, including
a. Screening investigations for underlying medical conditions (e.g., fasting glucose, chest x-ray);
b. Nerve conduction studies;
c. Vascular studies;
3) Construct an effective initial management plan, including
a. Discussing possible pharmacotherapeutic options;
b. Counselling, including prevention of progression (e.g., chronicity of symptoms, exercise,
activity modification);
c. Optimal treatment of any underlying medical conditions (e.g., diabetic management);
d. Determining whether the patient needs a referral to a pain clinic or pain specialist.

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68 – PALPITATIONS
Rationale

Palpitations are sensations of a rapid or irregular heartbeat. Palpitations are a common symptom and although
the cause is often benign, it may indicate the presence of a serious underlying problem.

Causal conditions (list not exhaustive)

1) Supraventricular
a. Sinus tachycardia
i. Increased demand (e.g., pregnancy, anemia)
ii. Metabolic (e.g., thyrotoxicosis, pheochromocytoma)
iii. Anxiety
iv. Pharmacologic (e.g., cocaine, caffeine)
b. Atrial fibrillation/flutter
c. Supraventricular tachycardia (atrioventricular nodal reentrant tachycardia), Wolff-Parkinson-
White syndrome
d. Junctional tachycardia
e. Premature junctional complexes and premature atrial contractions
2) Ventricular
a. Ventricular tachycardia
b. Premature ventricular contractions
c. Ventricular fibrillation

Key objectives

Given a patient with palpitations, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate will select patients in need of urgent
treatment and differentiate palpitations due to intrinsic heart disease from those that are a manifestation of
anxiety, physical exertion, or of another systemic disease.

Enabling objectives

Given a patient with palpitations, the candidate will

1) List and interpret critical clinical findings, including

a. Perform a history and physical examination to determine the cardiac rate and rhythm and the
hemodynamic stability of the patient;
b. Identify underlying precipitants of the cardiac arrhythmia;
2) List and interpret critical investigations, including
a. Electrocardiogram and Holter monitoring;
b. Appropriate investigations for underlying causes of the cardiac arrhythmia (e.g.,
echocardiogram, thyroid stimulating hormone);
3) Construct an effective initial management plan, including
a. Immediate medical management in case of hemodynamic instability;
b. Anticoagulation for stroke prevention, if indicated;
c. Determination as to whether the patient requires hospitalization and specialized care;
d. Reassuring the patient with a benign condition.

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69 – ANXIETY
Rationale

Excessive anxiety is a common problem in both the primary care and hospital settings. It is often co-morbid
with other medical conditions, and can be the presenting feature of an underlying medical condition (e.g.,
hyperthyroidism). When severe, it can be associated with life-threatening complications (e.g., suicide).

Causal conditions (list not exhaustive)

Anxiety disorders are caused by a complex interaction of biological (e.g., genetic, substance use), social (e.g.,
domestic violence), and psychological factors (e.g., uncertainty). They frequently co-exist with other psychiatric
(as well as medical) conditions, but may present in isolation. Common anxiety disorders include:

1) Generalized anxiety disorder

2) Post-traumatic stress disorder
3) Separation anxiety disorder
4) Phobias
5) Panic disorder
6) Adjustment disorder

Key objectives

Given a patient with anxiety, the candidate will diagnosis the cause, severity, and complications, and will initiate
an appropriate management plan.

Enabling objectives

Given a patient with anxiety, the candidate will

1) List and interpret critical clinical findings, including an appropriate history and physical examination in
order to
a. Differentiate situational stress from a true anxiety disorder;
b. Rule out an underlying medical condition as the cause of the anxiety (e.g., adrenal tumors);
c. Identify possible co-morbid conditions (e.g., substance-related or addictive disorder);
d. Determine the severity of symptoms and assess for the presence of life-threatening features
(e.g., suicidal ideation);
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations based upon clinical findings (e.g., toxicology screen);
3) Construct an effective initial management plan, including
a. Ensuring the safety of the patient and others;
b. Treating the anxiety disorder using appropriate pharmacological, environmental (e.g.,
hospitalization), psychologic (e.g., psychotherapies) interventions;
c. Treating any underlying medical and/or co-morbid conditions if appropriate;
d. Providing support to family and/or caregivers;
e. Referring the patient for specialized care, if necessary.

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71 – PEDIATRIC EMERGENCIES
71.1 Crying or fussing child

Rationale

While it is common for children to cry/fuss, it is important to distinguish between benign and organic causes of
crying/fussing in an infant or child.

Causal conditions (list not exhaustive)

1) Functional (e.g., hunger, irritability)

2) Colic
3) Trauma
4) Illness

Key objectives

Given a crying or fussing infant or child, the candidate will diagnose the cause, severity, and complications of
the underlying problem, and will initiate an appropriate management plan. In particular, the candidate will
differentiate pediatric emergencies from conditions not requiring emergency treatment.

Enabling objectives

Given an infant/child who is crying and fussing, the candidate will

1) List and interpret critical clinical findings, including

a. Eliciting a history of patient's previous behavior, sleep pattern, oral intake, associated
symptoms (e.g., fever, pain);
b. Performing a full physical examination in order to determine whether the child is sick or not;
2) List and interpret critical investigations, including investigations for any suspected underlying disease or
trauma;
3) Construct an effective initial management plan, including
a. Counselling caregivers if the fussy or crying child does not have an organic disease;
b. Determining if the child requires follow-up for additional investigation and management;
c. Determining if the patient needs a referral, either immediate or elective.

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71.2 Hypotonic infant

Rationale

Hypotonia in an infant can be an indication of severe systemic disease requiring urgent intervention, or
neurological disease potentially requiring long-term multidisciplinary care.

Causal conditions (list not exhaustive)

1) Neurologic (e.g., perinatal asphyxia, spinal muscular atrophy, myasthenia gravis)

2) Disorders of skeletal muscle (e.g., muscular dystrophy)
3) Genetic/metabolic (e.g., Prader-Willi, hypothyroidism)
4) Systemic illness (e.g., sepsis, dehydration)

Key objectives

The candidate will recognize hypotonia in an infant as a finding requiring urgent attention. Considering the
presence or absence of other clinical findings, the candidate will formulate an appropriate differential diagnosis,
assess the severity of the condition, and will initiate an appropriate management plan.

Enabling objectives

Given a hypotonic infant, the candidate will

1) List and interpret critical clinical findings, including

a. Assessment of physiologic stability (e.g., oxygenation, cardiovascular function);
b. A thorough history including a perinatal history;
c. A complete physical examination, including a detailed neurological and musculoskeletal
examination;
2) List and interpret critical investigations appropriate to the clinical condition, which may include
a. Urgent investigations relevant to an acutely ill infant (e.g., electrolytes, blood glucose, arterial
blood gas);
b. Diagnostic investigations (e.g., computerized tomography scan, creatine kinase,
electromyogram, genetic studies);
3) Construct an effective initial management plan, including:
a. Immediate supportive care (when required);
b. Supportive communication with family;
c. Referral for specialized care, if necessary.

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73 – PELVIC PAIN
Rationale

Acute pelvic pain may be secondary to a life-threatening condition. Chronic pelvic pain is one of the most
common problems in gynecology.

Causal conditions (list not exhaustive)

1) Pregnancy related (e.g., ectopic, molar, abruption)

2) Gynecological
a. Ovary (e.g., ruptured cyst, torsion)
b. Tube (e.g., pelvic inflammatory disease, endometriosis)
c. Uterus (e.g., leiomyoma, endometriosis)
3) Other (dysmenorrhea, ovulation pain, dyspareunia)
4) Systemic conditions
a. Urologic (interstitial cystitis, renal colic)
b. Musculoskeletal (fibromyalgia)
c. Gastrointestinal (irritable bowel, diverticulitis, inflammatory bowel disease, hernias)
5) Mental health issues
a. Depression, somatization
b. Sexual, physical, and psychological abuse/domestic violence

Key objectives

Given a female patient with pelvic pain, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, the candidate will identify patients with acute pain
caused by a life-threatening condition, will determine whether pregnancy is likely, and will provide stabilization
for those patients who are hemodynamically unstable.

Enabling objectives

Given a female patient who presents with pelvic pain, the candidate will

1) List and interpret critical clinical findings, including

a. Determining if urgent stabilization is required;
b. Performing a history and physical exam to determine the underlying cause (e.g., menstrual
history, pelvic and speculum exam);
2) List and interpret relevant investigations, including
a. A pregnancy test, if indicated;
b. Appropriate diagnostic imaging testing (e.g., pelvic ultrasound);
3) Construct an effective initial management plan, including
a. Stabilization of the patient and consideration of need for emergency surgery;
b. Appropriate treatment of the underlying condition (e.g., dysmenorrhea, pelvic inflammatory
disease);
c. Recommending appropriate non-pharmacologic and pharmacologic treatment for chronic
pelvic pain;
d. Counseling the patient regarding the prevention of sexually transmitted infections;
e. Determining whether the patient requires specialized or urgent gynecologic care.

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74 – PERIOD HEALTH ENCOUNTER/PREVENTIVE HEALTH
ADVICE
Rationale

A periodic health encounter/preventive health advice session represents an opportunity for the prevention or
early detection of health-related problems. The nature of the examination will vary in timing and frequency,
depending on the age, sex, occupation and psychosocial background of the patient. The encounter may take the
form of an in-person visit, electronic or phone encounters, or delegated acts by other health care team
members.

Causal conditions (list not exhaustive)

1) All ages
a. Injury prevention (e.g., noise control, seat belts, bicycle helmets)
b. Lifestyle modification (e.g., physical activity, smoking prevention/cessation, sun exposure)
c. Immunization 74-2 - Immunization
2) Infant and child
a. Nutrition
b. Growth
c. Development
d. Behaviours
e. Other (e.g., hearing, amblyopia)
3) Adolescence
a. Sexual activity (e.g., contraception, sexually transmitted infections [STI])
4) Young adult
a. Female reproductive health (e.g., Papanicolaou test, STI screening, folic acid)
5) Middle-aged adult
a. Cardiovascular health risks (e.g., blood glucose, blood pressure, lipid profile)
b. Cancer screening (e.g., breast, colon, prostate, skin)
c. Osteoporosis
6) Older adult
a. Fracture and fall prevention (e.g., osteoporosis screening)
b. Nutrition
c. Dementia screening

Key objectives

Given a patient presenting for a preventive health encounter/health advice session, the candidate will
determine the patient's risks for age and sex-specific conditions in order to guide history, physical examination,
screening investigations and counselling.

Enabling objectives

Given a patient presenting for a preventive health encounter/preventive health advice session, the candidate
will

1) Perform an appropriate history and physical examination based on the patient's age, sex, and
background;
2) List and interpret appropriate investigations, including
a. Results of evidence-based screening investigations specific to age and sex (e.g., fasting glucose,
mammography);

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3) Construct an effective initial management plan, including
a. Communicating effectively with the patient to reach a common ground regarding goals related
to disease prevention and risk reduction;
b. Recommending proven prevention strategies (e.g., smoking cessation, regular exercise);
c. Incorporating the preventive health principles into the care of the patient in case of a chronic
disease.

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74.1 Newborn assessment

Rationale

Primary care physicians play a vital role in identifying children at risk for disorders that are threatening to life or
long-term health before they become symptomatic. In most cases, caregivers require reassurance and
anticipatory guidance regarding the health of their newborn infant.

Key objectives

Given a newborn presenting for routine assessment the candidate will conduct a skilled and comprehensive
assessment to identify any significant abnormalities or risk factors and counsel caregiver(s) on newborn care.

Enabling objectives

Given a newborn for routine assessment, the candidate will

1) List and interpret critical clinical findings, including

a. Maternal and perinatal history (e.g., intrapartum fever, medications);
b. Neonatal history (e.g., Apgar scores, feeding and elimination);
c. Psychosocial history (e.g., maternal mental health, home environment, family supports);
d. Systematic newborn physical examination, with particular attention to indications of an acute
illness (e.g., jaundice, hydration status);
e. Screening for important congenital malformations (e.g., red reflex, heart murmur);
f. Caregiver(s)' concerns;
2) List and interpret critical investigations, including
a. Screening tests for acute illness (e.g., serum glucose);
b. Screening tests for clinical abnormalities (e.g., echocardiogram, genetic testing);
c. Bilirubin measurement;
3) Construct an effective initial management plan, including
a. Managing any acute illness appropriately, including referral for specialized care if needed;
b. Counselling caregiver(s) regarding breastfeeding and infant nutrition;
c. Counselling caregiver(s) about routine infant care (e.g., umbilical cord care) and safety (e.g., car
seat, prevention of sudden infant death syndrome);
d. Discussing with caregiver(s) newborn metabolic screening;
e. Addressing any parental concerns.

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74.2 Immunization

Rationale

Immunization has either reduced or eradicated many infectious diseases and has improved overall health the
world over. Recommended immunization schedules are constantly updated as new vaccines become available.

Key objectives

The candidate must be able to recommend an appropriate schedule of vaccinations, discuss with
patients/parents the risks and benefits of vaccination and be able to identify patients in need of vaccination
who do not come in for routine visits (e.g., when presenting for assessment of new illness).

Enabling objectives

Given a patient needing vaccination, the candidate will

1. list and interpret clinical findings, including
1. an immunization history as well as any contraindication to vaccination (e.g., anaphylaxis,
immunosuppression);
2. construct an effective initial management plan, including
1. obtaining informed consent;
2. giving patients/parents the information they need to manage possible vaccine reactions;
3. outlining an appropriate immunization schedule, including modifications to the usual schedule
for special circumstances (e.g., catch-up schedules, immunocompromised patients);
4. counselling patients/parents who refuse vaccinations (e.g., re prevention of individual and
community diseases);
5. reporting adverse immunization reactions, as required;
6. reaching out to population segments specifically at risk (e.g., the elderly, transplant and
asplenic patients).

128
74.3 Pre-operative medical evaluation

Rationale

Evaluation of patients prior to surgery is an important element of comprehensive medical care. The objectives
of such an evaluation include the detection of an unidentified disease that may increase the risk of surgery and
how to minimize such risk.

Causal conditions (list not exhaustive)

1) Optimal care of chronic diseases (e.g., coronary artery disease, diabetes mellitus)
2) Identification of perioperative risk
a. Cardiopulmonary
i. Myocardial (e.g., ischemia, heart failure, arrhythmia)
ii. Pulmonary (e.g., chronic obstructive pulmonary disease, infection)
b. Anaesthesic
i. Systemic (e.g., malignant hyperthermia, sleep apnea)
ii. Intubation/airway (e.g., C-spine stability)
c. Thromboembolic (prior deep vein thrombosis, thrombophilia)
d. Medication-related (e.g., prednisone use, immunosuppressants)

Key objectives

Given a patient who requires surgery, the candidate will assess the perioperative issues based on the history and
physical examination. In particular, the candidate will recommend strategies to minimize perioperative
morbidity and mortality.

Enabling objectives

Given a patient who requires surgery, the candidate will

1) List and interpret key clinical findings, including

a. Determine current functional capacity of the patient and prior anesthetic history;
b. Perform a history and physical examination to allow classification of perioperative risk and to
optimize the patient's care (e.g., full medication list, cardiovascular examination);
2) List and interpret appropriate clinical investigations, including
a. Required investigations based upon risks identified from the history and physical examination
(e.g., c-spine x-ray in rheumatoid arthritis, hemoglobin a1c [hba1c], diabetes);
b. Investigations for further risk stratification (cardiac stress testing, sleep study), if necessary;
3) Construct an effective management plan, including
a. Optimization of the care of pre-existing medical conditions (e.g., diabetes);
b. Communicating the perioperative risks to the patient and other health professionals;
c. Communicating to the patient and other health professionals required medication changes
around the time of surgery (e.g., stopping anticoagulants, deep vein thrombosis prophylaxis).

129
74.5 The well child and adolescent

Rationale

Primary care physicians assess the dynamic stages of growth, development and behaviours of infants, children
and adolescents. Physicians must be able to distinguish age-appropriate normal patterns, which require no
intervention, from pathological deviations, which require further evaluation. A comprehensive awareness of the
difference between normal and abnormal growth, development and/or behaviours minimizes the risks of
inaccurate diagnoses and inappropriate investigations while allowing for early diagnosis and intervention in case
of abnormal trajectory.

Milestones (list not exhaustive)

1) Somatic growth (head circumference, length/height, weight)

2) Pubertal development
3) Development
a. Motor skills
i. Gross motor (e.g., walking, riding a bicycle)
ii. Fine motor (e.g., ability to transfer objects from one hand to another)
b. Communication and language
i. Expressive
ii. Receptive
iii. Mixed
c. Cognitive
i. Problem-solving skills
ii. Rate of learning, memory, executive functioning
d. Self-care skills
e. Behaviour (e.g., head banging)
f. Social/emotional health (e.g., stranger anxiety, relationship building)
g. Pre-academic/academic skills

Key objectives

Given an infant, child or adolescent, the candidate will identify normal milestones of chronological and
developmental age, with regards to growth, development and behaviours. Concerns from parents or guardians
will be addressed and reassurance given if the individual is growing and developing within the expected limits.
Abnormal findings should be addressed through proper investigations and referrals, when indicated.

Enabling objectives

Given an infant, child or adolescent, the candidate will

1) List and interpret relevant clinical findings, including those based on

a. A proper history of growth and developmental milestones appropriate for the age group of the
individual;
b. An appropriate physical examination with particular attention to the milestones of the
chronological/developmental age;
c. Proper documentation of growth and development;
2) List and interpret relevant preliminary investigations if the individual is found to have abnormal growth
and/or development milestones;
3) Conduct an effective initial management plan, including
a. Reassurance in case of normal growth/development or variants of these;

130
b. Referral to appropriate specialized care (e.g., pediatrics, speech and language therapy,
psychology) in case of abnormal findings.

131
75 – PERSONNALITY DISORDERS
Rationale

Personality disorders are pervasive and maladaptive patterns of behavior exhibited over a wide variety of social,
cultural, occupational, and relationship contexts and leading to distress and impairment. They represent
important risk factors for a variety of medical, interpersonal, and psychiatric difficulties.

Causal conditions (list not exhaustive)

The emergence of a personality disorder is a complex interaction of biological (e.g., genetic), social (e.g.,
poverty), and psychological factors (e.g., stress).

Key objectives

Given a patient with a personality disorder, the candidate will differentiate between a personality disorder and
other mental illness, recognizing the high prevalence of co-morbidities. The candidate will formulate an
appropriate management plan.

Enabling objectives

Given a patient with a personality disorder, the candidate will

1) List and interpret critical clinical findings, including

a. Sufficient clinical information (e.g., mental status examination) to diagnose the type of
personality disorder;
b. Risk factors associated with personality disorders (e.g., suicidal ideation, substance use);
c. Any co-existing psychiatric conditions (e.g., mood disorder);
2) Construct an effective initial management plan, including
a. Proper management in the case of a patient requiring immediate intervention (e.g., suicide risk,
risk to others);
b. Judicious use of pharmacotherapy, with consideration of the risk for abuse or overdose;
c. Referral for multi-disciplinary and/or specialized care, if necessary.

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76 – PLEURAL EFFUSION
Rationale

Pleural effusions are common and may represent local or systemic disease. An organized approach including
assessment of pleural fluid usually leads to a correct diagnosis.

Causal conditions (list not exhaustive)

1) Transudative (e.g., congestive heart failure, nephrotic syndrome, cirrhosis)

2) Exudative
a. Infectious/inflammatory causes (e.g., parapneumonic, empyema, rheumatoid arthritis)
b. Neoplastic causes (e.g., primary, metastatic, mesothelioma)
c. Pulmonary embolus
d. Gastrointestinal causes (e.g., ruptured esophagus, pancreatitis, chylothorax)

Key objectives

Given a patient with pleural disease, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate should be able to differentiate between
causes of pleural effusion on the basis of pleural fluid analysis.

