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FAMILY MEDICINE CLERKSHIP HANDBOOKEffective 2016Department of Family Medicine Undergraduate Medical Education University of OttawaAbout the Authors:Katherine Li and Olivia Margie, third year medical students at the University of Ottawa with a passion for family medicine, updated the handbook for the 2016-2017 academic year to reflect the most recent guidelines. The handbook was originally crafted in 2011 by Stephanie Ahken, a second year University of Ottawa medical student, as part of the Faculty of Medicine Undergraduate Summer Studentship program. The handbook has since served as a valuable resource for all clerkship students rotating through their core family medicine rotation!We would also like to acknowledge previous medical students at the University of Ottawa for their contributions in updating this handbook. These include:Kimberly Reiter (MD2016)Sarina Scaffidi Argentina (MD2016)Kelly Frydrych (MD2015)Bonnie Tang (MD2014)Please Note:We have made every effort to ensure that the information and references in this handbook are correct at the time of printing. However errors may be present and web based references may change. Please refer to the original references whenever possible in making decisions relating to patient care. For a comprehensive list of links to resources pertaining to all learning objectives, please visit the University of Ottawa Department of Family Medicine Website (Undergraduate Medical Education). This handbook is intended as a reference document to 3rd year medical students during their family medicine clerkship rotation. It outlines specific objectives and includes references to various resources such as best current practice guidelines as well as diagnostic and management algorithms on selected topics. Content of the handbook is based-on (but not exclusive to) the University of Ottawa Family Medicine clerkship learning objectives.Table of Contents TOC \o "1-3" \h \z \u Common Problems PAGEREF _Toc478472532 \h 7Abdominal Pain PAGEREF _Toc478472533 \h 7Differential Diagnosis by Quadrant PAGEREF _Toc478472534 \h 7Red Flags PAGEREF _Toc478472535 \h 7Irritable Bowel Syndrome PAGEREF _Toc478472536 \h 7Alopecia PAGEREF _Toc478472537 \h 9Male-pattern hair loss PAGEREF _Toc478472538 \h 9Female pattern hair loss PAGEREF _Toc478472539 \h 9Trichotillomania PAGEREF _Toc478472540 \h 10Alopecia Areata PAGEREF _Toc478472541 \h 10Cicatricial (scarring) Alopecia PAGEREF _Toc478472542 \h 10Asthma PAGEREF _Toc478472543 \h 11Diagnosis PAGEREF _Toc478472544 \h 11Triggers PAGEREF _Toc478472545 \h 11Management PAGEREF _Toc478472546 \h 11MDI Techniques PAGEREF _Toc478472547 \h 13Monitoring PAGEREF _Toc478472548 \h 14Asthma Control Criteria: PAGEREF _Toc478472549 \h 14COPD PAGEREF _Toc478472550 \h 15Targeted Screening PAGEREF _Toc478472551 \h 15Assessment PAGEREF _Toc478472552 \h 15Management PAGEREF _Toc478472553 \h 15Indications for home oxygen therapy PAGEREF _Toc478472554 \h 16Examples of Drugs Used in Asthma and COPD PAGEREF _Toc478472555 \h 17Diabetes/Dysglycemia PAGEREF _Toc478472556 \h 18Diagnosis PAGEREF _Toc478472557 \h 1810g Monofilament Test PAGEREF _Toc478472558 \h 18Diabetes Monitoring & Targets PAGEREF _Toc478472559 \h 19Gestational Diabetes PAGEREF _Toc478472560 \h 21Screening and Diagnosis PAGEREF _Toc478472561 \h 21Risk Factors for GDM PAGEREF _Toc478472562 \h 21Management PAGEREF _Toc478472563 \h 21Prognosis PAGEREF _Toc478472564 \h 21Dizziness/Vertigo PAGEREF _Toc478472565 \h 22Approach to Dizziness PAGEREF _Toc478472566 \h 22Dyslipidemia PAGEREF _Toc478472567 \h 23Target Lipid Levels PAGEREF _Toc478472568 \h 23Treatment of Hypercholesterolemia/Hypertriglyceridemia PAGEREF _Toc478472569 \h 23Dyspepsia/GERD PAGEREF _Toc478472570 \h 24Investigation PAGEREF _Toc478472571 \h 24Gout PAGEREF _Toc478472572 \h 24Risk factors PAGEREF _Toc478472573 \h 24Diagnostic criteria PAGEREF _Toc478472574 \h 24Precipitants of Gout PAGEREF _Toc478472575 \h 25Treatment PAGEREF _Toc478472576 \h 25Recommendations for Combination Therapy PAGEREF _Toc478472577 \h 27Uralte lowering therapy (ULT) PAGEREF _Toc478472578 \h 27Anti-inflammatory Prophylaxis PAGEREF _Toc478472579 \h 29Headaches PAGEREF _Toc478472580 \h 30Red Flags PAGEREF _Toc478472581 \h 30Treatment PAGEREF _Toc478472582 \h 30Hypertension PAGEREF _Toc478472583 \h 32Diagnosis PAGEREF _Toc478472584 \h 32Treatment PAGEREF _Toc478472585 \h 33Fibromyalgia PAGEREF _Toc478472586 \h 34Associated symptoms PAGEREF _Toc478472587 \h 34Management PAGEREF _Toc478472588 \h 34Lower Back Pain PAGEREF _Toc478472589 \h 35Assessment PAGEREF _Toc478472590 \h 35Indications for Diagnostic Imaging PAGEREF _Toc478472591 \h 35Acute Ottis Media PAGEREF _Toc478472592 \h 36Diagnosis PAGEREF _Toc478472593 \h 36Treatment PAGEREF _Toc478472594 \h 36Osteoarthritis PAGEREF _Toc478472595 \h 36Treatment of Osteoarthritis PAGEREF _Toc478472596 \h 36Osteoporosis PAGEREF _Toc478472597 \h 37Indications for BMD Testing PAGEREF _Toc478472598 \h 37Pain PAGEREF _Toc478472599 \h 39Neuropathic Pain PAGEREF _Toc478472600 \h 39Nociceptive Pain PAGEREF _Toc478472601 \h 40Anxiety PAGEREF _Toc478472602 \h 40DSM-V Criteria for Generalized Anxiety Disorder PAGEREF _Toc478472603 \h 40GAD Pharmacological Treatment PAGEREF _Toc478472604 \h 40Depression PAGEREF _Toc478472605 \h 41DSM-V Criteria for Major Depressive Disorder PAGEREF _Toc478472606 \h 41Psychiatry PAGEREF _Toc478472607 \h 42Common Psychiatric Medication Side Effects PAGEREF _Toc478472608 \h 42Skin Conditions PAGEREF _Toc478472609 \h 42Acne PAGEREF _Toc478472610 \h 42Eczema (Atopic Dermatitis) PAGEREF _Toc478472611 \h 43Actinic Keratosis (Solar Keratosis) PAGEREF _Toc478472612 \h 44Basal Cell Cacinoma PAGEREF _Toc478472613 \h 45Squamous Cell Carcinoma PAGEREF _Toc478472614 \h 45Red Eye PAGEREF _Toc478472615 \h 41Red Flags for Urgent Ophthalmology Referral: PAGEREF _Toc478472616 \h 43Problems in the Elderly PAGEREF _Toc478472617 \h 43Elder Abuse PAGEREF _Toc478472618 \h 43Suspicion Index (EASI) PAGEREF _Toc478472619 \h 43Assessment & Management of Falls PAGEREF _Toc478472620 \h 44Dementia PAGEREF _Toc478472621 \h 45Comparison of types of Dementia PAGEREF _Toc478472622 \h 45Management PAGEREF _Toc478472623 \h 45Pseudodementia PAGEREF _Toc478472624 \h 47Health Promotion and Screening PAGEREF _Toc478472625 \h 48Periodic Health Examination PAGEREF _Toc478472626 \h 48Breast Cancer Screening PAGEREF _Toc478472627 \h 49Cervical Cancer Screening PAGEREF _Toc478472628 \h 50Special Circumstances PAGEREF _Toc478472629 \h 50Colorectal Cancer Screening PAGEREF _Toc478472630 \h 51Skin Cancer Screening PAGEREF _Toc478472631 \h 52Smoking Cessation Medications PAGEREF _Toc478472632 \h 53Smoking Cessation Flow Sheet PAGEREF _Toc478472633 \h 55Family Planning PAGEREF _Toc478472634 \h 56Contraception Options PAGEREF _Toc478472635 \h 56Quick Reference Guide PAGEREF _Toc478472636 \h 59Common Antibiotics PAGEREF _Toc478472637 \h 59Common Antivirals PAGEREF _Toc478472638 \h 59Immunization Schedule PAGEREF _Toc478472639 \h 60Vaccine Contraindications PAGEREF _Toc478472640 \h 61Live Attenuated Vaccines: PAGEREF _Toc478472641 \h 61Developmental Milestones PAGEREF _Toc478472642 \h 61Dermatology Glossary PAGEREF _Toc478472643 \h 62Antenatal Care Timelines PAGEREF _Toc478472644 \h 63Pediatric Visit Schedule PAGEREF _Toc478472645 \h 64Common ProblemsAbdominal PainRightCentreLeftRight HypochondriumGallbladderLiverRLL PneumoniaEpigastricGERDPeptic Ulcer DiseasePancreatitisCardiac (i.e. MI)Left HypochondriumSpleenLLL PneumoniaCardiac (i.e. MI)Right LumbarKidney StoneRenalUmbilicalAbdominal Aortic AneurysmEarly AppendicitisLeft LumbarKidney stoneRenalRight IleacAppendicitisGynecological (PID, ovarian, ectopic)Hypogastric/suprapubicUrinary (UTI)GynecologicalLeft IliacConstipationDiverticulitisGynecologicalDifferential Diagnosis by QuadrantRed FlagsAcute onsetFeverNausea/vomitingHematocheziaMelenaAnemiaWeight loss >10lbs (unintentional)Change in bowel habitsChest painNo improvement with current managementFamily history of colon cancer or IBDWakes from sleepSources:Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-HillEducation; 2013.Kolodziejak L, Schuster B, Reiger L, Jensen B. Irritable bowel syndrome (IBS). RxFiles Drug ComparisonCharts. 8th ed. Saskatoon, SK: Saskatoon Heath Region; 2010; 43.Wald, A. Clinical manifestations and diagnosis of irritable bowel syndrome. Uptodate. Retreieved from. Accessed June 10, 2014.Wald, A. Treatment of irritable bowel syndrome. Uptodate. Retreieved from. Accessed June 10, 2014.Irritable Bowel SyndromeRome III CriteriaRecurrent abdominal pain or discomfort for =/> 3 days/ month over the last 3 months. Symptoms must be present for 6 months with at least 2 of the following:Improvement with defecationChange in stool frequencyChange in stool consistencyInvestigationsTypical history with no red flag: obtain baseline labs and begin treatmentTreatment resistant: further imaging and scopeBaseline labs as needed specific to patient’s symptoms:Diarrhea predominant: ESR, CBC, TTG, TSH, O&PConstipation: CBC, TSH, lytes, CaAbdo pain: LFTs and amylaseTreatmentEducation and strong therapeutic allianceDietary changes: stool bulking (psyllium, polycarbophils), increase fluid intake, decrease caffeine and alcohol intakeProbiotics for minimum 4 weeksAlopeciaSource: Mubki T, Rudnicka L, Olszewska M, et al. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014;71(3):415.el-415.e15Male-pattern hair loss ? Slow frontotemporal hair loss advancing to vertex and possibly entire scalp ? Treatment: Minoxidil (Rogaine), finasteride (Propecia), hair transplant Female pattern hair loss ? Hair thinning in frontal and vertex scalp with sparing of the occipital region ? Treatment: Minoxidil (Rogaine), Spirinolactone, Cyproterone acetate (Diane-35), hair transplant Trichotillomania ? Individuals compulsively pull hair from the scalp or other regions ? Irregular shapes of hair loss with hair at different lengths Alopecia Areata ? Autoimmune disorder resulting in total hair loss of the scalp but can also include any body hair ? Spontaneous regrowth can occur but frequent recurrence precipitated by emotional stress ? Treatment: ? Intra-lesional or topical corticosteroids (Triamcinolone 2.5-5 mg/mL q4-6 weeks for 6 months) ? Topical immunotherapy ? For extensive scalp involvement ? Most effective ? Performed by Dermatologists Cicatricial (scarring) Alopecia ? Irreversible hair loss ? Physical: radiation, burns ? Infections: fungal (tinea capitis), bacterial (cellulitis), viral (HSV), TB, leprosy ? Inflammatory: lichen planus, discoid lupus erythematosus ? Treatment: ? Treat underlying infection ? Intra-lesional or topical steroidsAsthmaDiagnosisSymptoms + Spirometry findingsConfirming diagnosis with spirometry for patients >6 y.o is an important step in managementChildren (6-11 y.o.)Adults (>12 y.o.)Reduced FEV1/FVC< 0.8<0.75ANDANDAND↑FEV1 post-bronchodilator≥12%≥12%TriggersEnvironmental irritantsAnimal furCold airExerciseURTIsCigarette smokeB-Blockers/ASAManagementSelf-management educationWritten action plan (see CTS reference below, Table 5 for action plan recommendations)Pharmacological managementCHILDREN (6 y.o.-11 y.o.)MAINTENANCERELIEVERNo maintenance therapy needed (mild, intermittent asthma)SABA PRNLow dose ICS (Budesonide ≤400mcg, Fluticasone ≤200mcg)Medium dose ICS (Budesonide 400-800 mcg, Fluticasone 200-400 mcg)Add LABA or LTRA+ Consider specialist referralADULTS (>12 y.o.)MAINTENANCERELIEVERNo maintenance therapy needed (mild, intermittent asthma)SABA PRNLow dose ICS (Budesonide ≤400mcg, Fluticasone ≤250mcg)SABA PRN1st line adjuncts: Add LABA*(if exacerbation prone and adequate control not achieved consider BUD/ FORM as controller and reliever)SABA PRN or BUD/FORM PRN2nd line adjuncts: Add LTRA or increase to medium dose ICS (Budesonide 400-800 mcg, Fluticasone 250-500 mcg)SABA PRNTheophyllineSABA PRNOmalizumab (in atopic asthma with poor control despite high dose ICS)SABA PRNBUD/FORM: Budesonide/Formoterol; SABA: Short-acting beta-agonist*Never give LABA as mono-therapyVery mild, intermittent asthma may be treated with fast-acting beta2-agonists taken as needed. Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for asthma, even in individuals who report asthma symptoms less than three times a week. Leukotriene receptor antagonists (LTRAs) are second-line monotherapy for mild asthma. If asthma is not adequately controlled by low doses of ICS, additional therapy should be considered. In children six to 11 years of age, the ICS should be increased to a moderate dose before an additional agent such as a long-acting beta2-agonist (LABA) or LTRA is added. In children 12 years of age and over, and adults, a LABA should be considered first as add-on therapy only in combination with an ICS. Increasing to a moderate dose of ICS or addition of a LTRA are third-line therapeutic options. Theophylline may be considered as a fourth-line agent in adults. Severely uncontrolled asthma may require additional treatment with prednisone. Omalizumab may be considered in individuals 12 years of age and over with poorly controlled atopic asthma despite high doses of ICS and appropriate add-on therapy, with or without prednisone. Asthma symptom control and lung function tests, inhaler technique, adherence to asthma treatment, exposure to asthma triggers in the environment and the presence of comorbidities should be reassessed at each visit and before altering the maintenance therapy. After achieving proper asthma control for at least a few weeks to months, the medication should be reduced to the minimum necessary to achieve adequate asthma control. HFA Hydrofluoroalkane; IgE Immunoglobulin E; mcg Micrograms; PEF Peak expiratory flow; yrs YearsSource: Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults ( guideline.pdf). This information was originally published in Can Respir J 2012;19(2):127-164.MDI TechniquesShake inhaler 3-4 timesBreath outPlace the inhaler around your teeth and close your mouth around itStart to breathe in slowly. Once you have started inhaling, press the top of the inhaler and keep breathing slowly until you have taken a full breathRemove inhaler from your mouth. Hold breath for 10 seconds. ExhaleWait 30 seconds and shake inhaler between puffsRinse out your mouth when finishedSee link for how to use other puffers ()MonitoringAt each visit and before increasing puffer doses, assess the following:Asthma symptom control (see below)Lung function testsInhaler