We are excited to see so many of you join our spring FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

Just a reminder… pay attention to the questions. Here are our general tips one more time:

1. Pay attention to the questions. Look carefully at how many items you are being asked to list. If the question asks for five items, you will not get more marks if you list eight items; the examiner will look at the first five and allocate marks only for the first five answers – so be careful. On a SAMP, if it is not clearly stated how many items you should list, look at the amount of points/marks being allocated for the question to get an idea of how many answers the examiner may be anticipating you write down.

2. Do not write lengthy answers. Most questions can be answered in 10 words or less!

3. Be specific when writing down investigations (hemoglobin instead of CBC; CT abdomen instead of CT).

4. Remember that trade names and generic names are both acceptable when writing down medications.

5. For more helpful tips, you can refer to CCFP’s SAMP instructions by clicking here.

SAMP

A 78-year-old male presents to you with a loud ringing sensation in his ear. His past medical history is significant for type 2 diabetes for 30 years, hyperlipidemia, and hypertension. He has a 30-pack-year smoking history. He drinks 14 beers per week. He used to work as a construction worker for the MTO and seldom used hearing protection as “that’s not what we did back in the day.†(20 points)

1. What is tinnitus? (1 point)

• • Tinnitus is a symptom that manifests as hearing a sound when really there is no acoustic stimulus present

2. List five differential diagnoses for tinnitus. (5 points)

• • Sensorineural hearing loss
  • Temporomandibular joint dysfunction
  • Meniere’s disease
  • Infectious (viral, bacterial, and fungal will be acceptable answers)
  • Head or neck injury
  • Multiple sclerosis
  • Cholesteatoma
  • Vestibular schwannoma
  • Ear trauma (e.g. inquire if there was any recent cerumen removal)
  • Idiopathic intracranial hypertension
  • Vestibular migraine
  • Medication exposure
  • Aortic dissection
  • Arterial bruit
  • Arteriovenous malformation
  • Vascular tumour

3. List two classes of medication that can precipitate tinnitus. (2 points)

• • Antimalarial agents
  • Anti-inflammatory agents
  • Antibiotics
  • Antineoplastic agents
  • Loop diuretics
  • Regional anesthetics

4. On history, what associated symptoms would you want to ask about to help narrow down your diagnosis? List three. (3 points)

• • Is the tinnitus pulsatile?
  • Is there associated hearing loss? If so, is it unilateral or bilateral?
  • Are there associated headaches?
  • Are there vertiginous symptoms?
•  Here is a helpful CFP article – see Figure 1: https://www.cfp.ca/content/cfp/64/7/491.full.pdf

5. What is one of the most common exposures that can precipitate tinnitus? (1 point)

• • Loud noise exposure

6. List two specialized tests that can be ordered for tinnitus? (2 points)

• • Auditory brainstem response
  • MRI/Contrast-enhanced MRI
  • Pure tone audiometry
  • Electronystagmography
  • Speech discrimination testing

7. What are three causes for pulsatile tinnitus? (3 points)

• • Arteriovenous fistula and arteriovenous malformation
  • Aberrant carotid artery
  • Benign intracranial hypertension
  • Glomus tympanicum
  • Venous hum and high-riding jugular bulb
  • Atherosclerosis of the carotid artery
  • Arterial bruits
  • Vascular tumours
  • Middle ear myoclonus
  • Palatal muscle contraction
  • Eustachian tube contraction

8. What are three non-pharmacologic management options for tinnitus? (3 points)

• • Improve sleep
  • Reduce stress
  • Reduce caffeine and alcohol intake
  • Sound amplification
  • Rehabilitation therapies (Cognitive behavioural therapy, dissociation of tinnitus from the negative response using counselling and noise generators)
  • Transmagnetic stimulation