Enabling objectives

Given a patient with pleural disease, the candidate will

1) List and interpret critical clinical findings, including results of a history and physical examination aimed
at:
a. Determining whether the patient has one of the edema states such as heart failure,
b. Has evidence of an infectious or neoplastic disease,
c. Or relevant workplace exposure;
2) List and interpret critical clinical investigations, including
a. Findings of a chest x-ray and identification of indications for thoracentesis;
b. Findings of a thoracentesis;
c. Computed tomography scanning, if indicated;
3) Construct an effective initial management plan, including
a. Initiating medical management for underlying conditions (e.g., congestive heart failure,
pneumonia);
b. Considering other treatment options (e.g., therapeutic thoracentesis, chest tube insertion) if
the patient is refractory to conventional treatments;
c. Determining whether the patient requires specialized care (e.g., thoracic surgery for empyema).

133
77 – POISONING
Rationale

Poisoning is common and potentially fatal. It can be accidental or intentional. Accidental poisoning is
particularly common in children.

Causal conditions (list not exhaustive)

1) Common
a. Household or work items (e.g., cleaning substances, or other chemical products, cosmetics,
plants)
b. Anticholinergics (e.g., antihistamines, tricyclics)
c. Sympathomimetic (e.g., cold remedies, amphetamines, cocaine)
2) Depressants (e.g., alcohol, opiate, sedatives, hypnotics)
a. Cholinergics (e.g., insecticides, nicotine)
3) Serotonergics (e.g., selective serotonin reuptake inhibitors)
4) Analgesics (e.g., acetylsalicylic acid [ASA], acetaminophen)
5) Cardiovascular drugs (e.g., digoxin, B-blockers, calcium channel blockers)
6) Others (e.g., hallucinogens)

Key objectives

Given a patient with poisoning, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. Particular attention should be paid to determining the nature of the
toxicity and exposure and provide specific and supportive care based on the identified cause.

Enabling objectives

Given a patient with poisoning, the candidate will

1) List and interpret critical clinical findings, including

a. Collateral history aimed at determining the substance involved and the potential severity of the
poisoning;
b. Results of a physical examination aimed at determining the stability of the patient and the
nature of the toxidrome (e.g., cholinergic crisis, serotonergic syndrome);
2) List and interpret critical investigations, including
a. Laboratory diagnosis of the substance ingested (e.g., acetaminophen, ASA levels);
b. Assessment of the toxic effects on the patient (e.g., arterial blood gases, anion and osmolar
gaps);
3) Construct an effective initial management plan, including
a. Supportive care before or at the same time as data gathering and investigation, (e.g., ensuring
airway adequacy, hemodynamic stability);
b. Appropriate decontamination or prevention of further absorption (e.g., activated charcoal);
c. Administration of specific antidotes, if indicated (e.g., naloxone, n-acetylcysteine);
d. Further elimination of the poison (e.g., alkalinization, dialysis);
e. Contacting poison control;
f. Referral for psychiatric assessment, if indicated.

134
78 – POPULATION HEALTH AND ITS DETERMINANTS
78.1 Concepts of health and its determinants

Rationale

Concepts of health, illness, disease and the socially defined sick role are fundamental to understanding the
health of a community and to applying that knowledge to the patients that a physician serves. With advances in
care, the aspirations of patients for good health have expanded and this has placed new demands on physicians
to address issues that are not strictly biomedical in nature. These concepts are also important if the physician is
to understand health and illness behavior.

Key objectives

Define and discuss the concepts of health, wellness, illness, disease and sickness.

Describe the determinants of health and how they affect the health of a population and the individuals it
comprises.

Enabling objectives

1) As defined by Health Canada and the World Health Organization:

a. Discuss alternative definitions of health;
b. Describe the determinants of health. These include:
i. Income and Social Status
ii. Social Support Networks
iii. Education and Literacy
iv. Employment and Working Conditions
v. Social and Work Environments
vi. Physical Environments
vii. Personal Health Practices and Coping Skills
viii. Healthy Child Development
ix. Biology, Genetics and Epigenetics
x. Health Services
xi. Gender
xii. Culture
c. Explain how the differential distribution of health determinants influences health status, and
d. Explain the possible mechanisms by which determinants influence health status.
e. Discuss the concept of life course, natural history of disease, particularly with respect to
possible public health and clinical interventions.
f. Describe the concept of illness behavior and the way this affects access to health care and
adherence to therapeutic recommendations.
g. Discuss how culture and spirituality influence health and health practices, and how they are
related to other determinants of health.

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78.2 Assessing and measuring health status at the population level
Rationale

Knowing the health status of the population allows for better planning and evaluation of health programs and
tailoring interventions to meet patient/community needs. Physicians are also active participants in disease
surveillance programs, encouraging them to address health needs in the population and not merely health
demands.

Key objectives

1) Describe the health status of a defined population.

2) Measure and record the factors that affect the health status of a population with respect to the
principles of causation.

Enabling objectives

1) Know how to access and collect health information to describe the health of a population:
a. Describe the types of data and common components (both qualitative and quantitative) used
in creating a community health needs assessment.
b. Be aware of important sources of clinical / population-level health data and recognize the
advantages and disadvantages of each of them.
c. Critically evaluate possible sources of data to describe the health of a population including the
importance of accurate coding and recording of health information.
d. Describe the uncertainty associated with capturing data on the number of events and
populations at risk.
e. Understand surveillance systems and the role of physicians and public health in reporting and
responding to disease.
2) Analyze population health data using appropriate measures:
a. Apply the principles of epidemiology in analyzing common office and community health
situations.
b. Describe the concepts of, and be able to calculate, incidence, prevalence, attack rates, case
fatality rates and to understand the principles of standardization.
c. Discuss different measures of association including relative risk, odds ratios, attributable risk
and correlations.
3) Interpret and present the analysis of health status indicators:
a. Demonstrate an ability to use practice-based health information systems to monitor the health
of patients and to identify unmet health needs.
b. Understand the appropriate use of different graphical presentations of data.
c. Describe criteria for assessing causation.
4) Demonstrate an ability to critically appraise and incorporate research findings with particular reference
to the following elements:
a. Characteristics of study designs (RCT, cohort, case-control, cross sectional);
b. Measurement issues (validity, sensitivity, specificity, positive predictive value, negative
predictive value; bias, confounding; error, reliability);
c. Measures of health and disease (incidence and prevalence rates, distributions; measures of
central tendency) and sampling.
5) Apply the principles of epidemiology by accurately discussing the implications of the measures.

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78.3 Interventions at the population level
Rationale

Many interventions at the individual level must be supported by actions at the community level. Physicians will
be expected to advocate for community wide interventions and to address issues that occur to many patients
across their practice.

Key objectives

1) Understand the three levels of prevention (primary, secondary and tertiary).

2) Describe strategies for community needs assessments, health education, community engagement and
health promotion.
3) Appreciate the role that physicians can play in promoting health and preventing diseases at the
individual and community level (e.g. prevention of low birth weight, immunization, obesity prevention,
smoking cessation, cancer screening, etc.).
4) Understand how public policy can influence population-wide patterns of behaviour and affect the
health of a population.

Enabling objectives

1) Be able to both define the concept of levels of prevention at the individual (clinical) and population
levels, as well as formulate preventive measures into their clinical management strategies.
2) Name and describe the common methods of health protection (such as agent-host-environment
approach for communicable diseases, and source-path-receiver approach for
occupational/environmental health).
3) Describe the importance and impact of good, culturally-appropriate communication with the patient,
the patient's family and, if necessary, the community as a whole with regard to risk factors and their
modification.
4) Apply the principles of screening and be able to evaluate the utility of a proposed screening
intervention, including being able to discuss the potential for lead-time bias and length-prevalence bias.
5) Understand the importance of disease surveillance in maintaining population health and be aware of
approaches to surveillance.
6) Identify ethical issues with the restricting of individual freedoms and rights for the benefit of the
population as a whole (e.g., issues in designating non-smoking areas or restricting movements of
person with active tuberculosis).
7) Describe the advantages and disadvantages of identifying and treating individuals versus implementing
population-level approaches to prevention.
8) Describe the five strategies of health promotion as defined in the Ottawa Charter and apply them to
relevant situations.
9) Describe one or more models of behavior change, including predisposing, enabling and re-enforcing
factors.
10) Identify the potential community, social, physical, environmental factors and work practices that might
promote healthy behaviors, as well as ways to assist communities and others to address these factors.
11) Be aware of the role of, and work collaboratively with, community and social service agencies (e.g.,
schools, occupational therapists, municipalities, non-governmental and other agencies).
12) Demonstrate awareness of the contribution of allied professionals such as social workers in addressing
population health issues.
13) Be able to describe the health impact of community-level interventions to promote health and prevent
disease.
14) Describe examples of public policies which have had an effect on population health.

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78.4 Administration of effective health programs at the population level

Rationale

Knowing the organization of the health care and public health systems in Canada as well as how to determine
the most cost-effective interventions are becoming key elements of clinical practice. Physicians also must work
well in multidisciplinary teams within the current system in order to achieve the maximum health benefit for all
patients and residents.

Key objectives

1) Know and understand the pertinent history, structure and operations of the Canadian health care
system.
2) Be familiar with economic evaluations such as cost-benefit / cost effectiveness analyses as well as
issues involved with resource allocation.
3) Describe the approaches to assessing quality of care and methods of quality improvement.

Enabling objectives

1) Describe at a basic level:

a. Methods of regulation of the health professions and health care institutions;
b. Supply, distribution and projections of health human resources;
c. Health resource allocation;
d. Organization of the public health system; and
e. The role of complementary delivery systems such as voluntary organizations and community
health centres.
2) Describe the role of regulated and non-regulated health care providers and demonstrate how to work
effectively with them.
3) Outline the principles of and approaches to cost containment and economic evaluation.
4) Describe the main functions of public health related to population health assessment, health
surveillance, disease and injury prevention, health promotion and health protection.
5) Demonstrate an understanding of ethical issues involved in resource allocation.
6) Define the concepts of efficacy, effectiveness, efficiency, coverage and compliance and discuss their
relationship to the overall effectiveness of a population health program.
7) Be able to recognize the need to adjust programs in order to meet the needs of special populations
such as new immigrants or persons at increased risk.
8) Participate effectively in and with health organizations, ranging from individual clinical practices to
provincial organizations, exerting a positive influence on clinical practice and policy-making.
9) Define quality improvement and related terms: quality assurance, quality control, continuous quality
improvement, quality management, total quality management; audit.
10) Describe and understand the multiple dimensions of quality in health care, i.e. what can and should be
improved.

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78.5 Outbreak management

Rationale

Physicians are crucial participants in the control of outbreaks of disease. They must be able to diagnose cases,
recognize outbreaks, report these to public health authorities and work with authorities to limit the spread of
the outbreak. A common example includes physicians working in nursing homes and being asked to assist in
the control of an outbreak of influenza or diarrhea.

Key objectives

1) Know the defining characteristics of an outbreak and how to recognize one when it occurs.
2) Demonstrate essential skills involved in controlling an outbreak and its impact on the public, in
collaboration with public health authorities as appropriate.

Enabling objectives

1) Define an outbreak in terms of an excessive number of cases beyond that usually expected.
2) Describe and understand the main steps in outbreak management and prevention.
3) Demonstrate skills in effective outbreak management including infection control when the outbreak is
due to an infectious agent.
4) Describe the different types of infection control practices and justify which type is most appropriately
implemented for different outbreak conditions.
5) Demonstrate effective communication skills with patients and the community as a whole.
6) Describe appropriate approaches to prevent or reduce the risk of the outbreak recurring.

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78.6 Environment

Rationale

Environmental issues are important in medical practice because exposures may be causally linked to a patient's
clinical presentation and the health of the exposed population. A physician is expected to work with regulatory
agencies and allied health professionals (e.g., occupational hygienists), where appropriate, to help implement the
necessary interventions to prevent future illness. Physician involvement is important in the promotion of global
environmental health.

Key objectives

1) Recognize the implications of environmental hazards at both the individual and population level.
2) Respond to the patients concerns through appropriate information gathering and treatment.
3) Work collaboratively with local, provincial and national agencies/governments as appropriate to
address the concerns at a population level.
4) Communicate with patients, communities, and employers, where appropriate, concerning
environmental risk assessment.

Enabling objectives

1) Identify common environmental hazards and be able to classify them into the appropriate category of
chemical, biological, physical and radiation.
2) Identify the common hazards that are found in air, water, soil and foods.
3) Describe the steps in an environmental risk assessment and be able to critically review a simple risk
assessment for a community.
4) Conduct a focused clinical assessment of exposed persons in order to determine the causal linkage
between exposure and the clinical condition.
5) Be aware of local, regional, provincial and national regulatory agencies that can assist in the
investigation of environmental concerns.
6) Describe simple interventions that will be effective in reducing environmental exposures and risk of
disease (e.g. sunscreen for sunburns, bug spray for prevention of West Nile Virus infection).
7) Communicate simple environmental risk assessment information to both patients and the community.

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78.7 Health of special populations

Rationale

Health equity is defined as each person in society having an equal opportunity for health. Each community is
composed of diverse groups of individuals and sub-populations. Due to variations in factors such as physical
location, culture, behaviours, age and gender structure, populations have different health risks and needs that
must be addressed in order to achieve health equity. Hence physicians need to be aware of the differing needs
of population groups and must be able to adjust service provision to ensure culturally safe communications and
care.

Key objectives

1) Understand how variation in the determinants of health in different populations promotes or harms
their health status.
2) Discuss how populations may have challenges with respect to access to health services, and how
members of the population may rely on traditional or alternative sources of health services that are not
commonly used by society as a whole.
3) Discuss the implications of the different cultural perspective and how this affects the planning, delivery
and evaluation of services (both preventive and curative).
4) Discuss how to provide culturally safe care with different populations.
5) Discuss the unique roles provided by government, social agencies, or special groups (e.g. Indigenous
health centres, Traditional healers) in providing services to the population.

Enabling objectives

First Nations, Inuit and Métis peoples are the original inhabitants of Canada. Collectively, they have a special
relationship with the federal government due to their treaty status, and many historical events have had a strong
impact on their health expectancy.

1) Describe the diversity amongst First Nations, Inuit, and/or Métis communities in your local area in
terms of their various perspectives, attitudes, beliefs and behaviours. Describe at least three examples
of this cultural diversity.
2) Describe the connection between historical and current government practices towards First Nations,
Inuit, Métis peoples (including, but not limited to colonization, residential schools, treaties and land
claims), and the intergenerational health outcomes that have resulted.
3) Describe how the medical, social and spiritual determinants of health and well-being for First Nations,
Inuit, Métis peoples impact their health.
4) Describe the various health care services that are delivered to First Nations, Inuit, Métis peoples, and
the historical basis for the systems as they pertain to these communities.

Increasing transportation of people, food and consumer goods is breaking down previous geographic
boundaries. Diseases such as SARS can travel quickly around the world and events in other parts of the world
affect medical practice in Canada. Canada is also dependent on new immigrants for growth with many locations
having a very high proportion of new immigrants and refugees.

1) Identify the travel histories and exposures in different parts of the world as risk factors for illness and
disease.
2) Appreciate the challenges faced by new immigrants in accessing health and social services in Canada.
3) Appreciate the unique cultural perspective of immigrants with respect to health and their frequent
reliance on alternative health practices.

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 4) Discuss the impact of globalization on health and how changes in one part of the world (e.g. increased
rates of drug-resistant Tuberculosis in one country) can affect the provision of health services in
Canada.

Persons with physical, mental, or sensory disabilities have unique needs and may require health and social
services to be provided in alternative ways.

1) Identify the challenges of persons with disabilities in accessing health and social services in Canada.
2) Discuss the issues of stigma and social challenges of persons with disabilities in functioning as
members of society (link to mental health).
3) Discuss the unique health and social services available to some persons with disabilities (e.g. persons
with Down's syndrome) and how these supports can work collaboratively with practicing physicians.

Homeless persons have unique needs due to their physical lack of basic shelter and ability to bath and prepare
food safely. In addition, being homeless is associated with many other conditions such as mental health and
may require health and social services to be provided in alternative ways.

1) Identify the challenges of providing preventive and curative services to homeless persons.
2) Discuss the major health risks associated with homelessness as well as the associated conditions such
as mental illness.

The elderly and very young children both share the challenges of being at high risk for certain medical
conditions (e.g. Hemolytic Uremic Syndrome) as well as being very vulnerable to changes in the determinants
of health. For example, children living in poverty or poor seniors living in isolation are both at high risk for
adverse health outcomes.

1) Identify the challenges of providing preventive and curative services to isolated seniors and children
living in poverty.
2) Discuss the major health risks associated with isolated seniors and children living in poverty.
3) Discuss potential solutions to these concerns.

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78.8 Work-related health issues

Rationale

Workplace health and safety hazards can contribute to many different health problems. Physicians play an
important role in the prevention and management of occupational injury, illness and disability.

Causal conditions (list not exhaustive)

1) Ergonomic hazards (e.g. awkward postures and movements, poor lighting)

2) Chemical hazards (e.g. organic solvents, metals, asbestos, toxic gases)
3) Physical hazards (e.g. noise, vibration, radiation)
4) Biological hazards (e.g. blood or other body fluids, animal and bird droppings)
5) Psychological and work organization hazards (e.g. workplace stressors, workplace bullying)

Key objectives

Given a patient with a health problem, the candidate will evaluate the possible workplace etiological factors, to
assess the contribution of occupational exposures for the most common pathologies, to assess the impact of
the condition on the ability to work, and develop an appropriate management plan. Particular attention should
be paid to the identification of occupational risks for the patient and his/her co-workers.

Enabling objectives

Given a worker with a health problem, the candidate will

1) List and interpret critical clinical findings, including:

a. Perform a history and focused physical examination to identify the illness and determine the
possible relationship of symptoms to work;
b. Identify hazards in the workplace that could have had an impact on the health problem (work
and exposure history);
c. Identify protective equipment being used and environmental controls that are in place;
d. Identify non occupational factors that could influence the condition.
2) List and interpret critical investigations, including:
a. Appropriate laboratory or radiologic investigations depending on the presenting health
problem (e.g. Chest radiography, ultrasound);
b. Physiologic and/or functional assessments (e.g. PFTS, audiograms, occupational therapy
assessment).
3) Construct an effective initial management plan, including:
a. Initiate specific therapy as required for the health problem;
b. Determine whether the patient should be assigned to a different work, or stop work and
advise the patient on this topic;
c. Determine follow up care and whether further consultation, counselling and/or a multi-
disciplinary approach to care is needed;
d. Advise the patient on workers compensation;
e. Advise the relevant authorities if necessary (notifiable disease, reporting a dangerous situation).

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79 – POTASSIUM CONCENTRATION, ABNORMAL
79.1 Hyperkaliemia

Rationale

Elevated serum potassium levels may be life-threatening and may also be indicative of the presence of other
serious associated medical conditions.

Causal conditions (list not exhaustive)

1) Increased intake (usually associated with low excretion)

2) Redistribution
a. Decreased entry into cells (e.g., insulin deficiency, beta 2 blockade)
b. Increased exit from cells (e.g., metabolic acidosis, rhabdomyolysis)
3) Reduced urinary excretion
a. Decreased glomerular filtration rate (e.g., acute or chronic kidney injury)
b. Decreased secretion (e.g., aldosterone deficiency, drugs)

Key objectives

Given a patient with hyperkalemia, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan, including indications for specialized care. In particular, the candidate
will recognize the urgency of hyperkalemia associated with electrocardiogram (ECG) abnormalities.