techniqueAdherence to asthma treatmentExposure to asthma triggers in the environmentPresence of co-morbiditiesAsthma Control Criteria:*Inadequate control prompts assessments for reason for poor control and may warrant dose increaseCharacteristicsFrequency or valueDaytime symptoms<4 days/wkNight-time symptoms<1 nightwkPhysical activityNormalExacerbationsMild, infrequentAbsence from school/work d/t asthmaNoneNeed for a fast-acting beta<4 doses/wkFEV1 or PEF≥90% of personal bestPEF diurnal variation< 10-15%Sputum eosinophils(Consider in adults with uncontrolled moderate to severe asthma who are assessed in specialist centres)<2-3%Source: Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. ( 2012_cts_asthma_guideline.pdf). This information was originally published in Can Respir J 2012;19: (2):127-164.COPDTargeted ScreeningMass screening of asymptomatic individuals is not recommendedPatients ≥40 y.o. who are current/ex-smokers (no minimum # of pack years) who answer yes to ≥1 of the following should have spirometryDo you cough regularly?Do you cough up phlegm regularly?Do even simple chores make you short of breath?Do you wheeze when you exert yourself, or at night?Do you get frequent colds that persist longer than those of other people you know?AssessmentCTS Disease SeverityBased on symptoms (MRC Dyspnea Scale)Based on lung functionNormalMRC 1: Dyspnea only with strenuous exerciseNormal spirometryMildMRC 2: Dyspnea when hurrying on the level or walking up a slight hillFEV1/FVC <0.7 FEV1 ≥80%ModerateMRC 3: Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the levelMRC 4: Stops for breath after walking about 90 m or after a few minutes on the levelFEV1/FVC <0.7FEV1 50-80% predictedSevereMRC 5: Too breathless to leave the house or breathless when dressing or undressingFEV1/FVC <0.7FEV1 30-49% predictedVery SevereN/AFEV1/FVC <0.7FEV1 <30% predictedManagementCOPD is treatable at any stage of the illnessGoals: alleviate symptoms; prevent acute exacerbationsEducationInhaler techniqueEarly recognition of exacerbationsEnd-of-life issuesSmoking CessationSingle most important intervention in prevention of COPD and slowing lung function declineExercise or Pulmonary RehabilitationAll patients should exercise to prevent reconditioning which will worsen dyspneaIn patient whose symptoms are well controlled but who do not exercise consider referral for pulmonary rehabilitationVaccinationAnnual influenzaPneumococcal vaccination at least oncePharmacotherapyIndications for home oxygen therapySevere hypoxemia (PaO2 ≤55mmHg); orPaO2 <60mmHg + bilateral ankle edema or cor pulmonale or Hct >56%Source:CTS recommendations for management of COPD 2008 – highlights for primary care (. respiratoryguidelines.ca/sites/all/files/CTS_COPD_Highlights_2008.pdf). This information wasoriginally published in Can Respir J 2008; 15 (SupplA): 1A-8A.Examples of Drugs Used in Asthma and COPDDrug ClassCommon names and coloursSide effetcsSABASalbutamol (Ventolin) [light blue/navy]Terbutaline (Bricanyl) [blue/ white]Fast heartbeat, irregular heartbeat, irritability (feeling cranky), difficulty sleeping, muscle cramps, shaky hands LABAFormoterol (Oxeze) (fast acting)Salmeterol (Serevent) [teal/light teal]As above ICSBudenoside (Pulmicort) [white/ brown] Fluticasone (Flovent) [orange/ peach]Hoarseness, sore throat, thrush or yeast infection ICS/LABAAdvair (Fluticasone+Salmeterol) [purple disc]Symbicort (Pulmicort + Oxeze) [red/white] Shaky hands, fast heartbeat, thrush, sore throat, hoarse voice LTRAZafirlukast (Accolate) Montelukast (Singulair) Headache, dizziness, heart- burn, upset stomach, tiredness Theophyline(Uniphyll, TheoDur, Phyllocontin, TheoLair) Nausea, heartburn, restlessness, fast heartbeat Short-acting anticholinergicsIpratropium bromide (Atrovent)[clear/green]Dry mouth, urinary retentionLong--acting anticholinergicsTiotropium (Spiriva) [white/turquoise]As aboveSources: Canadian Lung Association (2010). Medications for COPD. ( maladies/copd-mpoc/treatment-traitement/medications-medicaments_e.php. athme/treatment- traitement/medications-medicaments_e.php)Diabetes/DysglycemiaDiagnosisTestResult (mmol/L)DiagnosisFasting Plasma Glucose (fasting for 8 hours)6.1-6.9Impaired Fasting Glucose>/= 7.0Diabetes2h Plasma Glucose in a 75g Oral Glucose Tolerance Test7.8-11.0Impaired Glucose Tolerance>/= 11.1DiabetesHbA1C6.0-6.4Pre-diabetes>/= 6.5DiabetesRandom Plasma glucose>/= 11.1DiabetesSymptomatic plus one of the above = diagnosisIf asymptomatic, repeat confirmatory test (fasting, 2h OGTT, HbA1C) in addition to one of the above = diagnosisScreen in individuals >40 y.o q3years or earlier and more frequently if at high risk10g Monofilament TestDemonstrate on patient’s forearm how the monofilament feelsInstruct the patient to close their eyes and say “yes” when they feel the filament appliedUsing a 10g monofilament and one smooth motion, apply pressure until the filament bends and then releaseDo this at four sites on the plantar surface of the patient’s foot (1st, 3rd, and 5th metatarsal heads and plantar surface of distal hallux)Diabetes Monitoring & TargetsAdapted from Canadian Journal of Diabetes. 