Enabling objectives

Given a patient with hyperkalemia, the candidate will

1) List and interpret critical clinical findings, including

a. Perform a history and physical examination to determine the underlying cause (e.g., potassium
sparing medications, signs of kidney injury);
2) List and interpret critical investigations, including
a. Those that can help in distinguishing between life-threatening hyperkalemia and
pseudohyperkalemia;
b. An ECG to determine the severity of the case;
c. Tests to distinguish between causes of hyperkalemia (e.g., serum creatinine, urine electrolytes);
3) Construct an effective initial management plan, including
a. Initiate emergency measures (e.g., intravenous calcium, glucose/insulin, potassium binders,
dialysis) in the case of hyperkalemia with ECG changes;
b. Refer the patient for specialized care (e.g., nephrology), if necessary.

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79.2 Hypokalemia

Rationale

Reduced serum potassium, a common clinical problem, is most often discovered on routine analysis of serum
electrolytes or suspected by electrocardiogram (ECG) results. Symptoms, such as muscle weakness, develop
when depletion is quite severe.

Causal conditions (list not exhaustive)

1) Decreased intake (e.g., anorexia nervosa)

2) Redistribution (e.g., alkalemia, insulin, beta 2-adrenergic stimulating drugs)
3) Increased losses
a. Renal losses
b. Gastrointestinal (GI) losses (e.g., vomiting, diarrhea)

Key objectives

Given a patient with hypokalemia, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate will recognize the urgency of hypokalemia
associated with severe muscle weakness and/or ECG abnormalities.

Enabling objectives

Given a patient with hypokalemia, the candidate will

1) List and interpret critical clinical findings, including

a. Performing a history and a physical examination to determine the cause and complications
(e.g., medications, blood pressure);
2) List and interpret critical investigations, including
a. An ECG to identify life-threatening conduction abnormalities;
b. Tests to distinguish between causes of hypokalemia (e.g., serum and urine electrolytes);
3) Construct an effective initial management plan, including
a. Ensuring appropriate potassium replacement with monitoring in a severe case;
b. Reducing renal excretion of potassium and/or GI losses;
c. Referring the patient for specialized care, if necessary.

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80 – PREGNANCY
80.1 Prenatal care

Rationale

Optimal prenatal care has the potential to reduce perinatal morbidity and mortality by identifying and reducing
potential risks, treating medical conditions, providing psychosocial support and promoting healthier lifestyles.

Key objectives

Provide prenatal care that integrates the best available evidence into a model of shared decision-making that
enables women to make informed decisions based on their needs in all aspects of preconception, pregnancy
and fetal health.

Enabling objectives

Given a patient that requires antepartum care, the candidate will

1) Understand and apply the principles of informed decision-making and patient-centered care, including
culturally sensitive issues;
2) Provide care for preconception counseling (e.g., folic acid supplementation, weight management,
smoking cessation);
3) Establish the desirability of the pregnancy in a patient with suspected or confirmed pregnancy and
construct an appropriate initial management plan;
4) Provide initial and subsequent prenatal visits that include an appropriate history, physical examination,
exploration of socio-economic determinants of pregnancy outcome, counseling, and laboratory
investigations;
5) Identify risk factors and common antenatal complications (e.g., hypertension, maternal age, intrauterine
growth restriction) and construct a plan for both the screening and initial management of these
conditions.

The candidate will also

1) List and interpret relevant clinical findings, including

a. Factors that contribute to the estimation of the date of confinement (e.g., last menstrual
period, date of positive pregnancy test);
b. Results of a thorough family, social, maternal health and obstetrical history;
c. Results of systematic screening for tobacco, alcohol and substance use / exposure;
d. Need for referral for therapeutic abortion as well as for counseling on the matter;
e. Use of medications and supplements and the need for appropriate counseling;
f. Need for timely counseling regarding prenatal genetic screening, including options, risks,
benefits, and possible outcomes;
g. Risk factors and signs of antenatal and post-partum depression;
h. Signs of intimate partner violence;
i. Physiological changes characteristic of pregnancy and determination as to whether pregnancy
is progressing satisfactorily (e.g., Normal pregnancy symptoms), or if complications are
present (e.g., hyperemesis, pain, bleeding);
j. In the 2nd and 3rd trimesters:
i. Fetal and maternal progress (e.g., weight gain, blood pressure, fetal heart rate and
movement;
ii. Signs and symptoms of preterm labour,

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 k. Determination of fetal lie and presentation in the 3 rd trimester;
l. Signs and symptoms consistent with the onset of labour;
2) List and interpret relevant investigations, including
a. Appropriate initial diagnostic/screening tests (e.g. Complete blood count, blood type, rubella
status);
b. Prenatal genetic screening options (e.g., serum integrated prenatal screen, nuchal
translucency);
c. Current recommendations for ultrasound examination in a normal pregnancy;
d. Indications and options for additional antenatal fetal surveillance (e.g., fetal movement
counting, non-stress test, biophysical profile);
e. Current recommendations regarding screening for prenatal complications / risk factors,
including (list not exhaustive):
i. Hemolytic disease of the newborn (e.g. From rhesus isoimmunization);
ii. Gestational diabetes mellitus;
iii. Sexually transmitted infections;
iv. Group b streptococcus;
3) Construct an effective initial management plan, including
a. Discussing the woman's adjustment to pregnancy (e.g., mood, work, stress, family);
b. Counselling, including referral to community resources
i. Prenatal and parenting classes;
ii. Nutrition;
iii. Substance use or abuse;
iv. Medication;
v. Lifestyle (e.g., physical and sexual activity, travel);
vi. Breastfeeding;
c. Management of common antenatal presentations and complications (e.g., nausea and
vomiting, bleeding, intra-uterine growth restriction);
d. Discussing an appropriate follow-up plan for women with a positive genetic screening result
(e.g., amniocentesis, specialist referral);
e. Management of post-term pregnancy;
f. Referral for additional or specialized care (e.g., pre-eclampsia, psychiatric disorders, substance
abuse), if necessary.

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80.2 Intrapartum and post-partum care

Rationale

Intrapartum and postpartum care includes the care of the mother and fetus during labour and the six-week
period following birth. The care provided during this period has the potential to impact the mother's physical
and emotional health in both the short and longer term.

Key objectives

The candidate will be able to provide intrapartum and postpartum care that integrates the best available
evidence into a model of shared decision-making that enables women to make informed decisions based on
their personal needs.

Enabling objectives

Given a pregnant patient requiring intrapartum and postpartum care, the candidate will

1) List and interpret relevant clinical findings, including

a. Those derived from an appropriate history and physical examination;
b. Ongoing emotional and physical needs of a woman in labour;
c. Pre-labour rupture of membranes;
d. Onset, stage, and progression of labour;
e. Indications and contraindications for induction of labour;
f. Features suggestive of a complicated labour (e.g., prolonged stage of labour, fever, meconium-
stained fluid);
g. Possible causes of a complicated labour (e.g., insufficient contractions, cephalopelvic
disproportion, infection);
h. Risk factors for and features of postpartum fever, hemorrhage, and pain;
i. Socio-economic determinants of pregnancy outcome.
2) List and interpret relevant investigations, including
a. Appropriate initial investigations for a woman presenting in labour;
b. Indications and options for fetal and maternal monitoring in labour (e.g., electronic fetal
monitoring, fetal blood sampling);
c. Appropriate maternal and fetal investigations to determine the need for rh immunoglobulin;
3) Construct an effective initial management plan, including
a. Reviewing maternal birth plans within a model of shared decision-making, including culturally
sensitive care;
b. Encouraging the involvement of birth partner(s) and of extended social supports, if
appropriate;
c. Informing the patient about the need for maternal examination and fetal health surveillance,
ensuring consent, privacy, dignity and comfort;
d. Assessing maternal knowledge of strategies for coping with pain and discuss options for pain
management;
e. Ensuring appropriate management of each stage of labour, including (list not exhaustive)
i. Determination as to when clinical intervention should not be offered or advised (e.g.,
normal labour);
ii. Indications and options for augmentation and active management of labour;
iii. Use of prophylactic antibiotics to reduce the risk of group b streptococcal disease in
the neonate;
iv. Appropriate counselling and support when complications are anticipated or
encountered (e.g., prolonged stage of labour, non-reassuring fetal status);
v. Initial immediate management if there are signs of fetal distress;

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 vi. Determination as to when surgical intervention (e.g., cesarean section, episiotomy) or
instrumental birth (e.g., forceps) is indicated;
vii. Initial management of postpartum complications (e.g., hemorrhage, fever, depression);
f. Ensuring management of preterm labour and pre-labour rupture of membranes;
g. Determining whether the patient requires specialized care.

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81 – EARLY PREGNANCY LOSS / SPONTANEOUS ABORTION
Rationale

Spontaneous abortion (miscarriage) is a loss of an early pregnancy and is very common. Spontaneous abortion
occurs most frequently in the first trimester. A threatened abortion is the more common presentation. When
recurrent, spontaneous abortion can be associated with infertility. Spontaneous abortion can result in grief
reactions. Thus, effective primary care management of this common problem is important.

Causal conditions (list not exhaustive)

The cause is usually not determined but may include:

1) Genetic factors (e.g., chromosomal abnormalities)

2) Reproductive tract abnormalities (e.g., uterine anomalies)
3) Prothrombotic factors (e.g., thrombophilia)
4) Endocrinologic factors (e.g., polycystic ovary syndrome)
5) Immunologic factors (e.g., antiphospholipid syndrome)

Key objectives

Given a patient with a threatened abortion, the candidate will clarify the status of the pregnancy, will identify
any complications, and will initiate an appropriate management plan. Particular attention should be paid to
supportive counseling of parents, and to appropriate investigation in cases of recurrent abortion.

Enabling objectives

Given a patient with threatened abortion, the candidate will

1) List and interpret critical clinical findings, including

a. The results of a thorough obstetrical history;
b. The results of a physical examination, with an emphasis on the status of the pregnancy (e.g.,
speculum examination, evidence of an ectopic pregnancy);
c. Identification of urgent complications (e.g., assessment of hemodynamic stability);
2) List and interpret critical investigations, including
a. Transvaginal ultrasound;
b. Laboratory investigations when appropriate (e.g., maternal antibody screen, complete blood
count, beta-hCG);
c. Proper investigation regarding recurrent abortion (e.g., anti-phospholipid antibody screen,
karyotype, hystero-salpingogram);
3) Construct an effective initial management plan, including
a. Emergent management in case of hemodynamic instability (e.g., ruptured ectopic pregnancy);
b. Referral for surgical evacuation or medical management (e.g., incomplete or missed abortion),
if necessary;
c. Counseling (e.g., grief, fertility implications, contraception);
d. Referral for specialized care, if indicated (e.g., serious hemorrhage, recurrent abortion).

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82 – PRETERM LABOUR
Rationale

Preterm birth (prior to 37 weeks gestation) is the leading cause of perinatal morbidity and mortality in
developed countries. Rates of preterm birth are rising with increasing maternal age and growing use of assisted
reproductive technologies. Medical management of preterm labour can significantly impact maternal and
neonatal outcomes.

Causal conditions (list not exhaustive)

1) Fetal (e.g., multiple gestation, congenital anomalies)

2) Placental (e.g., abruption, placental insufficiency)
3) Uterine (e.g., cervical anomalies)
4) Maternal (e.g., substance abuse, chronic illness, infection)
5) Iatrogenic (indicated induction of labour e.g., eclampsia, intrauterine growth restriction, premature
rupture of membranes)

Key objectives

Given a patient with preterm labour, the candidate will investigate the cause, determine the level of maternal
and fetal risk, and initiate an appropriate initial management plan. Particular attention should be paid to the
identification of patients requiring immediate transfer to a centre with appropriate neonatal intensive care
facilities.

Enabling objectives

Given a patient with preterm labour, the candidate will

1) List and interpret critical clinical findings, including those based on

a. Risk factors (e.g., maternal age, smoking, prior preterm deliveries);
b. Status of current pregnancy (e.g., gestational age, contractions, spontaneous rupture of
membranes);
c. Results of an appropriate physical examination (e.g., maternal blood pressure, speculum
examination with swabs for culture and sensitivity (c and s) and fetal fibronectin);
2) List and interpret critical investigations, including
a. Assessment of fetal well-being (e.g., ultrasound, fetal monitoring);
b. Identification of contributing factors requiring treatment (e.g., urine c and s, group b
streptococcus status);
3) Construct an effective initial management plan, including
a. Initiating appropriate medical therapy (e.g., antenatal steroids, group b streptococcal
prophylaxis, tocolysis);
b. Referring the patient for specialized care and/or transfer to an appropriate facility, if
necessary;
c. Counselling the parents about relevant immediate and long-term health problems encountered
by premature infants;
d. Referring the patient for assistance with social and economic issues related to preterm labour,
if necessary.

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83 – UTERINE PROLAPSE / PELVIC RELAXATION
Rationale

Pelvic relaxation is a common disorder which may impact physical well-being and social functioning. The
symptoms associated with pelvic relaxation may be embarrassing, and may not be raised spontaneously. The
physician should be familiar with, and screen for, the manifestations of pelvic relaxation.

Causal conditions (list not exhaustive)

This condition is usually multifactorial. Potential causal conditions include:

1) Damage to vagina and pelvic support system

a. Vaginal birth
b. Prior pelvic surgery
c. Chronic increase in intra-abdominal pressure (e.g., chronic cough)
2) Neurogenic dysfunction of pelvic floor
3) Connective tissue disease
4) Genetic predisposition

Key objectives

Given a patient with prolapse/pelvic floor relaxation, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with prolapse/pelvic floor relaxation, the candidate will

1) List and interpret critical findings, including

a. The severity of symptoms, effect on activity, predisposing factors;
b. The results of a physical examination aimed at determining the anatomical abnormality;
2) List and interpret critical investigations, including
a. Investigation for urinary tract infection;
3) Conduct an effective initial management plan, including
a. Discussing benefits and limitations of treatment options (e.g., pelvic floor exercises, pessary,
surgery) and strategies to slow progression;
b. Determining whether the patient needs to be referred for specialized care.

152
84 – PROTEINURIA
Rationale

Proteinuria is often the first indicator of potentially serious underlying renal disease.

Causal conditions (list not exhaustive)

1) Orthostatic proteinuria
2) Tubulointerstitial (interstitial nephritis)
3) Glomerular
a. Active urine sediment
i. Primary (e.g., IgA nephropathy, membranoproliferative glomerulonephritis)
ii. Secondary (e.g., systemic lupus erythematosus (SLE), post-infectious)
b. Non-active urine sediment
i. Primary (e.g. minimal change, focal segmental glomerulosclerosis)
ii. Secondary (e.g., diabetes, amyloid)

Key objectives

Given a patient with proteinuria, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate should recognize the importance of
proteinuria as a predictor of chronic kidney disease.

Enabling objectives

Given a patient with proteinuria, the candidate will

1) List and interpret critical clinical findings, including

a. Perform a history and physical exam to elicit symptoms and signs of underlying diseases
associated with kidney disease (e.g., diabetes mellitus, connective tissue diseases);
2) List and interpret critical investigations, including
a. Quantitative measures of proteinuria (e.g., albumin/creatinine ratio, 24-hour protein
collection) to guide further diagnostic work-up;
b. Tests to determine the underlying cause of the proteinuria (e.g., blood glucose, serum protein
electrophoresis);
3) Construct an effective initial management plan, including
a. Initiate measures to delay progression of chronic kidney disease associated with proteinuria
(e.g., angiotensin-converting enzyme inhibition, treatment of hypertension and diabetes);
b. Refer the patient for specialized diagnostic tests and care (e.g., renal biopsy), if necessary.

153
85 – PRURITUS
Rationale

Itching is common symptom. In the absence of primary skin lesions, generalized pruritus can be indicative of
an underlying systemic disease, but itching in most cases is due to a cutaneous disorder.

Causal conditions (list not exhaustive)

1) Skin lesions
a. Primary skin disease
i. Blisters (e.g., dermatitis herpetiformis)
ii. Rash (e.g., psoriasis, lichen planus)
b. Parasitosis (e.g., scabies, pediculosis)
c. Allergy (e.g., eczema, allergic dermatitis, urticaria)
d. Arthropod bites
e. Factitious dermatitis
2) No skin lesions
a. Dry skin
b. Drugs/Foods
c. Obstructive biliary disease
d. Uremia/kidney injury
e. Haematological
i. Polycythemia Vera/Microcytic anemia
ii. Leukemia
iii. Lymphoma
f. Carcinoma/Carcinoid syndrome
g. Endocrine (diabetes, thyroid disease)
3) Psychiatric/Emotional disorders

Key objectives

Given a patient with pruritus, the candidate will differentiate excoriations due to scratching from primary skin
lesions. The candidate will identify skin lesions if present. In their absence, the candidate will identify the
underlying cause of pruritus.

Enabling objectives

Given a patient with pruritus, the candidate will

1) List and interpret critical clinical findings, including

a. Results of an appropriate history, including an occupational history, and of a physical
examination aimed at determining the cause of pruritus;
b. Differentiation of pruritus associated with skin lesions from that without primary skin disease;
c. Any primary skin lesions associated with the pruritus;
2) List and interpret critical investigations, including investigations to diagnose systemic disorders in the
absence of skin lesions;
3) Construct an effective plan of management, including
a. Providing local and other therapy for pruritus due to skin disease;
b. Initiating a therapy for pruritus due to an underlying systemic disease;
c. Initiating a referral for consideration of social issues related to infectious or parasitic causes;
d. Referring the patient for specialized care, if necessary.

154
86 – PSYCHOSIS
Rationale

Psychosis is a severe and disabling psychiatric symptom present in several disorders, the most common of
which is schizophrenia. It can be associated with severe psychosocial dysfunction and can be life threatening.

Causal conditions (list not exhaustive)

1) Psychotic disorders (e.g., schizophrenia, schizoaffective disorder)

2) Psychotic disorder due to a medical condition (e.g., seizure disorder, central nervous system tumors)
3) Substance induced psychotic disorder (e.g., corticosteroids, cocaine)

Key objectives

Given a patient with psychosis, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In acute psychosis, particular attention should be paid to
differentiating a primary psychotic disorder from delirium and from psychosis secondary to a medical condition
or substance induced psychosis.

Enabling objectives

Given a patient with psychosis, the candidate will

1) List and interpret critical clinical findings, including

a. Mental status examination, with attention to risk factors for harm to self or others and
assessment of capacity;
b. Collateral history (if available);
c. Physical examination (when safe to do so), with particular attention to findings suggesting an
underlying or coexisting medical condition or substance use;
2) List and interpret critical investigations, including
a. Appropriate laboratory investigations and other tests (e.g., neuroimaging);
3) Construct an effective management plan, including
a. Ensuring safety of patient and others (e.g., certification);
b. Ensuring ongoing assessment of capacity and the need for a substitute decision-maker;
c. Pharmacotherapy (both acute and maintenance);
d. Attending to the patient's psychosocial needs (e.g., community and family resources, housing);
e. Treating underlying disorders or comorbidities;
f. Counselling and supporting patient/caregiver/family about psychosis;
g. Referring the patient for specialized care, if necessary.

155
89 – RENAL FAILURE
89.1 Acute kidney disease

Rationale

Acute kidney injury is defined as a rising serum creatinine over a short period of time and is associated with
morbidity and mortality.

Causal conditions (list not exhaustive)

1) Pre-renal causes
a. Renal hypo-perfusion (e.g., hepato-renal syndrome, angiotensin-converting enzyme inhibitor
with bilateral renal artery stenosis)
b. Systemic hypo-perfusion (e.g., shock, hypovolemia)
2) Renal causes
a. Tubulointerstitial (e.g., acute tubular necrosis, interstitial nephritis)
b. Glomerular (e.g., glomerulonephritis, thrombotic thrombocytopenic purpura/hemolytic
uremic syndrome)
c. Vascular (e.g., cholesterol emboli)
3) Post-renal/Obstruction (e.g., prostatic hypertrophy, cervical cancer, calculi)

Key objectives

Given a patient with acute kidney injury, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, the candidate must recognize situations in which
urgent intervention is required.