2013 Clinical Practice Guidelines Sample Diabetes CareFlow Sheet for AdultsTargetMonitorPre-prandial Glucose (mmol/L)4.0-7.0Ask about hypoglycemic episodes every appointment.Educate on signs, symptoms, and treatment of hypoglycemia2hr Post-prandial Glucose (mmol/L)5.0-10.0 or 5.0-8.0 if not achieving A1C targetHbA1C≤7.0% for most adultsA1C testing q3moMay consider q6mo if lifestyle and glycemic targets have been consistently metBlood Pressure<130/80Measure BP at diagnosis and every visitLipidsLipid targets for those being treated:LDL≤2.0 mmol/L or ≥50% reductionapoB ≤0.8g/L or non-HDL ≤2.6 mmol/LBaseline fasting lipid profile (TC, HDL, TG, LDL) then yearlyIf treating, more frequent monitoring requiredChronic Kidney DiseaseNormal ACR <2.0 mg/mmol Normal eGFR >60 mL/minScreen for proteinuria with random urine ACR and renal function with serum creatinine/eGFRType 1 diabetes: at 5 yr duration then yearlyType 2 diabetes: at diagnosis then yearlyRetinopathyScreening by an eye care professionalType 1 diabetes: 5 years after diagnosis then yearlyType 2 diabetes: At diagnosis then repeat 1-2 years later. Follow-upinterval depending on severity of retinopathyNeuropathyScreen with 10g monofilamentType 1 diabetes: 5 years after diagnosis then yearlyType 2 diabetes: at diagnosis then yearlyWaist Circumference/ Body Mass IndexMaintain WC ≤102cm in males, ≤88cm in females (North America) Maintain BMI between 18.5-24.9Life style modificationAerobic: ≥150 minutes/week Resistance: 3 sessions/week Follow Eating Well with Canada’s Food GuideEncourage physical activity and nutritional therapy with registered dieticianTargetMonitorPre-prandial Glucose (mmol/L)4.0-7.0Ask about hypoglycemic episodes every appointment.Educate on signs, symptoms, and treatment of hypoglycemia2hr Post-prandial Glucose (mmol/L)5.0-10.0 or 5.0-8.0 if not achieving A1C targetHbA1C≤7.0% for most adultsA1C testing q3moMay consider q6mo if lifestyle and glycemic targets have been consistently metBlood Pressure<130/80Measure BP at diagnosis and every visitLipidsLipid targets for those being treated:LDL≤2.0 mmol/L or ≥50% reductionapoB ≤0.8g/L or non-HDL ≤2.6 mmol/LBaseline fasting lipid profile (TC, HDL, TG, LDL) then yearlyIf treating, more frequent monitoring requiredChronic Kidney DiseaseNormal ACR <2.0 mg/mmol Normal eGFR >60 mL/minScreen for proteinuria with random urine ACR and renal function with serum creatinine/eGFRType 1 diabetes: at 5 yr duration then yearlyType 2 diabetes: at diagnosis then yearlyRetinopathyScreening by an eye care professionalType 1 diabetes: 5 years after diagnosis then yearlyType 2 diabetes: At diagnosis then repeat 1-2 years later. Follow-upinterval depending on severity of retinopathyNeuropathyScreen with 10g monofilamentType 1 diabetes: 5 years after diagnosis then yearlyType 2 diabetes: at diagnosis then yearlyWaist Circumference/ Body Mass IndexMaintain WC ≤102cm in males, ≤88cm in females (North America) Maintain BMI between 18.5-24.9Life style modificationAerobic: ≥150 minutes/week Resistance: 3 sessions/week Follow Eating Well with Canada’s Food GuideEncourage physical activity and nutritional therapy with registered dieticianManagement of Hyperglycemia in Type 2 DiabetesGestational DiabetesScreening and DiagnosisAll pregnant women between 24-28 wk GA (or at any stage if high risk)2 screening options1-step screening with fasting 75g OGTT; GDM if ≥1 of:FPG ≥5.1 mmol/L1h PG ≥10.0 mmol/L2h PG ≥8.5 mmol/L2-step screening:Step 1: Perform a random non fasting 50g OGTT1h PG <7.8 mmol/L is normal1h PG ≥11.1 mmol/L is GDMif 1h PG 7.8-11.0 mmol/L, proceed to Step 2Step 2: Perform a fasting 75g OGTT, GDM if ≥1 of:FPG ≥5.3 mmol/L1h PG ≥10.6 mmol/LRisk Factors for GDMAge >25 yrObesityEthnicity (Aboriginal, Hispanic, Asian, African)FHx of DMPrevious history of GDMPrevious child with birthweight >4.0 kgPolycystic ovarian syndromeCurrent use of glucocorticoidsEssential HTN or pregnancy-related HTNManagementFirst line is management through diet modification and increased physical activityInitiate insulin therapy if glycemic targets not achieved within 2wk of lifestyle modification aloneGlycemic targets: FPG <5.3 mmol/L, 1h PG <7.8 mmol/L, 2h PG <6.7 mmol/LUse of oral agents can be used in pregnancy but is off-label and should be discussed with patientStop insulin and diabetic diet postpartumFollow-up with 75g OGTT 6 wk-6 mo postpartumPrognosis50% risk of developing type 2 DM in the next 20 years in patients with GDMSources:Boulton, A. J. M. et al. Comprehensive Foot Examination and Risk Assessment. Diabetes Care 31, 1679-1685 (2008).Harper W, Clement M, Goldenberg R, et al. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: pharmacologic management of type 2 diabetes. Can J Diabetes 2013;37(suppl 1):S61-S68.Canadian Journal of Diabetes. 2013 Clinical Practice Guideline – Diabetes and Pregnancy. Retrieved fro Journal of Diabetes. 2013 Clinical Practice Guidelines - Quick Reference Guide. Retrieved from Journal of Diabetes. 2013 Clinical Practice Guideline – Sample Diabetes Care Flow Sheet for Adults. Retrieved from Diabetes_Care_Flow_ Sheet_for_Adults_Fillable_Saveable.pdfCheng, AYY., et al. Clinical Practice Guidelines 2013. Canadian Journal of Diabetes, 2013; 37. Retrieved from to DizzinessSource: Post, R.E., & Dickerson, L.M. (2010) Dizziness: A Diagnostic Approach. Am Fam Physician, 82(4), 361-368. ()DyslipidemiaTarget Lipid LevelsRisk LevelInitiate treatment if:Primary TargetsLDC-CPrimary TargetsAlternateHIGH CAD, PVD, atherosclerosis Most patients with diabetes FRS ≥ 20% RRS ≥ 20% Consider treatment in all patients <2 mmol/L or ≥ 50% ↓ LDL-C apoB ≤ 0.80g/L Non-HDL-C ≤ 2.6 mmol/L MODERATE FRS 10-19% LDL-C > 3.5 mmol/L For LDL-C < 3.5 consider if: Apo B ≥ 1.2 g/L or Non-HDL-C ≥ 4.3 mmol/L <2 mmol/L or ≥ 50% ↓ LDL-C apoB ≤ 0.80g/L Non-HDL-C ≤ 2.6 mmol/L LOW FRS < 10% LDL-C ≥ 5.0 mmol/L Familial hypercholesterolemia ≥ 50% ↓ LDL-C N/AFRS = Framingham Risk Score RRS = Reynolds Risk ScoreSource: 2012 HYPERLINK "" Update of the Canadian Cardiovascular Society guidelines for the diagnosis andtreatment of dyslipidemia for prevention of cardiovascular disease in the adult – )This article was published in Can J Cardiol, Volume 29 (2), TJ Anderson, J Gregoire, RA Hegele, et al., Update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for prevention of cardiovascular disease in the adult, p. 151-167, Copyright Elsevier (2012)Treatment of Hypercholesterolemia/HypertriglyceridemiaTreatment of HypercholesterolemiaTreatment of HypertryglyceridemiaConservative: 4-6 mo trial unless high risk group, in which case medical treatment should start immediatelyDietDecrease fat: <30% caloriesDecrease saturated fat: <10% caloriesDecrease cholesterol: <200 mg/dIncrease fibre: >30 g/dDecrease alcohol intake to ≤1-2 drinks/dSmoking cessationAerobic exercise: ≥150 min/wk in bouts of≥10 minWeight loss: target BMI <25Medical: HMG-CoA reductase inhibitors,ezetimibe, bile acid sequestrates, niacinConservative: 4-6 mo trialDietDecrease fat and simple carbohydratesIncrease omega-3 polyunsaturated fattyacidControl blood sugarsDecrease alcohol intake to ≤1-2 drinks/dSmoking cessationAerobic exercise: ≥150 min/wk in bouts of≥10minWeight loss: target BMI <25Medical: fibrates, niacinIndications:Failed conservative measuresTG >10 mmol/L to prevent pancreatitisCombined hyperlipidemiaSource: Toronto Notes 2015 Endocrinology E5Dyspepsia/GERDInvestigationRecommendations for the investigations of GERDRecognize the archetypal symptoms of GERD: heartburn and acid regurgitationLook for alarm features: vomiting, evidence of GI blood loss, anemia, involuntary weight loss, dysphagia, or chest painDo not endoscope routinely to diagnose GERDUse endoscopy to:Investigate atypical or alarm featuresDetect Barrett’s esophagousInvestigate dysphagia that has not resolved within 2-4 weeks of adequate PPI therapyDetermine severity of erosive esophagitis (look for erosions or mucosal breaks)You do not need to test for H. pylori before starting treatment for typical GERD symptomsTreatment: H. pylori EradicationTriple therapy for 7-14 d (Hp-Pac): PPI bid (e.g. lansoprazole 30mg bid) + amoxicillin 1g bid + clarithromycin 500mg bid80% success rateQuadruple therapy for 10-14 d: PPI bid + bismuth 525mg qid + tetracycline 500mg qid + metronidazole 250mg qidonly recommended as first line therapy if resistance to clarithromycin or metronidazole is high, or in patients with recent or repeated exposure to these drugslevofloxacin can replace metronidazole or tetracyclineSources:Ontario Guidelines Advisory Committee (2007). Gastroesophageal Reflux Disease (GERD) in Adults. Ref.#248 () Toronto Notes 2015 Gastroenterology G14GoutRisk factorsBody mass indexHypertensionDiuretic useCoffee consumptionAlcohol intakeSweetened beverage consumptionMeat/seafood consumptionDairy product consumptionVitamin C intakeDiagnostic criteriaPresence of characteristic urate crystals in the joint fluidORPresence of a tophus proven to contain urate crystals by chemical means or polarized light microscopyORPresence of six or more of the following clinical, laboratory, or radiologic findings:Asymmetric swelling within a joint on radiographyAttack of monoarticular arthritisCulture of joint fluid negative for microorganisms during attack of joint inflammationDevelopment of maximal inflammation within one dayHyperuricemiaJoint rednessMore than