Enabling objectives

Given a patient with acute kidney injury, the candidate will

1) List and interpret critical clinical findings, including

a. Results of history and physical examination aimed at determining the most likely cause of the
acute kidney injury (e.g., medications, volume status);
2) List and interpret critical investigations, including
a. Laboratory tests to determine the underlying cause and severity (e.g., urinalysis, serum/urine
electrolytes, serum creatinine and potassium);
b. Renal ultrasonography, if indicated;
3) Construct an effective initial management plan, including
a. Assessing the need for urgent intervention (e.g., dialysis, fluid resuscitation, or urinary
catheterization);
b. Managing the patient's fluid and dietary intake;
c. Determining whether the patient requires specialized care (indications for dialysis).

156
89.2 Chronic kidney disease

Rationale

Chronic kidney injury is defined as persistently elevated serum creatinine. It is associated with increased
morbidity, mortality, and health care costs.

Causal conditions (list not exhaustive)

1) Pre-renal causes (e.g., blood pressure)

2) Renal causes
a. Glomerular (e.g., IgA nephropathy, diabetic nephropathy)
b. Tubulo-interstitial (e.g., drug toxicity)
c. Ischemic
d. Congenital (e.g., dysplasia, polycystic kidney disease)
3) Post-renal (e.g., obstructive uropathy)

Key objectives

Given a patient with chronic kidney injury, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan.

Enabling objectives

Given a patient with chronic kidney injury, the candidate will

1) List and interpret critical clinical findings, including

a. Those derived from an appropriate history and physical examination aimed at determining
causal conditions and manifestations of chronic kidney injury;
2) List and interpret the appropriate laboratory, including
a. Diagnostic imaging investigations needed to make the diagnosis and determining potential
complications;
3) Construct an effective initial management plan, including
a. Instituting immediate measures to correct metabolic abnormalities (e.g., fluids, electrolytes,
treatment of acidosis);
b. Instituting immediate measures to prevent further loss of renal function (e.g., blood pressure
control, steroids for autoimmune disorders);
c. Determining whether the patient requires urgent or specialized care (e.g., dialysis);
d. Determining whether the patient requires more specialized management (e.g., intensive long-
term integrated care, dialysis and/or transplantation);
e. Counseling re lifestyle changes in anticipation of long-term consequences and prevention of
further complications.

157
90 – SCROTAL MASS
Rationale

In children and adolescents, scrotal masses do not always require treatment; other times, urgent treatment is
required. Although a scrotal mass in adults is likely to be benign, it is important to recognize when it is a
malignant tumor.

Causal conditions (list not exhaustive)

1) Cystic (e.g., hydrocele)

2) Solid
a. Benign (e.g., hematoma)
b. Malignant (e.g., seminoma)
c. Inflammatory or infectious (e.g., orchitis, scrotal abscess)

Key objectives

Given a patient with a scrotal mass, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management, in particular, differentiate malignant testicular tumors from other types of
scrotal masses.

Enabling objectives

Given a patient with a scrotal mass, the candidate will

1) List and interpret critical clinical findings, including

a. History and physical examination results, in particular to diagnose an urgent case (i.e., right-
sided varicocele, malignant testicular tumor, and torsion);
2) List and interpret critical investigations, including
a. Laboratory and radiological studies, in particular, tumor markers, doppler ultrasound, or
computed tomography (CT) scan, as appropriate;
3) Construct an effective initial management plan, including
a. In the case of a young patient, counsel and educate him about regular testicular self-
examination;
b. Determine whether the patient requires an urgent or a non-urgent referral;
c. Counsel, educate, and reassure the patient with a benign scrotal mass.

158
91 – SCROTAL PAIN
Rationale

Scrotal pain is a common presentation to both primary care and Emergency Department settings. Of the
potential underlying causes, certain conditions require urgent diagnosis and management to avoid serious and
long-standing complications. Pain may also precede the development of an obvious mass in the scrotum.

Causal conditions (list not exhaustive)

1) Testicular torsion
2) Inflammation (e.g., acute epididymitis, orchitis, trauma)
3) Incarcerated/Strangulated hernia
4) Hemorrhage into testicular tumor

Key objectives

Given a patient with scrotal pain, the candidate will diagnosis the cause, severity and complications, and will
initiate an appropriate management plan. Particular attention should be paid to the sudden onset of pain, which
requires emergent investigation for testicular torsion.

Enabling objectives

Given a patient with scrotal pain, the candidate will

1) List and interpret critical clinical findings, including

a. A thorough history of the presentation, including a sexual history;
b. An appropriate abdominal and genital examination;
c. Identifying the urgency of the presentation;
2) List and interpret critical clinical and laboratory findings which were key in the processes of exclusion,
differentiation, and diagnosis (e.g., ultrasound, screening for sexually transmitted infections, complete
blood count)
3) Construct an effective initial plan of management, including
a. Referral for specialized care (e.g., operative intervention), if necessary;
b. Appropriate pharmacologic management (e.g., antibiotics, analgesics);
c. Counseling regarding safe sexual practices when appropriate.

159
92 – SEIZURES / EPILEPSY
Rationale

Seizures are common and present in a variety of settings. They have many underlying causes and can be both
disabling and life-threatening.

Causal conditions (list not exhaustive)

1) Primary neurological disorders (e.g., idiopathic epilepsy, head trauma, encephalitis)

2) Systemic disorders (e.g., hypoglycemia, electrolyte disorders)
3) Other (e.g., febrile seizures, withdrawal)

Key objectives

Given a patient presenting with (a) seizure(s), the candidate will diagnose the cause, severity, and complications,
and will initiate appropriate management. The candidate will differentiate a seizure from other transient but
non-seizure conditions (e.g., syncope, conversion disorder). As well, the candidate will consider the presence of
seizures in patients presenting with episodic neurological symptoms (e.g., inattention, psychosis). The candidate
will outline a plan for the emergent treatment of a patient presenting with a seizure.

Enabling objectives

Given a patient presenting with (a) seizure(s), the candidate will

1) List and interpret critical clinical symptoms and findings, including those uncovered during an
appropriate history and physical examination conducted in order to
a. Differentiate between a true seizure and non-seizure conditions;
b. Categorize the type(s) of seizure(s);
c. Determine if seizures are secondary to co-existing medical conditions;
d. Identify pre-morbid conditions, triggers, and circumstances leading to the seizure (e.g.,
medication non-adherence);
e. Monitor for complications resulting from seizure prophylaxis medications (e.g., weight gain);
2) List and interpret critical investigations, including those conducted in order to
a. Exclude underlying medical conditions (e.g., serum glucose);
b. Investigate for possible intracranial pathology (e.g., computed tomography scan, magnetic
resonance imaging);
c. Investigate seizure type (e.g., electroencephalography);
d. Monitor for complications related to seizure prophylaxis medications (e.g., lipid profile);
3) Construct an effective initial management plan, including
a. Providing emergent management of an ongoing seizure;
b. Ensuring appropriate management if the patient presents with a history of seizures, including
counselling (e.g., personal safety, psychosocial impact), pharmacotherapy and appropriate
follow-up;
c. Referring the patient for specialized care, if necessary;
d. Notifying the patient and/or the appropriate authorities in case of inability to drive.

160
93 – SEXUAL MATURATION
93.1 Abnormal pubertal development

Rationale

Puberty is the transition from childhood to adolescence, physiologically and psychosocially. Questions about
typical and atypical pubertal development are a common reason for presentation to primary care clinics.
Abnormalities in pubertal development can be indicators of severe underlying disorders, and can be a cause of
significant anxiety for patients and families. They require careful investigation and follow-up.

Causal conditions (list not exhaustive)

1) Delayed puberty
a. Variant of normal constitutional delay of puberty
b. Primary gonadal disorders
i. Congenital
1. Chromosomal (e.g., Turner and Kleinfelter Syndromes)
2. Congenital malformations
ii. Acquired gonadal disorders (e.g., gonadal infection, trauma, neoplasm)
c. Secondary gonadal disorders
i. Functional (e.g., chronic illness, malnutrition)
ii. Hypothalamic dysfunction (e.g., hyperprolactinemia, exogenous steroids)
iii. Pituitary dysfunction (e.g., central nervous system [CNS] tumor)
2) Precocious puberty
a. Central precocious puberty (gonadotropin-dependent)
i. Idiopathic
ii. Central nervous system (e.g., neoplasms, hydrocephalus)
b. Peripheral precocious puberty (gonadotropin-independent)
i. Autonomous gonadal function (e.g., ovarian cysts, Leydig cell tumors of ovaries or
testes)
ii. Adrenal pathology (e.g., tumors, congenital adrenal hyperplasia)
iii. Exogenous sex hormone exposure
3) Incomplete precocious puberty (e.g., premature thelarche, premature adrenarche)

Key objectives

Given a patient with concerns about pubertal development, the candidate will identify the cause, severity, and
complications, and will initiate an appropriate management plan. Particular attention should be paid to
distinguishing normal variants of pubertal development from symptoms of serious underlying disorders, and to
supportive counseling regarding the psychosocial aspects of puberty.

Enabling objectives

Given a patient with concerns about pubertal development, the candidate will

1) List and interpret relevant clinical findings, including

a. Obtaining an appropriate history with particular attention to growth and development,
nutrition, and symptoms of underlying systemic disease;
b. Performing an appropriate physical examination with particular attention to tanner staging of
pubertal development, and to signs of underlying disorders (e.g. CNS tumors, eating
disorders);

161
2) List and interpret relevant investigations, including
a. Differentiation of normal variants from serious or urgent underlying conditions (e.g., central
nervous system or pelvic imaging if neoplasm is suspected);
3) Conduct an effective initial management plan, including
a. Reassurance in case of normal variants of pubertal development;
b. Referral for appropriate specialized care (e.g., pediatrics, endocrinology, genetics, neurology),
in case of abnormal pubertal development;
c. Supportive counseling to the patient and his family regarding the psychosocial implications of
abnormal pubertal development.

162
94 – SEXUAL DYSFUNCTIONS AND DISORDERS
Rationale

Sexual dysfunction includes clinically significant disturbances in the ability to respond sexually or to experience
sexual pleasure. Some sexual behaviours may cause harm.

Causal conditions (list not exhaustive)

1) Erectile or orgasmic dysfunctions

a. Psychological or emotional (e.g., depression, abuse)
b. Neurologic dysfunction (e.g., spinal cord injury)
c. Vascular insufficiency (e.g., diabetes)
d. Drug adverse effects (e.g., β-blockers)
e. Aging
2) Genito-pelvic pain or penetration issues (dyspareunia)
a. Trauma (e.g., episiotomy)
b. Hormonal (e.g., vulvovaginal atrophy postmenopause)
c. Other pelvic pathology (e.g., endometriosis, pelvic inflammatory disease)
3) Substance- or medication-induced sexual dysfunction (e.g., alcohol, sedatives)
4) Gender dysphoria
5) Sexual disorders
a. Paraphilic disorders (e.g., sexual sadism, pedophilia, fetishes causing harm)
b. Sexual addiction
c. Arousal disorders
d. Anorgasmia

Key objectives

Given a patient with sexual dysfunction or disorder, the candidate will address the issues and offer appropriate
support and management measures. Because these issues can be emotional, physicians should strive to
approach them in an unbiased and nonjudgmental way, with respect for the patient's wishes and values.

Enabling objectives

Given a patient with sexual issues, the candidate will

1) List and interpret critical clinical findings, including those derived from an appropriate history,
including the patient’s physical and sexual development and their comfort with their sexuality, and a
physical examination, where appropriate, to
a. Identify treatable causes (e.g., atrophic vaginitis, diabetes, antidepressant medications);
b. Differentiate between sexual dysfunction versus sexual activity causing harm;
2) List and interpret critical investigations as required to identify underlying causes;
3) Construct an effective initial management plan for underlying issues:
a. Construct a relevant safety plan where appropriate;
b. Prescribe medications where appropriate (e.g., sildenafil, estrogen);
c. Determine whether the patient requires specialized care;
d. Engage psychosocial support where appropriate;
e. Counsel and educate.

163
94.1 Gender and sexuality

Rationale

Gender-and/or sexuality-related issues may include sexual function, navigating sexual relationships, sexual
orientation, gender identity, gender expression, access to care, and other issues. Physicians should be sensitive
to gender and/or sexuality as part of any patient encounter, whether patients explicitly express concerns in this
regard. Physicians should put patients at ease to facilitate discussion.

Various populations (list not exhaustive)

1) Children and adolescents

2) Adults
3) Elderly patients
4) Patients living with disabilities
5) Heterosexual
6) Lesbian, gay, bisexual, and/or queer
7) Cisgender
8) Transgender, two-spirit, and/or nonbinary

Key objectives

Given a patient with gender- and/or sexuality-related issues, the candidate will provide respectful care and offer
appropriate support and management measures, regardless of patient sexual orientation and gender identity.
Physicians should strive to approach discussions about gender and/or sexuality in an unbiased and
nonjudgmental way, with respect for patients’ wishes and values.

Enabling objectives

Given a patient with gender- and/or sexuality-related issues, the candidate will

1) List and interpret critical clinical findings, including those derived from an appropriate history,
including cultural factors, and a physical examination to
a. Determine social and physical sexual development and behaviour, as well as sexual orientation
and gender identity;
b. Identify risk factors for related physical or mental health issues;
c. Differentiate between diversity within sexual practices and expression and experiences of
sexually-related illnesses or disorders;
d. Detect individuals who have experienced sexual abuse or assault;
2) Construct an effective initial management plan, including
a. Ensuring the management plan aligns with the patient's goals and desires;
b. Recognition and reassurance that no intervention may be required;
c. Pharmacotherapy where appropriate (e.g., oral contraceptives, hormonal therapy,
immunization);
d. Counselling and educating of patients;
e. Determining whether the patient requires specialized care (e.g., psychologist, sexual therapist);
f. Engaging community and family support, where appropriate.

164
97 – SKIN RASH / PAPULES
97.2 Urticaria / Angioedema

Rationale

Urticaria is a common disorder, and if chronic, may result in significant disability. Angioedema, which may
coexist with urticaria, may be life threatening if airway obstruction occurs from laryngeal edema or tongue
swelling. Both may occur with anaphylaxis.

Causal conditions (list not exhaustive)

1) Idiopathic
2) Associated with identifiable causes
a. Allergic (e.g., drugs, insects, food)
b. Direct mast cell release (e.g., opiates, radio-contrast agents)
c. Complement-mediated (e.g., serum sickness, infections)
d. Physical (e.g., dermatographism, cold)
e. Other (e.g., mastocytosis, hereditary angioedema)

Key objectives

Given a patient with urticaria/angioedema, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, the candidate will determine whether the
condition is acute and/or life threatening and requires immediate treatment.

Enabling objectives

Given a patient with urticaria/angioedema, the candidate will

1) List and interpret critical clinical findings, including

a. Elicit a history and physical examination including timing of symptom onset, duration of
lesions, and identification of precipitants;
b. Detect the presence of or the risk for serious cardio-respiratory distress or anaphylaxis;
c. Determine chronicity, and possible association with systemic disease;
2) List and interpret critical investigations, including
a. Recognizing that laboratory investigation in both acute and chronic disease is often normal
and therefore unnecessary;
3) Construct an effective initial management plan, including
a. Determination of the need for emergent/urgent intervention;
b. Identification and discontinuation of offending trigger or pharmacologic agents;
c. Initiation of appropriate medication (e.g., antihistamine, steroids);
d. Prescription of and counseling in use of injectable epinephrine.

165
98 – SLEEP-WAKE DISORDERS
Rationale

Sleep-Wake Disorders are commonly encountered in medical practice and various medical specialties. They
may be episodic or persistent, but the result is inadequate quantity or quality of sleep and impaired daytime
functioning.

Causal conditions (list not exhaustive)

1) External Factors contributing to sleep disruption (e.g. Poor sleep environment)

2) Intrinsic sleep disorders (e.g. Circadian rhythm disorders, insomnia, sleep-disordered breathing)
3) Co-morbid conditions (e.g. Psychiatric disorders, neurologic disorders, substance abuse, dyspnea)

Key objectives

Given a patient with a sleep disorder, the candidate will diagnose the cause, severity and complications, and will
initiate an appropriate plan for management.

Enabling objectives

Given a patient with a sleep disorder, the candidate will

1) Conduct a thorough sleep history, including collateral history and sleep log, if necessary;
2) Conduct a physical examination, if appropriate;
3) Determine if a patient requires specialized investigations (e.g. Polysomnography);
4) Counsel the patient on the management of the sleep disorder, depending on the underlying cause;
5) Screen for safety concerns (e.g. excessive daytime somnolence).

166
99 – SODIUM CONCENTRATION SERUM, ABNORMAL
99.1 Hypernatremia

Rationale

Increased serum sodium concentration is encountered more frequently in the elderly and in infants. Both
hypernatremia and treatment of hypernatremia may be associated with neurological complications.

Causal conditions (list not exhaustive)

1) Water depletion (dehydration)

a. Decreased intake of water (e.g., impaired thirst)
b. Increased loss
i. Renal loss (e.g., osmotic diuresis)
ii. Gastrointestinal loss (e.g., diarrhea)
iii. Increased insensible loss (e.g., prolonged exercise)
2) Sodium gain (e.g., hypertonic fluid replacement)

Key objectives

Given a patient with hypernatremia, the candidate will diagnose the cause, severity and complications, and
initiate an appropriate management plan. In particular, the candidate will recognize that most cases occur in the
frail elderly population due to conditions associated with water depletion.

Enabling objectives

Given a patient with hypernatremia, the candidate will

1) List and interpret critical clinical findings, including

a. History aimed at identifying the common triggers and the clinical consequences of
hypernatremia;
b. Physical examination with careful assessment of volume status and the neurological effects of
hypernatremia;
2) List and interpret critical investigations, including
a. Estimation of water deficit;
b. Specific laboratory and other investigations for underlying medical conditions (e.g., blood
glucose, brain imaging);
3) Construct an effective initial management plan, including
a. Establishing a short-term and long-term plan for correcting the sodium concentration, with
recognition of the neurological consequences of overly rapid correction;
b. Correcting causes of hypernatremia.

167
99.2 Hyponatremia

Rationale

Decreased serum sodium concentration is common with a multitude of underlying etiologies. Both
hyponatremia and treatment of hyponatremia may be associated with neurological complications.

Causal conditions (list not exhaustive)

1) Hyponatremia with normal serum osmolality (e.g., hyperlipidemia)

2) Hyponatremia with high serum osmolality (e.g., hyperglycemia)
3) Hyponatremia with low serum osmolality
a. Total body water low, elevated antidiuretic hormone (ADH) level (e.g., gastrointestinal loss,
diuretic use)
b. Total body water volume normal (e.g., syndrome of inappropriate ADH secretion,
hypothyroidism, adrenal insufficiency)
c. Total body water high, elevated ADH level (e.g., congestive heart failure, nephrotic syndrome,
cirrhosis)

Key objectives

Given a patient with hyponatremia, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan, recognizing that severe hyponatremia can be life-threatening.

Enabling objectives

Given a patient with hyponatremia, the candidate will

1) List and interpret critical clinical findings, including

a. Appropriate history and physical examination, with particular attention to assessment of
volume status;
2) List and interpret key investigations directed towards establishing the underlying etiology, including
plasma and urine osmolality and urine electrolytes;
3) Construct an effective initial management plan, including
a. A therapeutic approach based on the underlying etiology;
b. Understanding the risk factors for, and how to avoid central pontine myelinolysis;
c. Correcting serum sodium at an appropriate rate and understanding the risks and indications
for more rapid correction of sodium concentration.

168
100 – SORE THROAT / RHINORRHEA
Rationale

Sore throat and rhinorrhea are very common clinical presentations. Inappropriate use of antibiotics for viral
pharyngitis is a significant contributing factor to antibiotic resistance.

Causal conditions (list not exhaustive)

1) Infections (e.g., viral, bacterial, candidial)

2) Allergic (e.g., chronic allergic rhinosinusitis)
3) Other (e.g., trauma, neoplasm, foreign body)

Key objectives

Given a patient with a sore throat and/or rhinorrhea, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with a sore throat and/or rhinorrhea, the candidate will

1) List and interpret critical clinical findings, including

a. Presence or absence of fever, cough, cervical lymphadenopathy, tonsillar exudates;
b. Relationship to environmental exposure;
c. Visual inspection of the nose and oropharynx;
2) List and interpret critical clinical investigations, including
a. Determining whether further testing for group a streptococci is indicated;
b. Determining if an allergy or more unusual cause for rhinorrhea is present;
c. Determining the need for blood testing (e.g., monospot);
3) Construct an effective initial management plan, including
a. Appropriate use of antibiotics;
b. Recognition of the role of antibiotics (e.g., prevention of acute rheumatic fever);
c. Determination as to whether the patient requires specialized care.

169
101 – STATURE ABNORMAL (TALL STATURE / SHORT
STATURE)
Rationale

Normal growth is a reflection of a child's general health. Deviations may be due to illness, genetics or other
environmental factors.

Causal conditions (list not exhaustive)

1) Tall Stature
a. Genetic (e.g., Marfan's syndrome)
b. Endocrine (e.g., excess growth hormone)
2) Short Stature
a. Genetic (e.g., Down syndrome)
b. Systemic disorders (e.g., chronic disease and treatment complications)
c. Environmental
i. Malnutrition
ii. Psychosocial deprivation
iii. Toxins/drugs
d. Intrauterine growth restriction [WEIGHT (LOW) AT BIRTH/INTRAUTERINE
GROWTH RESTRICTION]

Key objectives

Given a patient with abnormal stature, the candidate will diagnose the cause, severity, and complications, and
will initiate an appropriate management plan. In particular, the candidate will determine whether the growth
pattern is pathological or normal and determine whether the child has dysmorphic features.

Enabling objectives

Given a patient with abnormal stature, the candidate will

1) List and interpret critical findings, including

a. Determine if the child is following normal growth pattern (e.g., accurate growth chart, family
history);
b. Take a history to identify factors resulting in abnormal growth:
i. Maternal or intra-uterine environmental factors;
ii. Phases of growth;
iii. Underlying medical conditions or other environmental factors;
c. Identify dysmorphic features on physical examination;
2) List and interpret critical investigations, if needed (e.g., x-ray of wrist for bone age);
3) Construct an effective initial management plan, including
a. Counsel the family and the child with questions about stature;
b. Refer the patient for specialized care, if necessary.

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102 – STRABISMUS / AMBLYOPIA
Rationale

Screening programs for strabismus, as well as parental concern about children with a wandering eye, crossing
eye, or poor vision in one eye, require physicians to be able to detect this condition and be familiar with initial
management steps. Failure to identify and treat this condition in a timely manner may result in visual defects
and psychosocial and vocational consequences.

Causal conditions (list not exhaustive)

1) Esotropia (convergent, internal, cross-eye) -- congenital and acquired

2) Transient (e.g., presents at less than 4 months of age)
3) Idiopathic (esotropia and exotropia)
4) Neurogenic strabismus (e.g., cranial nerve paresis)
5) Myogenic strabismus (e.g., mechanical restriction, neuromuscular junction defect, muscle
disease/inflammation)
6) Sensory strabismus (loss of vision due to organic ocular anomalies causing strabismus)
7) Amblyopia without strabismus

Key objectives

Given a patient with strabismus and/or amblyopia, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriately timed management plan. In particular, he will determine the
type of strabismus and the necessary urgency of intervention, in order to prevent the development of severe
amblyopia.

Enabling objectives

Given a patient with strabismus and/or amblyopia, or a history of risk factors for same, the candidate will

1) Identify the risk factors for the development of strabismus or amblyopia in a child (e.g., prematurity,
family history);
2) List and interpret key components of the history and physical exam with particular attention to
a. Differentiating pseudo strabismus (e.g., lid configuration) from true strabismus;
b. Conducting a thorough ocular exam including visual acuity if appropriate;
3) Construct an effective initial management plan, including
a. Determine if the patient requires further investigation or a referral based on the risk factors or
the clinical findings;
b. Counsel parents about the need for timely referral to manage strabismus in order to prevent
the development of amblyopia.

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103 – SUBSTANCE USE OR ADDICTIVE DISORDERS
Rationale

Substance use disorders include addiction to substances such as stimulants (e.g., cocaine, amphetamines),
depressants (e.g., opioids, benzodiazepines) and other substances (e.g., nicotine, alcohol). Addictive disorders
include process (behavioural) addictions such as gambling. The neurobiological basis of addiction is similar for
substance use disorders and addictive disorders. Both disorders can cause direct or indirect harm to patients
and families. Harm can occur during intoxication and withdrawal and may adversely affect the individual’s
social functioning. There is frequently overlap between addictions, and comorbidities are the rule rather than
the exception. Physicians should be aware of the risk of addiction and adhere to best practices when prescribing
potentially habit-forming medications.

Causal conditions (list not exhaustive)

1) Adverse childhood or traumatic experiences

2) Epigenetic factors
3) Comorbid illnesses (e.g., mental illness, chronic disease, trauma, including acute and chronic pain)
4) Psychosocial stressors (e.g., unemployment, social isolation, and systemic racism and other social
determinants)

Key objectives

Given a patient with substance use or addictive disorders, the candidate will identify the issue, potential
consequences, and the need for immediate intervention and ongoing support. Given a patient with chronic pain
or other condition who is at risk for substance use and/or addictive disorder, the candidate will prescribe
medications with due care. Because these issues can be emotional, physicians should strive to approach them in
an unbiased and nonjudgmental way, with respect for patient wishes and values.

Enabling objectives

Given a patient with chronic pain or other condition who is at risk for substance use and/or addictive disorder,
the candidate will

1. List and interpret clinical findings, including the potential for habituation, and indicate the most
appropriate medication for the diagnosis;
2. Construct a management plan, including
1. Prescribing according to evidence-based guidelines (e.g., dosage, prescription interval,
monitoring of drug use) to minimize addiction;
2. Initiating alternative therapy or taper/stop therapy where there is evidence of ineffectiveness
or habituation (e.g., physiotherapy, psychotherapy).

Given a patient with a substance use disorder, the candidate will

1) List and interpret critical findings, including those derived from

a. An appropriate history, including a collateral history, relevant to the presenting problem and
previous, possibly addictive behaviour and patient insight into the condition, to determine the
duration and severity of any substance overuse or addiction;
b. An appropriate physical examination aimed at determining potential withdrawal symptoms and
comorbidities, if necessary;
2) List and interpret critical investigations, including laboratory or diagnostic imaging (e.g., drug
screening, liver function studies); and recognition of when explicit consent (e.g., drug testing) may be
required;

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 3) In collaboration with the patient, construct an initial management plan, including
a. Explaining behavioural modification options and appropriate pharmacological intervention
(e.g., nicotine or opioid replacement therapy);
b. Determining whether the patient or their family members require specialized psychological or
other support services (e.g., addiction treatment) delivered at the individual, family, and/or
community level;
c. Anticipating medium- and long-term complications (e.g., psychosocial effect, safety);
d. Advocating for harm reduction strategies (e.g., safe injection sites, naloxone administration
education).

Given a patient with a behavioural addictive disorder, the candidate will

1. List and interpret critical clinical findings including, those derived from
1. An appropriate history, including a collateral history, relevant to the presenting problem and
previous, possibly addictive behaviour and patient insight into the condition, to determine the
duration and severity;
2. An appropriate physical examination aimed at determining potential symptoms and
comorbidities (e.g., lack of sleep, social neglect, physical deconditioning, depression), if
necessary;
2. In collaboration with the patient, construct an initial management plan, including
1. Explaining behavioural modification options and appropriate pharmacological intervention
(e.g., SSRIs, SNRIs);
2. Determining whether the patient or their family members require specialized psychological or
other support services delivered at the individual, family, or community level (e.g., addiction
treatment);
3. Anticipating medium- and long-term complications (e.g., psychosocial effect, safety).

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103.1 Substance withdrawal

Rationale

Substance withdrawal has been shown to cause significant morbidity and mortality worldwide and enormous
impacts on public health. Depending on the type of substance, there are withdrawal syndromes, which are
important to identify and treat.

Causal conditions (list not exhaustive)

1) Chemical dependency (e.g., alcohol, illicit drugs, tobacco, prescription drugs)

Key objectives

Given a patient with suspected substance withdrawal, the candidate will be able to identify the issue, potential
consequences and the need to provide immediate and continuing support and intervention.

Enabling objectives

Given a patient with suspected substance withdrawal, the candidate will

1. List and interpret critical clinical findings, including those derived from:
1. A thorough medical, family and social history (see also substance-related and addictive
disorders);
2. Collateral history, if indicated;
3. A physical examination with particular attention to mental status examination and autonomic
instability;
2. List and interpret critical investigations, including
1. Drug screening;
2. Use of appropriate screening tools (e.g., MMSE, CAGE, withdrawal assessment tools);
3. Laboratory or other investigative tests to screen for organ damage and other complications as
appropriate (e.g., liver function tests, chest radiography);
3. Construct an effective management plan, including
1. Supportive measures if required acutely (e.g., airway, fluid resuscitation, pain management);
2. A safe environment (e.g.: hospitalization, recovery centres);
3. Appropriate pharmacological intervention (e.g., thiamine, long-acting benzodiazepines,
sedation);
4. Referral for specialized care (e.g., addiction programs, family counseling, mental health
services), if necessary.

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104 – SUDDEN INFANT DEATH SYNDROME (SIDS)
Rationale

Sudden Infant Death Syndrome (SIDS) is a leading cause of death in infants between one month and one year
of life. SIDS is defined as the sudden death of an infant, which remains unexplained after a complete clinical
evaluation, including a complete autopsy and an examination of the death scene. Providing appropriate support
to grieving parents is an important management step. Awareness of known risk factors for SIDS and proven
preventive strategies is imperative.

Causal conditions (list not exhaustive)

By definition, the precise etiology of SIDS is currently unknown. Affected infants appear to have:

1) Underlying genetic or anatomic (e.g., brainstem abnormality) predisposition

2) A trigger event (e.g., maternal smoking, airflow obstruction)
3) Timing of a. And b. At a vulnerable stage of development.

Risk factors for SIDS and effective protective factors are known.

1) Risk factors:
a. Maternal factors
i. Young maternal age (less than 20 years)
ii. Maternal smoking during pregnancy
iii. Maternal alcohol and drug abuse during pregnancy
iv. Late or no prenatal care
b. Infant factors
i. Preterm birth and/or low birth weight
ii. Prone sleeping position
iii. Sleeping on a soft surface and/or with bedding accessories such as blankets and
pillows
iv. Sibling of a SIDS victim
c. Environmental factors
i. Exposure to second hand smoking
ii. Bed sharing
iii. Overheating
iv. Swaddling
d. Protective factors:
i. Room sharing
ii. Pacifier use
iii. Breastfeeding
iv. Fan use
v. Immunizations

Key objectives

Given the arrival of a new infant in a family, the candidate will provide preventive counselling to every parent
and caregiver about the known risk factors and preventive factors for SIDS.

Given the presentation of an infant with sudden infant death (SID), the candidate will evaluate fully the
possible risk factors and/or causes and initiate an appropriate management plan including a detailed clinical
evaluation, a request for a complete autopsy and involvement of the medical examiner (coroner).

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The candidate will also counsel the infant's parents/caregivers and family.

Enabling objectives

Given the arrival of a new infant in a family, the candidate will

1. Counsel parents/caregivers about preventative measures (e.g., smoking cessation during pregnancy and
during infancy, proper sleep attire/position of newborn);

Given an infant presenting with sudden unexpected infant death, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A detailed history of the event;
b. An evaluation of maternal, infant and environmental risk factors;
2) Include in the acute management a request for a complete autopsy and communication with the
medical examiner;
3) Effectively communicate the death of the infant to parents and families;
4) Initiate bereavement support.
5)

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104.1 Brief resolved unexplained event (BRUE)

Rationale

Life-threatening events involving infants are devastating to parents, caregivers and health care workers alike.
Brief resolved unexplained events (BRUE) are characterized by a non-specific, resolved and episodic
presentation, including any of the following: cyanosis or pallor; absent, decreased or irregular breathing; marked
change in tone (hypertonia or hypotonia; and/or altered responsiveness). The etiology of these events is
heterogeneous for a majority of infants; a specific cause may be identified following a focused history, physical
examination and targeted investigations.

Causal conditions (list not exhaustive)

An underlying etiology may be found in over half of infants presenting with BRUE. For those infants where a
cause cannot be identified through a focused clinical evaluation and/or initial investigations, stratification for
risk/probability of an occult pathology should guide further investigations and monitoring interventions.
Possible causes of BRUE include:

1) Misinterpretation of normal physiology in an infant (e.g., transient choking with rapid feeding or with
coughing during feeding, periodic breathing/ respiratory pauses of 5-15 seconds)
2) Infectious disease (e.g., respiratory infection, sepsis, meningitis, encephalitis)
3) Cardiopulmonary abnormalities (e.g., central or obstructive sleep apnea, arrhythmia)
4) Neurologic disease (e.g., epilepsy)
5) Child abuse (e.g., intentional suffocation, non-accidental head injury)
6) Metabolic disease (e.g., inborn error of metabolism)
7) Other (e.g., toxic ingestion, poisoning)

Key objectives

Given the presentation of an infant with a BRUE, the candidate will evaluate possible risk factors and/or
causes and initiate an appropriate management plan including investigations, interventions and follow-up. If an
etiology is not identified through the initial evaluation, the candidate will determine whether the severity of the
BRUE warrants more extensive investigation through the process of risk categorization.
The candidate will also counsel the infant's parents/caregivers and family.

Enabling objectives

Given an infant presenting with a BRUE, the candidate will

1) list and interpret critical clinical findings, including those derived from
a. a detailed history of the event;
b. an evaluation of maternal, infant and environmental risk factors;
c. the physical examination and/or direct observation;
2) list and interpret critical investigations based upon the clinical features (e.g., viral studies, chest
radiograph)
3) construct an effective initial management plan, including
a. admitting the patient for observation;
b. counselling and supporting the parents' emotional needs, clarifying the difference between
BRUE and sudden infant death syndrome (SIDS);
c. referring the parents if further investigations or interventions are required (e.g., high-risk
BRUE, cardiopulmonary resuscitation training for recurrent events);
d. referring the patient for specialized care/investigations, if required (e.g., metabolic testing,
cardiac evaluation).

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105 – SUICIDAL BEHAVIOUR
Rationale

Suicidal behavior is a common psychiatric emergency and a major cause of death across age groups. It causes
major distress to surviving relatives and others.

Causal conditions (list not exhaustive)

1) Psychiatric disorder (e.g., depression, schizophrenia)

2) Psychosocial stressors (e.g., divorce, adverse childhood experience)
3) Substance use
4) Other (e.g., serious chronic disease)

Key objectives

Given a patient with suicidal behavior, the candidate will determine the degree of risk and institute appropriate
management.
Enabling objectives

Given a patient with suicidal behavior, the candidate will

1) List and interpret critical clinical findings, including

a. Potential contributing conditions identified through an appropriate history and physical
examination;
b. Assessed and quantified risk for suicide, including imminent risk, recent stresses and life
events;
2) List and interpret critical investigations, including
a. Illicit drug and alcohol screen, where appropriate;
3) Construct an effective initial management plan, including
a. Ensuring the safety of patient at imminent risk for self-harm (e.g., urgent hospitalization),
including continuous observation while arrangements are being made;
b. Assessing capacity to make decisions if patient demands to leave;
c. Initiating management of underlying problems if the risk for suicide is not imminent (e.g.,
depression, psycho-social stressor);
d. Maintaining confidentiality while recognizing the benefits of support networks (e.g. Family,
culturally specific interventions);
e. Referring the patient for specialized care, if necessary.

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106 – SYNCOPE AND PRE-SYNCOPE
Rationale

Syncopal episodes, an abrupt and transient loss of consciousness followed by a rapid and usually complete
recovery, are common. Pre-syncope refers to the prodromal state of syncope. Syncope can easily be confused
with other symptoms (e.g. seizures) and is associated with a wide range of underlying conditions, both benign
and serious. In a subset of patients, a diagnosis will not be found.

Causal conditions (list not exhaustive)

1) Cardiovascular
a. Cardiac arrhythmia
b. Reduced cardiac output (e.g., aortic stenosis, myocardial infarction)
c. Reflex or underfilling (e.g., vasovagal, orthostatic)
2) Cerebrovascular causes (e.g., carotid artery disease, transient ischemic attack)
3) Other
a. Metabolic (e.g., hypoglycemia)
b. Drugs (e.g., anti-hypertensive medications)
c. Psychiatric (e.g., panic disorders)

Key objectives

Given a patient with syncope or pre-syncope, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, it is important to differentiate syncope from
seizure and identify patients with syncope due to serious underlying disorders.

Enabling objectives

Given a patient with syncope or pre-syncope, the candidate will

1. List and interpret key clinical findings, including

1. A targeted history and physical examination directed towards establishing an underlying
etiology;
2. List and interpret key investigations supported by the history and physical examination, with particular
attention to diagnosing disturbances of cardiac rhythm and function (e.g., electrocardiogram,
echocardiogram)
3. Construct an effective initial management plan, including
1. Medication management, if indicated;
2. Evaluating the patient for fitness to drive or work;
3. Counseling the patient who has had a syncope;
4. Determining whether the patient requires specialized care and/or consultation.

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107 – TEMPERATURE, ABNORMAL / FEVER AND/OR CHILLS
107.1 Fever and Hyperthermia

Rationale

Fever is an elevation of body temperature above the normal variation, which is induced by cytokine activation.
Fever is often due to infection but can be associated with malignancy, inflammatory disease or other causes. In
contrast, hyperthermia is an elevation in core body temperature due to thermoregulation failure.

Elevated body temperature is a common presentation which can be due to a mild, self-limited illness or to a
life-threatening medical emergency. Fever in an infant/child (107-3) is described in a separate objective.

Causal conditions (list not exhaustive)

1) Infectious causes
a. Bacteria (e.g., group A Streptococcus, Escherichia coli)
b. Viruses (e.g., influenza, measles)
c. Parasites (e.g., malaria)
d. Fungi (e.g., cryptococcus)
2) Inflammatory and malignant conditions (e.g., systemic lupus erythematosus, lymphoma)
3) Drugs (e.g., bleomycin, interferon)
4) Increased heat load (e.g., heat stroke)
5) Diminished heat dissipation (e.g., medications and illicit drugs)
6) Factitious

Key objectives

Given a patient with elevated body temperature, the candidate will diagnose the cause, severity and
complications, and will initiate appropriate management. In particular, the candidate will rule out life-
threatening conditions (e.g., meningococcal meningitis).

Enabling objectives

Given a patient with fever, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A relevant history;
i. Infectious symptoms (e.g., productive cough, dysuria, diarrhea);
ii. Travel history (e.g., geographic location and timing of trip, use of chemoprophylaxis);
iii. Host factors (e.g., immunocompromised state due to HIV, previous splenectomy);
iv. Non-infectious symptoms (e.g., weight loss, night sweats, arthralgias);
v. Environmental factors (e.g., heat exposure, exertion);
vi. Drug therapy (e.g., corticosteroids);
b. A relevant physical examination aiming at determining the cause;
2) List and interpret critical investigations, including
a. Targeted initial investigations, if required, to determine the cause (e.g., chest radiograph,
urinalysis, blood cultures);
b. Additional investigations for fever of unknown origin (e.g., bone marrow biopsy,
echocardiogram);
3) Construct an effective initial management plan, including
a. Initiating measures to reduce body temperature (e.g., acetaminophen, evaporative cooling);

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b. Treating the underlying cause (e.g., antimicrobials);
c. Determining whether specialized care is required;
d. Determining whether further preventative measures such as immunizations are necessary.