one attack of acute arthritisPain or redness in the first metatarsophalangeal jointSubcortical cyst without erosions on radiographySuspected tophusUnilateral attack involving first metatarsophalangeal jointUnilateral attack involving tarsal joint*Normal serum urate levels do not exclude the diagnosis of goutPrecipitants of GoutDrugs are FACT Furosemide Aspirin/Alcohol Cytotoxic drugs Thiazide diureticsFoods are SALT SeafoodAlcohol (beer and spirits)Liver and kidneyTurkey (meat)TreatmentTreatment principles: Anti-inflammatory medications (acute and prophylaxis) +/- ULT(see following pages for detailed management algorithm and medication recommendations)ULT: Urate lowering therapySource: Khanna, D. et al. 2012 American College of Rheumatology Guidelines for Management of Gout . Part 2 : Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. 64, 1447–1461 (2012).Recommendations for Combination TherapyColchicine + NSAIDsColchicine + Oral CorticosteroidsIntra-articular steroids + all other modalities*Note: Oral/IV corticosteroids, NSAIDS, and colchicine are equally effective in treating acute flares**Please consider following factors when prescribingMedicationRegimenNotesNSAIDSIndomethacin 50mg TID1st line therapy; all NSAIDS are equally effective; adverse effects include gastric bleeding and kidney injuryColchicine1.2mg initially, then 0.6mg one hour later, then 0.6 to 1.2mg ODNo analgesic properties; GI side-effects are common; avoid use in patients with renal and hepatic insufficiency; contraindicated in patients receiving clarithromycinCorticosteroidsOral, IM, or intra-articular routes, variable dosing (e.g. prednisone 40mg for four days, then 20mg for four days, then 10mg for four days)Preferred therapy for patients in whom NSAIDS and colchicine are contraindicated; when discontinuing oral corticosteroids, taper to avoid rebound flaresUralte lowering therapy (ULT)Indications:≥2 flares/year≥1 flare/year in persons with CKD stage 2 or greaterTophiHistory of nephrolithiasisAgents used:First line: Allopurinol (xanthine oxidase inhibitor), Febuxostat (xanthine oxidase inhibitor; $$$), Colchicine (A/E: axonal neuromyopathy and rhabdomyolysis)Second line: Probenecid (↑ urinary uric acid excretion; multi drug interactions; A/E: nephrolithiasis) Third line: Pegloticase (administered by rheumatologist)Duration of treatment:No ongoing symptoms: continue for 3-6 months after a flareOngoing signs or symptoms (e.g., tophi on examination): continue indefinitely*ULTs can be started during acute gout flares if used in conjunction with an NSAID and colchicine*Anti-inflammatory prophylaxis should not be continued for long periods without ULT because uric acid crystals continue to accumulate and damage the joint despite a lack of clinical signs/ symptoms.Sources:Hainer, B. L., Matheson, E., Wilkes, R. T. & Carolina, S. Diagnosis, Treatment, and Prevention of Gout. (2014).Khanna, D. et al. 2012 American College of Rheumatology Guidelines for Management of Gout . Part 2 : Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. 64, 1447–1461 (2012).Anti-inflammatory ProphylaxisSource:Khanna, D. et al. 2012 American College of Rheumatology Guidelines for Management of Gout . Part 2 Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. 64, 1447–1461 (2012).Headaches Red FlagsRed FlagsDifferential DiagnosisPossible work-upHeadache beginning after 50 years of ageTemporal arteritisMass lesionESR, neuroimagingSudden onsetSubarachnoid hemorrhagePituitary apoplexy hemorrhage into a mass lesion or vascular malformationMass lesion (esp. posterior fossa mass)NeuroimagingLP if neuroimaging negativeHeadaches of increasing frequency and severityMass lesionSubdural hematomaMedication overuseNeuroimaging, drug screenNew-onset headache in a patient with risk factors for HIV or cancerMeningitis (chronic or carcinomatous)Brain abscess (incl. toxoplasmosis)MetastasisNeuroimagingLP if neuroimaging negativeHeadache with signs of systemic illness (fever, stiff neck, rash)MeningitisEncephalitis (Lyme disease)Systemic infectionCollagen vascular diseaseNeuroimaging, LP, serologyFocal neurological signs or symptoms of disease (other than typical aura)Mass lesionVascular malformationStrokeCollagen vascular diseaseNeuroimagingCollagen vascular evaluation (including anti-phospholipid antibodies)PapilledemaMass lesionPseudotumorCerebri meningitisNeuroimaging LPHeadache subsequent to head traumaIntracranial hemorrhageSubdural hematomaEpidural hematomaPost-traumatic headacheNeuroimaging of brain, skull and possibly cervical spineSource: Clinch,C.R.