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107.4 Fever in the immune compromised host / Recurrent fever

Rationale

Patients with immunodeficiencies are at high risk for infections. The infective organism and site depend on the
type and severity of immunosuppression. Many of these infections are life-threatening.

Causal conditions (list not exhaustive)

1) Host defense defects

a. Cellular (e.g., human immunodeficiency virus (HIV), steroids)
b. Humoral (e.g., congenital)
c. Neutropenia (e.g., medication induced)
2) Anatomic barrier defects (e.g., surgery, burns)
3) Others (e.g., splenectomy, diabetes)

Key objectives

Given a patient with fever and immunodeficiency, the candidate will diagnose the cause, severity, and
complications, and will initiate appropriate management. In particular, the candidate will determine whether the
patient with fever is immunocompromised and the likely nature of the immune defect, perform appropriate
investigations to diagnose the source of infection, and will initiate appropriate management based on the type
and severity of the immunosuppression.

Enabling objectives

Given a patient with fever and immunodeficiency, the candidate will

1) List and interpret critical clinical findings, including

a. Conduct a focused history and physical examination to determine the site and type of
infection;
b. Determine the chief underlying immunologic defect and class of organisms likely to be
involved;
2) List and interpret critical investigations, including
a. Appropriate tests and investigations relevant to the suspected underlying immunologic defect
(e.g., complete blood count, bronchoscopy);
3) Construct an effective initial management plan, including
a. Outline strategies for prevention of infection (e.g., prophylactic immunization);
b. Outline the initial and urgent management for fever;
c. Determine if the patient requires specialized care.

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107.5 Hypothermia

Rationale

Hypothermia (central temperature less than 35 °C) can represent a medical emergency. Severe hypothermia is
defined as a core temperature of less than 28 °C.

Causal conditions (list not exhaustive)

1) Decreased heat production (e.g., hypothyroidism)

2) Increased heat loss (e.g., exposure)
3) Impaired thermoregulation (e.g., neurologic, metabolic, alcohol)

Key objectives

Given a patient with hypothermia, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate will recognize the severity of hypothermia
and provide urgent therapy.

Enabling objectives

Given a patient with hypothermia, the candidate will

1) List and interpret critical clinical findings, including

a. Determine the severity of hypothermia by using appropriate methods;
b. Determine whether concomitant illnesses, alcohol or drugs may have precipitated the
hypothermia;
2) List and interpret critical investigations, including
a. Investigations for underlying causes (e.g., thyroid-stimulating hormone);
3) Construct an effective initial management plan, including
a. Initiating life-saving treatment in case of severe hypothermia;
b. Understanding the advantages and disadvantages of active/passive external re-warming and
active core re-warming;
c. Conducting ongoing monitoring of patient during rewarming to identify complications (e.g.,
arrhythmia);
d. Determining if the patient requires further specialized care;
e. If the hypothermic patient is arrested, recognizing the need for rewarming prior to ceasing
resuscitation (particularly in the case of a child).

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108 – TINNITUS
Rationale

Tinnitus is an awareness of sound without an obvious external source. Although not usually related to serious
medical problems, it may interfere with daily activities, affect quality of life, and occasionally be indicative of
serious organic disease.

Causal conditions (list not exhaustive)

1) Auditory
a. External/Middle ear (e.g., otitis, wax)
b. Cochlear-vestibular end organ (e.g., medications, otosclerosis, environmental exposure)
c. Cochlear nerve (e.g., acoustic neuroma)
d. Brainstem/Cortex (e.g., ischemia, infection)
2) Para-auditory (e.g., venous hum, arterial bruits)

Key objectives

Given a patient with tinnitus, the candidate will diagnose the cause, severity, and complications, and will initiate
an appropriate management plan. In particular, the candidate should understand the distress that is caused by
this usually benign condition.

Enabling objectives

Given a patient with tinnitus, the candidate will

1) List and interpret critical clinical findings, including

a. Conduct an appropriate history and physical examination to classify and diagnose the cause
(e.g., disease-related, noise-related);
2) List and interpret critical clinical and laboratory findings which were key in the processes of exclusion,
differentiation, and diagnosis, including
a. Determination as to whether the patient requires further investigation based on clinical
findings;
3) Construct an effective plan of management, including
a. Refer the patient for specialized care, if necessary;
b. Counsel the patient if causes of tinnitus are deemed to be relatively benign (e.g., stop
medication, remove wax or foreign body).

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109 – TRAUMA
Rationale

Trauma is common. Physicians must be capable of assessing and treating patients with life-threatening
traumatic injuries.

Causal conditions (list not exhaustive)

1) Blunt trauma (e.g., blast injuries, deceleration injuries)

2) Penetrating trauma (e.g., stabbing, shooting)

Key objectives

Given a patient who has sustained trauma, the candidate will diagnose the cause, severity, and complications of
the injury, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with trauma, the candidate will

1) List and interpret critical clinical findings, including those derived from:
a. An appropriate history taken from patient or collateral;
b. An appropriate examination performed according to Advanced Trauma Life Support (ATLS)
guidelines, completing primary and secondary surveys in order to ensure that all external
evidence of injury is assessed;
2) Construct an effective initial management plan:
a. Initiate resuscitation of the injured patient and assess the patient's response to resuscitation;
b. Prevent secondary injury of the injured patient (e.g., hypoxia, hypovolemia, spinal injury);
c. Determine whether the patient needs to be referred for specialized care;
3) List and interpret investigations useful in the management of the injury (e.g., imaging,
electrocardiogram), keeping in mind that such tests should be deferred if the patient is unstable.

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109.1 Abdominal injuries

Rationale

Abdominal injuries are common and may be life threatening. Assessment of a patient with an abdominal injury
may be difficult as it may produce few clinical signs. Interpretation of the findings of physical examination of
the abdomen may also be difficult in the multiply injured patient who is unconscious.

Causal conditions (list not exhaustive)

1) Blunt trauma (e.g., blast injuries, deceleration injuries)

2) Penetrating trauma (e.g., stabbing, shooting)

Key objectives

Given a patient with an abdominal injury, the candidate will diagnose the cause, severity and complications, and
will initiate an appropriate management plan

Enabling objectives

Given a patient with trauma, the candidate will

1) list and interpret critical clinical findings, including

a. the mechanism of injury;
b. the signs of injury;
c. the identification of an abdominal injury that commonly occurs in association with other
serious injuries;
2) construct an effective initial management plan, including
a. initiate resuscitation and assess the patient's response to resuscitation;
b. determine whether the patient requires specialized care;
3) list and interpret critical investigations, including
a. appropriate laboratory investigations (e.g., serial CBC, urinalysis);
b. appropriate diagnostic testing (e.g., imaging, peritoneal lavage).
c.

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109.3 Bone or joint injury

Rationale

Bone and joint injuries are a frequent cause of musculoskeletal pain and may contribute to premature death.
Major fractures and dislocations may be associated with other injuries which may take priority. Unexplained
fractures in children should alert physicians to the possibility of abuse.

Causal conditions (list not exhaustive)

1) High energy trauma

2) Non-accidental injuries (e.g., domestic violence)
3) Falls
4) Pathologic conditions pre-disposing to injury (e.g., osteoporosis, ligamentous laxity)

Key objectives

Given a patient with acute onset of pain or deformity in the spine or extremities, the candidate will determine
whether the condition is due to a bone or a joint injury, assess the severity of the injury, identify possible
complications, and construct an appropriate management plan. The candidate will recognize situations where
the patient may have an increased risk of fracture.

Enabling objectives

Given a patient with acute onset of pain or deformity in the spine or extremities, the candidate will

1) List and interpret critical clinical findings, including

a. Mechanism of injury and, when required, exclusion of other immediately life-threatening
injuries through targeted examination;
b. Specific site of injury;
c. Neurological and vascular status;
d. Symptoms and signs suggestive of abuse;
e. History of recurrent falls;
f. Risks of bone abnormalities and/or increased risk of falls or injury;
g. Signs of pathologic fractures;
2) List and interpret critical investigations, including
a. An appropriate imaging modality as well as bone density test;
b. Investigations for causes of osteoporosis, where appropriate;
3) Conduct an effective initial management plan, including
a. Apply an appropriate splint, sling or brace;
b. Restrict weight bearing when indicated;
c. Prescribe analgesics and anti-inflammatory medications as required;
d. Refer to specialized care, if necessary;
e. Choose the correct treatment for prevention of fractures, including among pharmacological
and non-pharmacological treatments;
4) Provide follow-up care and address the following
a. Duration of immobilization;
b. Return to work and or normal activity;
c. Appropriate use of other health care professionals (e.g., physiotherapist, occupational
therapist);
d. Complications requiring further treatment or referral (e.g., complex regional pain syndrome,
compartment syndrome);

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e. Factors that will impact recovery from the injury (e.g., living situation, employment, nutrition,
addiction, general health).
f.

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109.4 Chest injuries

Rationale

Chest injuries are potentially life threatening. Injury to the chest may be blunt or penetrating.

Causal conditions (list not exhaustive)

1) Blunt trauma (e.g., blast injuries, deceleration injuries)

2) Penetrating trauma (e.g., stabbing, shooting)

Key objectives

Given a patient with a chest injury, the candidate will diagnose the cause, severity and complications, and
initiate an appropriate management plan. Since such patients frequently present in shock and/or respiratory
distress, particular attention should be paid to prompt resuscitation and stabilization of the patient.

Enabling objectives

Given a patient with chest injury, the candidate will

1) List and interpret critical clinical findings, including

a. The mechanism of injury;
b. The signs of injury;
c. The identification of signs and symptoms of common life-threatening chest injuries (e.g.,
aortic rupture, pericardial tamponade, tension pneumothorax, massive hemothorax);
2) Construct an effective initial management plan, including
a. Initiate resuscitation of the injured patient and assess the patient's response to resuscitation;
b. Recognize the indications for urgent intervention;
3) List and interpret critical investigations (e.g., imaging, electrocardiography), while keeping in mind that
such tests should be deferred until the patient is stabilized.

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109.6 Drowning (near-drowning)

Rationale

Near-drowning is defined as survival beyond 24 hours following a submersion event. Toddlers and young
children, adolescents and young adults, and the elderly are at increased risk.

Causal conditions (list not exhaustive)

1) Inability to swim (e.g., overestimation of capability)

2) Risk-taking behavior, boat accidents
3) Alcohol and substance abuse (over 50% of adult drowning deaths)
4) Inadequate adult supervision
5) Concomitant clinical difficulties
a. Trauma c. Cerebrovascular accident
b. Seizures d. Cardiac event

Key objectives

Given a patient with a history of a submersion event, the candidate with make the appropriate diagnosis of
near-drowning, assess the patient with respect to severity and complications, and will initiate an appropriate
management plan.

Enabling objectives

Given a patient with near-drowning, the candidate will

1) Recognize the need for careful rescue, paying attention to the safety and well-being of the rescuer(s)
2) Initiate appropriate cardiopulmonary resuscitation if/when appropriate
3) Demonstrate appropriate airway management when indicated (positive-pressure bag and mask,
endotracheal intubation)
4) Recognize the potential for co-existing trauma, including spinal cord injury, and implement appropriate
precautions
5) Initiate additional supportive therapy as indicated by the clinical situation, including oxygen
administration, intravenous fluid therapy and correction of hypothermia
6) Consult emergency medicine or critical care services appropriately when there is a need for intubation,
mechanical ventilation or cardiovascular support
7) Recognize the need to continue cardiopulmonary resuscitation until the victim's core body temperature
can be restored to 32-35 degrees Celsius in the event of a cold-water immersion/submersion
8) Recognize the need for an interval of observation (4 to 6 hours) following rescue/resuscitation from
near-drowning
9) Initiate appropriate cardiopulmonary and neurologic monitoring
10) Recognize potential complications of near-drowning, including cerebral edema, anoxic/ischemia
encephalopathy, cardiovascular collapse, ‘‘cardiac dysraspiration’’1, acute respiratory distress syndrome,
or co-existing trauma
11) Order and interpret diagnostic tests in a patient with suspected complications of near-drowning
(recommended: arterial blood gases, chest radiographs, complete blood count, electrolytes,
electrocardiogram; additional: international normalized ratio, partial thromboplastin time, urinalysis,
drug screen, urine myoglobin).

1 Note from the authors: this term is absent from the objectives in French, and seems to be a mistake/typo from the
MCC.

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109.8 Facial injuries

Rationale

Facial injuries have the potential to impact on both function and cosmetic appearance with resultant
psychological effects. Additionally, life-threatening complications due to damage to the airway and central
nervous system are possible.

Causal conditions (list not exhaustive)

1) Trauma (e.g., blunt, penetrating, crush injury)

2) Burns

Key objectives

Given a patient with a facial injury, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan, in particular, assess and control vital functions and give management
priority to life-threatening injuries.

Enabling objectives

Given a patient with a facial injury, the candidate will

1) List and interpret critical clinical findings, including

a. Elicit a history about the nature and mechanism of injury;
b. Evaluate airway, cardiopulmonary and neurologic status;
2) List and interpret critical investigations, including
a. Those used to determine the nature and severity of facial injuries;
3) Conduct an effective initial management plan, including
a. Outline the priorities in the treatment of the facial injury;
b. Outline and provide the initial treatment of the facial injury;
c. Address patient concerns regarding long-term complications (e.g., cosmetic appearance, effect
on function);
d. Determine whether the patient requires specialized care or referral.

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109.9 Hand / Wrist injuries

Rationale

Hand and/or wrist injuries are common problems. The impact of the injury on function depends upon the
severity of the original injury, the initial care, and rehabilitation.

Causal conditions (list not exhaustive)

1) Damage to tendons (e.g., laceration, tendonitis)

2) Damage to nerves (e.g., carpal tunnel syndrome)
3) Damage to bones and/or joints (e.g., fracture, dislocation)

Key objectives

Given a patient with a hand and/or wrist injury, the candidate will diagnose the cause, severity, and
complications, and initiate an appropriate management plan.

Enabling objectives

Given a patient with a hand and/or wrist injury, the candidate will

1) List and interpret critical clinical findings, including

a. If a history of trauma is present, a thorough exploration of the mechanism and timing of
injury;
b. Appropriate physical examination, including neurovascular assessment;
c. If appropriate screen for risk factors for repetitive strain injury;
d. An occupational and recreational history;
2) List and interpret critical investigations, including
a. Radiograph(s) of the affected bone(s) and joint(s), if indicated;
3) Construct an effective and relevant initial management plan, with particular attention to
a. Referral for specialist care, if appropriate;
b. Involvement of other health professionals as indicated;
c. If splinting is required, demonstration of proper "position of safety";
d. Appropriate analgesia;
e. Counselling regarding appropriate return to work or play;
f. Recognition of the potential for long-term impact on function.

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109.10 Head trauma / Brain death / Transplant donations

Rationale

While most head trauma is mild and not associated with long-term sequelae, clinical examination may fail to
detect serious intracranial injuries that are evident on radiological imaging. Therefore, it is imperative to
recognize head injured patients that require additional diagnostic imaging. When brain death has occurred,
organ transplantation should be considered.

Causal conditions (list not exhaustive)

1) Skull fracture, penetrating injury

2) Hemorrhage, hematoma (subdural, epidural, subarachnoid, shaken baby syndrome)
3) Cerebral contusion
4) Edema (midline shift)

Key objectives

Given a patient with a head/brain injury, the candidate will diagnose the cause, severity and complications. In
particular, the candidate will, based on the mechanism of injury and the clinical findings, determine the
appropriate management plan and select appropriate imaging and ongoing surveillance. In case where brain
death has occurred, ensure that appropriate organ donation protocol be activated.

Enabling objectives

Given a patient with a head/brain injury, the candidate will

1) List and interpret critical clinical findings, including those derived from
a. A history aimed at determining if the head injury was severe, or associated with complication
(e.g., mechanism of injury, loss of consciousness);
b. A physical examination aimed at determining if the head injury was severe, or associated with
complication (e.g., ecchymosis behind ear);
c. A repeat history or examination aimed at detecting evolving pathology;
d. Clinical signs of brain death;
2) List and interpret critical investigations, including
a. Determination as to whether the patient requires urgent brain imaging;
b. Confirmation of brain death with appropriate investigations;
3) Conduct an effective initial management plan, including
a. Determine if the patient requires specialized or urgent care;
b. In a patient whose head injury has caused brain death, but whose heart is still beating,
communicate this information to the transplantation team (or equivalent) if the deceased
patient or the family have indicated a desire to donate organ(s);
c. If there is no indication that organ donation has been considered, counsel the family about the
possibility.

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109.11 Nerve injury

Rationale

Peripheral nerve injuries often occur as part of more extensive trauma and often go unrecognized. Evaluation
of these injuries is based on an accurate knowledge of the anatomy and function of the nerve(s) involved.

Causal conditions (list not exhaustive)

1) Compression, stretch
2) Contusion
3) Laceration

Key objectives

Given a patient with a potential nerve injury, the candidate will diagnose the cause, severity and complications,
and initiate an appropriate management plan. In particular, the candidate will identify the peripheral nerve
involved, as well as the level and type of involvement.

Enabling objectives

Given a patient with a potential nerve injury, the candidate will

1) List and interpret critical clinical findings, including:

a. Features on occupational history and physical examination that can help determine whether a
peripheral nerve injury has occurred in the setting of other trauma;
b. The specific nerve involvement;
c. A differential diagnosis based on differentiation of a nerve injury from other neurologic
disorders (e.g., non-traumatic neuropathies, central lesions);
2) List and interpret critical investigations, including
a. Tests used to diagnose the presence of a traumatic peripheral neuropathy;
3) Construct an effective initial management plan, including
a. Listing indications for specialized care.

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109.12 Skin wounds

Rationale

Physicians must be able to deal with skin and subcutaneous wounds which occur commonly.

Causal conditions (list not exhaustive)

1) Lacerations
2) Puncture wounds (e.g., bites, needle sticks)
3) Crush injuries
4) Other (e.g., avulsions, abrasions)

Key objectives

Given a patient with a skin wound, the candidate will diagnose the cause, severity and complications, and
initiate an appropriate management plan. In particular, prior to wound closure, the candidate will look for
evidence of injuries involving important underlying structures and search for foreign bodies within the wound
and evidence of contamination, as well as consider tetanus immunization.

Enabling objectives

Given a patient with a skin wound, the candidate will

1) List and interpret critical clinical findings, including

a. Determination of the mechanism of injury, the nature and severity of the skin wound, the time
elapsed since injury, and symptoms suggesting wound infection based on the history and the
physical examination;
b. Signs and symptoms suggestive of underlying injury to tendon, nerve or blood vessel;
c. Risk of transmissible infection (e.g., HIV, rabies) from a bite;
d. Tetanus immunization status;
2) List and interpret critical investigations, including
a. Wound culture, if required;
b. Appropriate diagnostic imaging of underlying structures, if necessary (e.g., foreign material,
bones);
3) Construct an effective initial management plan, including
a. Determine the need for primary versus delayed closure;
b. Determine whether the patient requires specialized care;
c. Provide appropriate medical and surgical care of superficial wounds;
d. Determine the need for antibiotic or immunization prophylaxis;
e. Provide appropriate management in case of a puncture wound (e.g., needlestick, animal bite),
including mandatory reporting.

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109.13 Spinal trauma

Rationale

Traumatic spinal cord injuries may have life-altering effects on patient, family, and community. Initial
immobilization and maintenance of airway and ventilation can limit further injuries.

Causal conditions (list not exhaustive)

1) Traumatic (e.g., fracture/dislocation of vertebral column, penetrating injury)

2) Acute disc rupture

Key objectives

Given a patient with spinal trauma, the candidate will diagnose the cause, severity and complications, and will
initiate an appropriate management plan. Particular attention should be paid to initial immobilization and
maintenance of airway and ventilation.

Enabling objectives

Given a patient with spinal trauma, the candidate will

1) List and interpret critical clinical findings, including

a. Status of airway and respiratory function before ensuring protection;
b. Information from history and examination performed as the patient is being immobilized;
c. History about the mechanism of injury and the presence of symptoms and physical signs of
spinal injury;
d. Results of a complete neurological examination aimed at determining the function of major
cranial and peripheral nerves;
e. Consideration of the fact that spinal injuries commonly occur in association with other serious
injuries;
2) List and interpret critical investigations, including
a. Diagnostic imaging for assessment of spinal stability, while keeping in mind that such tests
should be deferred until the patient has been stabilized and immobilized;
3) Construct an effective initial management plan, including
a. Initiate and maintain spinal immobilization;
b. Perform catheterization of the bladder if indicated;
c. Initiate proper medical therapy;
d. Counsel and support patient and family;
e. Refer the patient for specialized care (e.g., surgical care, rehabilitation), if necessary.

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109.14 Urinary tract injuries

Rationale

Urinary tract injuries are usually blunt rather than penetrating. They may affect the kidneys and/or the
collecting system and may lead to life-threatening bleeding.

Causal conditions (list not exhaustive)

1) Kidney (BLOOD IN URINE/HEMATURIA)

2) Bladder and urethra
a. Distal urethra (e.g., straddle injuries bicycle riding, monkey bars)
b. Proximal urethra/bladder (e.g., pelvic fracture, abdominal injury)

Key objectives

Given a patient with a urinary tract injury, the candidate will diagnose the cause, severity and complications, and
initiate an appropriate management plan. In particular, the candidate will consider trauma to bladder or
posterior urethra in patients with pelvic fracture.

Enabling objectives

Given a patient with a potential urinary tract injury, the candidate will:

1) List and interpret the critical clinical findings, including

a. History data regarding the mechanism of the injury and symptoms (e.g., abdominal pain,
difficulty voiding, blood in urine or at meatus);
b. Perineal swelling/bruising;
c. Prostate gland injury detected by digital rectal examination;
2) List and interpret critical investigations, including
a. Appropriate imaging, if required (e.g., retrograde urethrogram for urethral injury, cystogram
for bladder injury, computed tomography scan for renal injury);
3) Construct an effective initial management plan, including
a. Initiate resuscitation of the injured patient and assess the patient's response to resuscitation;
b. Avoid repeated attempts at bladder catheterization when unsuccessful;
c. Initiate management of anterior urethral injury;
d. Refer the patient for specialized care, if necessary.
e.

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109.15 Vascular injury

Rationale

Vascular injuries are relatively common and may be limb, organ or life threatening.

Causal conditions (list not exhaustive)

1) Penetrating trauma (e.g., laceration)

2) Blunt trauma (e.g., contusion, spasm, compression)

Key objectives

Given a patient with vascular injury, the candidate will diagnose the cause, severity and complications, and will
initiate an appropriate management plan. In particular, the candidate will act quickly to ensure revascularization.

Enabling objectives

Given a patient with potential vascular injury, the candidate will

1) List and interpret critical clinical findings, including

a. History and physical examination data focused on vascular injury (e.g., acute limb ischemia,
compartment syndrome);
b. Consider blood loss that is not apparent on clinical examination (e.g., retroperitoneal
hemorrhage);
2) List and interpret critical investigations, including
a. Assessment of pulses using doppler probe, if appropriate;
b. Imaging studies to assess vessel integrity, if appropriate;
c. Assessment of compartment pressure, if required;
3) Construct an effective initial management plan, including
a. Initiate resuscitation and assess the patient's response to resuscitation;
b. Control external bleeding, if required;
c. Ensure timely referral of the patient for specialized care, if required.

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110 – URINARY FREQUENCY
110.1 Dysuria / Urinary frequency and urgency / Pyuria

Rationale

Cystitis describes a common clinical syndrome of dysuria, urinary frequency and urgency, which is sometimes
associated with suprapubic pain, and often found in the presence of pyuria. These symptoms, although
generally indicative of bacterial cystitis, may also be associated with other infections of the urethra or vagina.

Causal conditions (list not exhaustive)

1) Urinary tract infection (e.g., cystitis, prostatitis, pyelonephritis)

2) Sexually transmitted infection
3) Non-infectious urinary tract inflammation (e.g., traumatic, interstitial cystitis, bladder carcinoma,
bladder stones, urethral stricture)
4) External to lower urinary tract (vulvo-vaginitis)

Key objectives

Given a patient who presents with dysuria, urinary frequency and urgency, urethral discharge and/or pyuria, the
candidate will diagnose the cause, predisposing conditions, severity, and complications, and will initiate an
appropriate management plan.

Enabling objectives

Given the patient with dysuria, urinary frequency and urgency, urethral discharge and/or pyuria, the candidate
will

1) List and interpret critical clinical findings, including

a. Differentiation of urinary tract infections from non-infectious causes of cystitis and conditions
outside the urinary tract with similar presentation;
b. In case of recurring urinary tract infections, determination as to whether a predisposing
condition may be present (e.g., urine stasis, presence of stone or foreign body);
c. Results of prostate and urethra examinations, as the case may be;
d. A differential diagnosis based on age, gender and lifestyle;
2) List and interpret critical investigations, including
a. Urinalysis;
b. Urine culture and sensitivity;
c. Other investigations (e.g., vaginal and/or urethral swab, if indicated);
3) Construct an effective initial management plan, including
a. A selection of the most appropriate treatment for the underlying condition, including selection
of appropriate antibiotics, if indicated;
b. An assessment of the illness severity and the need for hospitalization;
c. A determination as to whether additional investigation and/or referral are required;
d. A brief outline of strategies for the prevention of recurrent urinary tract infections.

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110.2 Polyuria / Polydipsia

Rationale

Although not common, polyuria and/or polydipsia may be the presenting symptom(s) of a potentially serious
underlying condition. It may be confused with urinary frequency, a common complaint.

Causal conditions (list not exhaustive)

1) Water diuresis
a. Excessive intake
b. Excessive loss - diabetes insipidus
2) Osmotic diuresis
a. Sugar - diabetes mellitus
b. Urea - chronic renal disease
c. Salts - organic anions

Key objectives

Given a patient who presents with polyuria and/or polydipsia, the candidate will diagnose the cause, severity,
and complications, and will initiate an appropriate management plan.

Enabling objectives

Given a patient with polyuria and/or polydipsia, the candidate will

1) List and interpret critical clinical findings, including

a. Diagnose polyuria/polydipsia, causal factors, and severity, differentiating urinary frequency
from polyuria;
b. Inquire about any personal or family history of diabetes;
c. Identify neurological features that may suggest intracranial pathology as a cause of central
diabetes insipidus;
2) List and interpret critical investigations, including
a. Tests which distinguish between water and osmotic diuresis;
b. Screening for diabetes;
c. Use of a voiding diary, when appropriate;
3) Construct an effective initial management plan, including
a. Management of the underlying cause;
b. Determination as to whether the patient requires specialized care.

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111 – URINARY TRACT OBSTRUCTION
Rationale

Lower urinary tract symptoms (LUTS) are common in men and women of all ages. The prevalence and severity
of LUTS increase with age and they are a major burden for the aging population in particular. Although LUTS
do not usually cause severe illness, they are a common motivation for seeking medical care, can considerably
reduce quality of life, and may point to serious pathology of the urogenital tract.

Causal conditions (list not exhaustive)

1. Infections and inflammation (e.g., cystitis, prostatitis)

2. Structural (e.g., stones, tumors, prolapse, benign prostatic hypertrophy)
3. Medical conditions (e.g., diabetes mellitus, multiple sclerosis)
4. Drugs ( e.g., anticholinergics, opioids)

Key objectives

Given a patient with LUTS, the candidate will diagnose the cause, severity, predisposing conditions, and
complications, and will construct an appropriate initial management plan.

Enabling objectives

Given a patient with LUTS, the candidate will

1) List and interpret critical clinical findings, including those based on

a. The determination as to which LUTS are present (e.g., storage, voiding, and post-micturition
symptoms), including their time course, severity, and impact on quality of life;
b. The identification of possible causes and associated co-morbidities through a proper
assessment of the patient’s general medical history;
c. The use of medication, including herbal and over-the-counter medicines;
d. The presence or absence of systemic and uremic symptoms;
e. A physical examination that is appropriately guided by the urological symptoms and other
medical conditions (e.g., abdomen, pelvic exam, digital rectal exam);
2) Recognize that appropriate initial investigations vary depending on the individual presentation, and list
and interpret possible critical clinical investigations, including
a. Laboratory (e.g., renal function);
b. Imaging (e.g., ultrasound, computed tomography);
3) Construct an effective initial management plan, including
a. Determining whether conservative management is appropriate in this case;
b. Appropriate pharmacotherapy;
c. Immediate bladder catheterization, if indicated;
d. Appropriate counseling and use of screening measures (e.g., prostate specific antigen [PSA]);
e. Determining whether urgent and/or specialized care is required.

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112 – VAGINAL BLEEDING EXCESSIVE / IRREGULAR /
ABNORMAL
Rationale

Vaginal bleeding is considered abnormal when it occurs at an unexpected time (before menarche or after
menopause) or when it varies from the normal expected amount or pattern. It may be associated with
significant morbidity, and mortality, depending upon the underlying cause.

Causal conditions (list not exhaustive)

1) Pre-menarchal (e.g., trauma, sexual abuse)

2) Pre-menopausal
a. Ovulatory
i. Inter-menstrual (e.g., oral contraceptive, benign growths)
ii. Menorrhagia
iii. Neoplasms-coagulation disorders
iv. Other (e.g., endometritis, hypothyroidism)
b. Anovulatory
i. Age related-endocrine/metabolic (e.g., thyroid)
ii. Neoplasms (e.g., prolactinoma, ovarian tumor)
iii. Other (e.g., polycystic ovary, weight loss/exercise/stress, structural disease)
c. Pregnancy-related
3) Post-menopausal-structural/systemic
a. Genital tract disease (exclude trauma)
b. Neoplastic systemic disease
c. Drugs (e.g., hormone replacement therapy, anticoagulants)

Key objectives

Given a patient who presents with abnormal, irregular or excessive vaginal bleeding, the candidate will diagnose
the cause, severity, and complications, and will initiate an appropriate management plan.

Enabling objectives

Given the patient who presents with abnormal, irregular, or excessive vaginal bleeding, the candidate will

1) List and interpret critical clinical findings, including those based on

a. First and foremost, determining whether the patient is hemodynamically stable;
b. Differentiating between bleeding related to or unrelated to pregnancy;
c. Information gathered to determine the underlying cause (e.g., other bleeding, medications) if
pregnancy has been ruled out;
d. Results of an appropriate physical examination, including a pelvic examination unless
contraindicated (e.g., placenta previa);
2) List and interpret critical clinical investigations, including
a. Complete blood count, pregnancy test and, in women with recent pregnancy, qualitative and
quantitative beta hCG;
b. Determining ovulatory status and order clinically-indicated diagnostic tests;
c. Determining whether a referral for investigation is required;
3) Construct an effective initial management plan, including
a. Determining if the patient requires urgent or specialized care;
b. Resuscitating patient if hemodynamically unstable;

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c. Initiating first-line medical therapy, as appropriate, for control of abnormal vaginal bleeding
and referring the patient for specialized surgical care;
d. Outlining legal responsibilities (e.g., mandatory reporting obligations) if sexual abuse is
suspected;
e. Recognizing the potential need for counselling and support in case of sexual abuse.

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113 – VAGINAL DISCHARGE / VULVAR PRURITUS
Rationale

Vaginal discharge, with or without pruritus, is a common problem

Causal conditions (list not exhaustive)

1) Physiologic discharge and cervical mucus production

2) Non-physiologic
3) Genital tract infections
4) Genital tract inflammations (e.g., irritants)

Key objectives

Given a patient who presents with vaginal discharge or vulvar pruritus, the candidate will diagnose the cause,
severity, and complications, and will initiate an appropriate management plan. In particular, the candidate will
distinguish sexually transmitted infection (STI) from other causes of vaginal discharge or vulvar pruritus.

Enabling objectives

Given a patient who presents with vaginal discharge or vulvar pruritus, the candidate will

1) List and interpret critical clinical investigations, including

a. The precipitating or aggravating factors;
b. The diagnosis of the likely cause of vaginal discharge and/or vulvar pruritus;
c. The results of an appropriate abdominal and pelvic examination, including a speculum
examination;
2) List and interpret critical investigations, including
a. pH and wet or KOH smear;
b. Appropriate tests if the patient presents with purulent discharge;
3) construct an effective initial management plan, including
a. Recognize vulvovaginitis associated with sexual activity and counsel on risk reduction;
b. Initiate appropriate management plan (e.g., STI, non-STI causes);
c. Recognize the obligation to report to appropriate authority;
d. Refer the patient for specialized care, if indicated.

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114 – VIOLENCE, FAMILY
114.1 Child abuse

Rationale

Child abuse occurs when a caregiver whom a child trusts or depends on, compromises, either by acts of
omission or commission, the safety and/or physical, emotional or sexual well-being of a child and may lead to
significant morbidity and mortality.

Child abuse is a common, yet under-recognized and under-reported condition. Accurate and timely diagnosis of
children who are suspected victims of abuse can ensure appropriate evaluation, investigation, and outcomes for
these children and their families.

Causal conditions (list not exhaustive)

1) Physical abuse
2) Mental abuse
3) Sexual abuse
4) Emotional abuse
5) Neglect
6) Exposure to domestic violence

Key objectives

The candidate should be aware of presentations in which a history of abuse should be considered. Given a child
in whom a history of abuse is suspected, the candidate will construct an appropriate management plan with
particular attention to issues of safety and prevention.

Given a child in whom a history of abuse is disclosed, the candidate will identify the cause, severity,
complications, and contributing factors. An appropriate initial management and prevention plan should also be
constructed.

Enabling objectives

Given a child presenting with any injury, the candidate will recognize those injuries suspicious for abuse when
considering the nature of the injury, the caregiver's explanation for the injury, and whether that explanation is
supported by the characteristics of the injury and the child's developmental status.

Given a child in whom abuse is suspected or disclosed, the candidate will

1) List and interpret critical clinical findings, including

a. Key manifestations of abuse (e.g., sexually transmitted infections, developmental delay,
emotional/behavioural problems;
b. Family dynamics, parental characteristics and social situation that may be contributing factors;
c. Other potential signs of abuse (e.g., refusal by parent to have child interviewed alone);
d. Potential mimics of child abuse (e.g., accidental injury, medical conditions);
e. The need for an appropriate history and physical examination to look for further evidence of
abuse (e.g., bruising, scars);
2) List critical investigations, including
a. Radiologic studies directed at treating the current injury and investigating evidence of previous
trauma;

205
 b. Other investigations, as indicated (e.g., coagulation studies, toxicology);
3) Construct an effective initial management plan, including
a. Diligent documentation;
b. Outlining strategies for ensuring the child's safety, including specifically;
i. Reporting to appropriate child welfare agency;
ii. Determining whether other children are at risk and whether they should be examined;
c. Referral to a pediatrician or hospital child protection team for further evaluation/opinion, if
available.

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114.2 Elder abuse

Rationale

Elder abuse is action or neglect causing harm or distress to an older person where there is an expectation of
trust.

Causal conditions (list not exhaustive)

1) Physical abuse
2) Sexual abuse
3) Emotional or psychological abuse
4) Financial or material exploitation
5) Neglect (e.g., physical, social, emotional)

Key objectives

Given an older person in a state of distress or unexplained findings, the candidate will inquire about potential
elder abuse. In particular, the candidate will determine the level of immediate risk, identify potential
contributing factors, and outline an appropriate management plan.

Enabling objectives

Given a case of possible elder abuse, the candidate will

1. List and interpret critical clinical findings, including

1. Recognizing potential signs of abuse (e.g., fear, malnutrition);
2. Recognizing the importance of interviewing the patient alone;
3. Identifying risk factors for abuse including the patient's support structure and social
circumstances;
4. Assessing the capacity of the patient to make personal care decisions;
2. List and interpret critical investigations, including, where appropriate,
1. Assessment by appropriate medical investigations;
2. Assessment by appropriate health care agencies;
3. Construct an effective initial management plan, including
1. Ensuring the patient is in a safe environment;
2. Involving other team members or agencies, if indicated (e.g., social worker);
3. Providing support and education to the caregiver, if necessary.
4.

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114.3 Adult abuse / Intimate partner abuse

Rationale

Adult or intimate partner abuse is a common problem that can occur in all partnerships. Abuse is often kept
hidden by the victim and may be difficult to diagnose, yet it causes significant physical and emotional
morbidity. It can also lead to the death of the abused spouse.

Causal conditions (list not exhaustive)

Abuse may be classified into several types:

1) Physical abuse
2) Psychological abuse
3) Emotional abuse
4) Social isolation
5) Sexual abuse
6) Economic

Key objectives

Given a case of possible adult or intimate partner abuse, the candidate will diagnose the cause, severity and
complications, and will initiate an appropriate management plan. In particular, the candidate will assess
immediate and short-term risk to the victim, and devise a safe and effective plan for the patient.

Enabling objectives

Given a case of possible adult or intimate partner abuse, the candidate will

1) List and interpret critical clinical findings, including those based on

a. The identification of possible factors putting the patient at increased risk of abuse (e.g.,
pregnancy, threat to leave);
b. Whether the partner has risk factors for being violent (e.g., substance use);
c. The varied nature of symptoms and signs that may indicate potential abuse (e.g., recurrent
nature);
d. The nature of the interaction between partners as well as the importance to interview and
examine the patient alone;
e. The level of immediate-and-short term danger for the individual as determined through an
assessment of risk factors for lethality or serious injury;
2) List and interpret critical investigations, including
a. The careful documentation of the location and nature of injuries and appropriate investigation
of physical injuries via physical examination and other tests, as needed;
3) Construct an effective initial management plan, including
a. Maintaining an empathic relationship;
b. Ensuring confidentiality and communicate exceptions;
c. Assisting the individual in devising a safety plan;
d. Giving information regarding access to transition housing, and support services;
e. Arranging supportive follow-up.

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115 – VISUAL DISTURBANCE / LOSS
115.1 Acute visual disturbance / loss

Rationale

Sudden decreases in visual acuity or visual field are symptoms which require urgent evaluation. The outcome
may depend on early, accurate diagnosis and timely treatment. Many patients require an urgent ophthalmologic
opinion.

Causal conditions (list not exhaustive)

1) Painless
a. Vascular (e.g., retinal artery occlusion, giant cell arteritis)
b. Neurologic (e.g., optic neuritis)
c. Retinal (e.g., retinal detachment)
d. Other (e.g., conversion disorders)
2) Painful
a. Glaucoma
b. Inflammatory (e.g., uveitis, corneal ulcer)
c. Other (e.g., traumatic)

Key objectives

Given a case of sudden decrease in visual acuity or visual field, the candidate will construct a differential
diagnosis and recognize situations requiring urgent action. In particular, the candidate will recognize the need
for urgent referral to an ophthalmologist.

Enabling objectives

Given a case of sudden decrease in visual acuity or visual field the candidate will

1) List and interpret critical clinical findings, including

a. Determine the characteristics of the visual loss and other relevant medical history;
b. Conduct an appropriate eye examination;
c. Determine whether a vision threatening condition is present;
2) List and interpret critical investigations (e.g., imaging, erythrocyte sedimentation rate)
3) Construct an effective initial management plan, including
a. Institute urgent medical therapy where appropriate;
b. Refer the patient for specialized care, if necessary.
c.

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115.2 Chronic visual disturbance / loss
Rationale

Chronic, slowly progressive visual loss is a significant health issue in the elderly population and groups at risk
(e.g., diabetics).

Causal conditions (list not exhaustive)

1) Glaucoma
2) Cataract
3) Macular degeneration
4) Retinopathy due to chronic illness

Key objectives

Given a case of chronic visual loss, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate will recognize the populations at risk of
chronic visual loss and will institute screening and preventive measures.

Enabling objectives

Given a case of a patient at risk of chronic visual loss, the candidate will

1) List and interpret clinical findings, including

a. Determine the characteristics of the visual loss and other relevant medical history;
b. Conduct an appropriate eye examination;
c. Determine whether a vision threatening condition is present;
2) List and interpret critical investigations (e.g., fundoscopic examination, visual fields, ocular pressure)
3) Construct an effective initial management plan, including
a. Determine whether the patient is at risk and refer for appropriate screening, if such is the case;
b. Institute medical therapy, where appropriate;
c. If indicated, refer the patient for specialized care in an appropriately timely manner.

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116 – VOMITING / NAUSEA
Rationale

Nausea may occur alone, or along with vomiting, dyspepsia, and other gastrointestinal complaints. When
prolonged or severe, vomiting may be associated with disturbances of water and electrolyte balance that may
require correction prior to other specific treatment.

Causal conditions (list not exhaustive)

1) Gastrointestinal system
a. Esophagus/Stomach/Duodenum (e.g., obstruction, gastroenteritis, reflux, gastroparesis,
peptic ulcer disease)
b. Small bowel/Colon (e.g., acute infectious enteritis, obstruction, inflammatory bowel disease,
neoplasm)
c. Hepato-biliary disease or pancreatic disease (e.g., acute hepatitis / pancreatitis / cholecystitis)
d. Peritoneal irritation (e.g., appendicitis)
2) Central nervous system
a. Increased intracranial pressure (e.g., infection, trauma, tumor)
b. Vestibular nerve lesions
c. Brain stem lesions
d. Psychiatric/Psychological conditions
3) Other
a. Endocrine and/or metabolic (e.g., diabetes, hypercalcemia, pregnancy)
b. Cancer
c. Sepsis (e.g., pyelonephritis, pneumonia)
d. Drugs and toxins (e.g., chemotherapy, food poisoning)
e. Miscellaneous (e.g., acute myocardial infection, uremia)

Key objectives

Given a patient with vomiting and/or nausea, the candidate will diagnose the cause, severity, and
complications, and will initiate an appropriate management plan. In particular, candidates should recognize that
important causes of nausea and vomiting (e.g., raised intracranial pressure, metabolic conditions, myocardial
infarction) arise outside of the gastrointestinal system.

Enabling objectives

Given a patient with nausea and/or vomiting, the candidate will

1) List and interpret critical clinical findings, including

a. Obtain a history for non-gastrointestinal causes (e.g., medication history, neurological disease,
cardiac ischemia, metabolic conditions);
b. Obtain a complete review of gastrointestinal symptoms;
c. Physical examination targeting the gastrointestinal system, and salient findings in other systems
suggesting need for urgent intervention (e.g., papilledema, volume status);
2) List and interpret critical investigations to delineate both causes and effects
a. Serum electrolytes, creatinine, calcium, glucose, cortisol;
b. More targeted investigations (e.g., head imaging, cosyntropin stimulation test), if indicated;
c. More specialized gastrointestinal testing, if indicated;
3) Construct an effective initial management plan, including
a. Outline management plan targeting condition identified as causative, understanding that in
some patients no cause will be found;

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b. Recommend the appropriate use of commonly used anti-nausea/anti-emetic medications.

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117 – WEAKNESS (NOT CAUSED BY CEREBROVASCULAR
ACCIDENT)
Rationale

True weakness is abnormally decreased power of a muscle group, limb or in a more widespread distribution. It
can be acute, subacute or chronic, and has a wide differential diagnosis. In young children, this may present as
hypotonia. In its most severe form, it may present as paresis or paralysis and be accompanied by other
neurologic or systemic symptoms. Since the causal condition may be life-threatening or severely disabling in
many cases, skill is required to approach the problem effectively.

Causal conditions (list not exhaustive)

1) Muscular causes
a. Primary muscle disease
i. Congenital (e.g., muscular dystrophy)
ii. Acquired (e.g., myositis, myasthenia)
b. Central nervous system
i. Malignant
ii. Infectious (e.g., encephalitis)
iii. Degenerative
iv. Autoimmune or Inflammatory (e.g., multiple sclerosis)
v. Traumatic
vi. Vascular (41 Weakness (not caused by Cerebrovascular Accident)
vii. Other (e.g., genetic, cataplexy)

Key objectives

Given a patient exhibiting weakness not caused by a cerebrovascular accident, the candidate will differentiate
fatigue from inhibition and pain. In particular, the candidate will determine whether the condition is due to
muscle, nerve or upper neurological disorder, characterize the distribution and/or localize the lesion, and
determine the underlying cause.

Enabling objectives

Given a patient with weakness not caused by a cerebrovascular accident, the candidate will

1) List and interpret clinical findings, including results of an appropriate history and physical examination
aimed at determining
a. The source of the weakness (e.g., muscle, peripheral nerve);
b. The distribution of the weakness;
c. The most likely pathology or cause of the weakness (e.g., vascular, inflammatory, malignant);
2) List and interpret critical investigations, including
a. Laboratory data (e.g., creatine kinase, genetic testing);
b. Nerve conduction studies and electromyography;
c. Imaging, including computed tomography or magnetic resonance;
3) Construct an effective management plan, including
a. Perform acute medical or surgical intervention (e.g., correction of electrolytes abnormalities);
b. Treat underlying disease or correct causative factors (e.g., control of diabetes, cessation of
steroids or statins);
c. Take measures to support the patient and to retain function (e.g., physiotherapy, occupational
therapy);

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d. Anticipate medium- and long-term complications of the disorder (e.g., psychosocial impact,
safety).

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118 – WEIGHT ABNORMAL
118.1 Weight gain / Obesity

Rationale

Obesity is a complex multifactorial chronic disease that develops from social, behavioural, physiological, and
metabolic interactions. It is a risk factor for a wide range of serious illnesses.

Causal conditions (list not exhaustive)

1) Increased energy intake

a. Dietary (e.g., progressive hyperphagic, frequent eating, high fat diet, overeating)
b. Social and behavioral (e.g., socioeconomic, psychological)
c. Iatrogenic (e.g., drugs, hormones, hypothalamic surgery)
2) Decreased energy expenditure (e.g., sedentary lifestyle, smoking cessation)
3) Neuroendocrine (e.g., hypothyroidism, Cushing syndrome, polycystic ovarian syndrome)
a. Genetic (e.g., Prader-Willi)
b. Epigenetic

Key objectives

Given a patient with weight gain or obesity, the candidate will diagnose the cause, severity, and complications,
and will initiate an appropriate management plan. In particular, he will determine the degree and pattern of
obesity, exclude primary treatable causes, and assess the risk of associated morbidity and mortality.

Enabling objectives

Given a patient with weight gain or obesity, the candidate will

1) List and interpret critical clinical findings, including those based on

a. A determination of the presence of obesity using defined criteria in adult and pediatric
populations;
b. An assessment of the risk of morbidity and mortality by determining age at the onset of
obesity, its duration, the weight gained after 18 years of age, and the amount of central
adiposity and gender;
c. A measurement of waist circumference or waist-to-hip ratio and a calculation of body mass
index;
d. A screening for co-morbid conditions (e.g., hypertension, diabetes mellitus, dyslipidemia, sleep
apnea, hirsutism, amenorrhea);
2) List and interpret critical investigations, including
a. Investigation for a neuroendocrine cause of obesity, if required;
b. Appropriate laboratory investigations to screen for co-morbid conditions and complications;
3) Construct an effective initial management plan, including
a. Formulating an intervention strategy with an emphasis on long-term treatment and a
multidisciplinary approach, if indicated;
b. List the modalities of treatment for obesity including increased energy expenditure through
exercise, decreased energy intake through healthy diets and behavior modification;
c. Discussing indications, risks and benefits of anti-obesity drugs and bariatric surgery;
d. Demonstrating sensitivity to social and psychosocial consequences of obesity;
e. Identifying opportunities to address socio-economic factors leading to obesity.

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118.2 Weight loss / Eating disorders/ Anorexia

Rationale

Weight loss may be a symptom of a serious underlying condition.

Causal conditions (list not exhaustive)

1) Decreased nutritional intake

a. Psychiatric disease (e.g., anorexia nervosa, bulimia)
b. Medical disease (e.g., chronic illness, esophageal cancer)
c. Illicit drugs or medications (e.g., alcohol, opiates, cocaine, amphetamines, anticancer)
2) Increased energy expenditure
a. Hormonal (e.g., hyperthyroidism)
b. Chronic illness (e.g., chronic obstructive pulmonary disease, congestive heart failure)
c. Malignancy
d. Infection
e. Excessive physical activity (e.g., runners)
3) Caloric loss
a. Malabsorption (e.g., diarrhea)
b. Diabetes

Key objectives

Given a patient with weight loss, the candidate will diagnose the cause, severity, and complications, and will
initiate an appropriate management plan. In particular, the candidate will investigate for underlying medical
conditions where appropriate.

Enabling objectives

Given a patient with weight loss, the candidate will

1) List and interpret critical findings, including

a. Identify the primary mechanism of the weight loss (e.g., decreased nutritional intake, increased
expenditure);
b. Recognize the features of anorexia nervosa where present;
c. Identify the medical consequences of the weight loss;
2) List and interpret critical investigations, including
a. Assessment of the nutritional status of the patient, including appropriate laboratory
investigations;
b. Investigation of potential underlying medical condition (e.g., blood glucose, thyroid-
stimulating hormone);
c. Investigation of social and family history (psychosocial stressors);
3) Construct an effective initial management plan, including
a. Initiate nutritional support or counseling, where needed;
b. Initiate treatment of underlying medical condition, if appropriate;
c. Refer the patient for specialized care, if necessary.
d.

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118.3 Intrauterine growth restriction

Rationale

Intrauterine growth restriction is a pathological limitation of fetal growth. Intrauterine growth restriction
(IUGR) is an important risk factor for pre- and post-natal morbidity and mortality. It is also a risk factor for
atypical child development and adult health problems such as hypertension and diabetes. Infants with IUGR
must be distinguished from infants who are constitutionally small for gestational age (SGA) but otherwise well.

Causal conditions (list not exhaustive)

1. Maternal (e.g., nutritional status)

2. Fetal (e.g., genetic syndrome, intra-uterine infection)
3. Placental (e.g., maternal smoking

Key objectives

Given a pregnant patient with abnormal fetal growth, or a newborn with low birth weight, the candidate will
diagnose the cause, severity, and complications, and will initiate an appropriate management plan. Particular
attention should be paid to identification of modifiable risk factors for IUGR early in pregnancy, routine
monitoring of fetal growth throughout pregnancy to identify the need for specialized obstetrical management,
and careful evaluation of a neonate who is small for his gestational age to detect a possible case of IUGR and
assess potential causal conditions.

Enabling objectives

Given a pregnant patient with abnormal fetal growth, or a newborn with low birth weight, the candidate will

1) List and interpret critical clinical findings, including

a. Recognition of risk factors for IUGR;
b. Routine monitoring of fetal growth through physical examination;
c. Evaluation of a low birth weight infant to determine whether the case is one of IUGR or of a
neonate who is constitutionally small for his gestational age, paying particular attention to
features on history and physical examination that are indicators of potential causal conditions;
2) List and interpret critical investigations, including
a. Indications for pregnancy investigations to assess fetal growth and well-being (e.g., biophysical
profile, Doppler);
b. Indications for neonatal investigations for causal conditions of IUGR (e.g., karyotype);
3) Construct an effective initial management plan, including
a. Referral of the patient for specialized obstetrical investigation and management, if indicated;
b. Initiation of resuscitation of a distressed neonate, as required;
c. Referral for specialized pediatric care and developmental surveillance in the case of IUGR;
d. Counseling and education of the patient regarding risk factors, management, and sequelae of
IUGR, as appropriate.

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120 – WHITE BLOOD CELLS, ABNORMALITIES
Rationale

White blood cell (neutrophil and lymphocyte) abnormalities include abnormalities of number (leukocytosis or
leukopenia) and of function. Leukocytosis and leucopenia may occasionally indicate serious and potentially
urgent medical problems. Congenital white cell dysfunction is rare, but acquired dysfunction is associated with
common medical problems.

Causal conditions (list not exhaustive)

1) Leukocytosis
a. Reactive (e.g., bacterial infection, infectious mononucleosis)
b. Neoplastic (e.g., leukemias)
2) Leukopenia
a. Increased destruction (e.g., bacterial infection, human immunodeficiency virus)
b. Decreased/ineffective production (e.g., marrow suppression)
3) Leukocyte dysfunction (e.g., HIV, chronic granulomatous disease)

Key objectives

Given a patient with a white blood cell abnormality, the candidate will diagnose the cause, severity and
complications, and will initiate an appropriate management plan. In particular, attention should be paid to
distinguishing those conditions which are life threatening (overwhelming sepsis, acute leukemia, febrile
neutropenia) and require immediate treatment from those that are non-urgent.

Enabling objectives

Given a patient with abnormalities of white blood cells, the candidate will

1) List and interpret the critical clinical findings, including those derived from
a. A relevant history and an appropriate physical examination;
b. An assessment of urgent, life-threatening situations requiring immediate intervention;
2) List and interpret the critical investigations, including
a. The context of the clinical presentation (e.g., monospot, bacterial cultures);
3) Construct an effective initial management plan, including
a. Referring the patient for further specific investigation or specialized care (e.g., bone marrow
biopsy, neutrophil function test), if necessary;
b. Initiating treatment of underlying conditions.

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121 – LEGAL, ETHICAL AND ORGANIZATIONAL ASPECTS OF
MEDICINE
121.1 Consent

Rationale

Consent is an essential requirement for the initiation, continuation and termination of medical treatment or
medical research. In some circumstances, verbal consent is sufficient whereas in others (e.g., certain
investigations, surgery) written consent is necessary.

Key objectives

Given the necessity for consent, the candidate will be able to take the necessary steps in order to obtain valid
legal and ethical consent for the proposed action, taking into account issues related to decision-making capacity,
information sharing, the form of consent, limitations and exceptions to the requirement of consent.

Enabling objectives

Given the need to obtain consent, the candidate will

1) Be able to determine capacity to consent (e.g., cognitive impairment, coercion);

2) Know the steps that must be taken to obtain consent where there is a lack of capacity (e.g., substitute
decision maker, court order);
3) Identify the information that must be provided in order to ensure informed consent has been
obtained;
4) Differentiate the circumstances in which implied consent is acceptable;
5) Identify issues related to written and verbal consent including appropriate documentation;
6) Identify exceptions to the requirement for consent (e.g., mandatory reporting, risk of harm to others;
7) Describe the limitations and scope of the consent obtained in the particular situation (e.g., procedural
limitation, duration of consent).

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121.2 Truth telling

Rationale

Truth telling is an essential component to every patient or professional encounter and a basic ethical behavior
in a physician's daily practice.

Key objectives

Given a patient or professional encounter, the candidate must honestly and accurately convey relevant
information and explanations to patients, their families and other members of the health care team.

Enabling objectives

Given a patient or professional encounter, the candidate will

1) Adhere to the legal and ethical basis for truth telling;

2) Ascertain the personal and cultural context of the patient or professional situation;
3) Communicate effectively (e.g., using language adapted to the situation, checking for understanding);
4) Identify challenging situations and communicate accurately and effectively in such circumstances (e.g.,
delivering bad news, addressing medical error);
5) Recognize when it is necessary to disclose personal beliefs or values that could be in conflict with
patient choices.

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121.3 Negligence

Rationale

Negligence in providing care may result in legal liability.

Key objectives

Given a situation where a patient complains of negligent medical care, or the candidate is aware of negligence,
the candidate will consider the standard of care, the possibility of injury resulting from the care, and know what
action to take in the circumstances.

Enabling objectives

Given a situation where there may have been negligence, the candidate will

1) Know the elements required to prove negligence (e.g., a duty of care, a breach of the standard of care,
a resultant harm and a connection between the harm suffered and the breach of the standard of care);
2) Recognize differences in standards of care required based on the level of responsibility of the health
care provider;
3) Initiate appropriate communications with the patient, the health facility and the health care team
regarding the issue of possible negligence (e.g., relevant legislation, vicarious liability and ethical duties
of disclosure);
4) Initiate communications with the liability insurance carrier, such as the Canadian medical protective
Association (CMPA).
5)

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121.4 Confidentiality

Rationale

Confidentiality is a key component of the patient-physician relationship. The need for confidentiality is present
in every encounter.

Key objectives

The candidate will recognize the need for confidentiality and the circumstances where confidentiality must or
may be breached.

Enabling objectives

Given that confidentiality is a key component of the practice of medicine, the candidate will

1) Implement in all professional encounters, the ethical and legal aspects of confidentiality;
2) Know the exceptions to confidentiality and when it must or may be breached (e.g., duty to report,
prevention of harm);
3) Know the limitations in the consent to release information (e.g., extent of information released to third
parties, time restrictions);
4) Recognize the duty to inform patients about mandatory disclosure (e.g., communicable diseases);
5) Recognize the challenges to confidentiality posed by electronic medical records.

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121.5 Legal system

Rationale

Knowledge of the Legal System in Canada allows the physician to provide care to patients in the context of
federal, provincial and local laws and regulations.

Key objectives

Given a situation that may result in the involvement of the legal system, the candidate will be able to identify
the appropriate laws which apply to the particular situation and access and engage with the appropriate body.

Enabling objectives

The candidate will

1) Recognize the various sources of laws in Canada (e.g., federal and provincial statutes, the common law,
the Civil Code of Québec, licensing and regulatory bodies) as they apply to the practice of medicine;
2) Be familiar with the principles underlying the important court, tribunal and other legal decisions that
affect the practice of medicine;
3) Identify situations in which consultation or referral are appropriate (e.g., legal advice, child protection
services).

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123 – OBSESSIVE COMPULSIVE DISORDER (OCD) AND
RELATED DISORDER
Rationale

OCD is characterized by the presence of obsessions and/or compulsions. OCD and other disorders with
similar manifestations (body dysmorphic disorder, hoarding, trichotillomania, etc.) are a significant source of
morbidity and impaired quality of life. OCD is frequently comorbid with other disorders (see causal
conditions).

Causal conditions (list not exhaustive)

1) Adverse childhood experiences (e.g., abuse, behavioural inhibition)

2) Genetic neurological dysfunction
3) Other psychiatric disorders (e.g., tic disorder, anxiety disorders, depression, substance use disorder)
4) Other medical conditions (e.g., infections)

Key objectives

Given a patient with obsessions and/or compulsive behaviour, the candidate will diagnose the condition, along
with its severity and possible complications. Particular attention should be paid to possible etiology and
coexisting conditions.

Enabling objectives

Given an individual with an obsessive and/or compulsive behavior

1. List and interpret critical clinical findings, including those derived from
1. A thorough history aimed at estimating the severity of the disorder and other comorbid or
etiologic factors;
2. A physical examination aimed at ruling out physical complications (e.g., dermatologic);
2. List and interpret critical investigations, including where appropriate
1. Drug screening;
2. Neurological imaging;
3. Infectious agents;
3. Construct an effective management plan, including
1. Determining whether pharmacological intervention (e.g., SSRI medication) is indicated in this
case;
2. Referring for specialized care (e.g., psychological services, family counselling), if required;
3. Anticipating potential psychosocial impact.

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REFERENCES

Medical Council of Canada. Medical Council of Canada Qualifying Exam Part I [Internet] Ottawa: Medical
Council of Canada. Available from: https://mcc.ca/examinations/mccqe-part-i/

Medical Council of Canada. Examination Objectives Overview [Internet] Ottawa: Medical Council of Canada.
Available from: https://mcc.ca/objectives/

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