(2001). Evaluations of Acute Headaches in Adults. Am Fam Physician, 63(4),685-693. ()TreatmentMigraineClusterTensionAcute Medications1st line: Ibuprofen, ASA, Naproxen, Acetaminophen2nd line: Triptans, antiemetics (for nausea)3rd line: Naproxen+Triptan4th line: Combination analgesicsTriptans100% oxygenIbuprofen, orASA, orNaproxen, orAcetaminophenProphylactic Medications1st line: B-blocker or TCA2nd line: Topiramate, Candesartan,Gabapentin1st line: Verapamil2nd line: Lithium1st line: TCA2nd line:Mirtazapine,VenlafaxineSource: Top Optimized Practice. (2012). Summary Guideline For Management of Primary Headache in Adults. Edmonton, AB: Toward Optimized Practice. ( Summary%20Guideline%20for%20Management%20of%20Primary%20Headache%20in%20Adults.pdf?_20160716153801).Hypertension DiagnosisMeasurement using electronic (oscillometric) upper arm devices is preferred over auscultationABPM: Ambulatory Blood Pressure Measurement AOBP: Automated Office Blood Pressure HBPM: Home Blood Pressure Measurement OBPM: Office Blood Pressure MeasurementPreliminary investigations of patients with hypertension: Urinalysis, Blood chemistry (potassium, sodium and creatinine), Fasting blood glucose and/or glycated hemoglobin (A1c), Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides, Standard 12-lead ECGTarget BP <140/90Source: Reprinted with permission of the Canadian Hypertension Education ProgramTreatmentTarget BP is <140/90 mmHg; or <130/80 mmHg if DMLifestyle modificationsPharmacological treatmentDiet:Follow Canada’s Guide to Healthy EatingDASH diet? Limit daily sodium intake to 1.5-2.3 g30-60 min, 4-7 x/wk; higher intensity exercise is no more effectiveSmoking cessationStress managementLow-risk alcohol consumptionAchieve and maintain a healthy BMI (18.5-24.9 kg/m ) and waist circumference (<102 cm formen, <88 cm for women); use multidisciplinary approach to weight lossIndividualized cognitive behavioural interventions for stress managementIndications to start medication:dBP ≥90 mmHg with target organ damage or independent cardiovascular risk factorsdBP ≥100 mmHg or sBP ≥160 mmHg without target organ damage or cardiovascular risk factorssBP ≥140 with target organ damage1st line antihypertensives: thiazide/thiazide-like diuretic, ACEI (for non-African patients), ARB, long-acting CCB, β-blocker (if age <60)If partial response to standard dose monotherapy, add another first-line drugCaution with combination of non-DHP CCB and B-blocker*Combination of ACEI and ARB is not recommendedBe cautious of hypokalemia in patients treated with thiazide/thiazide-like diuretic monotherapyIf still not controlled or adverse effects, can add other classes of anti-hypertensivesImpact of Health Behaviour on Blood PressureInterventionSystolic BP (mmHg)Diastolic BP (mmHg)Diet and weight-6.0-4.8controlReduced salt/- 5.4- 2.8sodium intakeReduced alcohol-3.4-3.4intake (heavydrinkers)DASH diet-11.4-5.5Physical activity-3.1-1.8Relaxation-3.7-3.5therapiesMultiple-5.5-4.5interventionsSource: CHEP (Canadian Hypertension Education Program) Guidelines 2015. Available from: pain condition characterized by widespread pain (L and R sides, upper and lower body, and the axial skeleton) x ≥3 monthsAssociated symptomsFatigueSleep disturbanceMood disturbanceCognitive symptomsManagementMulti-component therapy using the Bio-Psycho-Social modelBIO:Exercise: 20-30 min of aerobic/flexibility/stretching/strengthening/yoga/tai chi, 2-3x/wkPharmacological Pain Management:*Only Duloxetine and Pregabalin are approved by Health Canada for FM treatmentWHO Pain ladder: Acetaminophen, NSAIDS, Tramadol, OpioidsAntidepressants with pain-relieving properties (SSRIs, SNRIs, TCAs)Anti-epilepticsCannabinoidsPSYCHO:CBTCoping skillsSOCIAL:Encourage self-efficacy and maintaining normal lifestyle/functioningLower Back Pain AssessmentIndications for Diagnostic ImagingHistory of significant traumaNeurologic deficitsSystemic symptomsTemperature greater than 38CUnexplained weight lossMedical history of cancer, corticosteroid use, drug or alcohol abuseAnkylosing spondylitis suspectedSource: Toward Optimized Practice. (2011). A Summary of the Guideline for the Evidence- Informed Primary Care Management of Low Back Pain, 2nd Edition. Edmonton, AB: Toward Optimized Practice. ()Acute Ottis MediaDiagnosisAcute onset of symptomsMiddle ear effusion (TM immobile +/- opacification, loss of bony landmarks, or ruptured TM with fluid in external ear canal),Middle ear inflammation (bulging/discolored TM)TreatmentIndications for immediate antibiotic treatment:Age < 6 moFever >39°CPerforated TM with purulent drainageSignificant comorbidities (eg. immune deficiency, cardiac/pulmonary disease, anatomicabnormalities of head & neck, Down syndrome)Previous complicated otitis mediaIndications for 48 h observation:age > 6 moreliable parents (able to recognize worsening symptoms and bring child back to clinic for f/u)*If child worsens/fails to improve over 48 hours (from onset of symptoms), start antimicrobialtherapyAntibiotics:Amoxicillin 75-90mg/kg/day divided BID x 5 days (>2 y.o.) or 10 days (<2 y.o.)IF ALLERGIC TO PENICILLIN: Cefuroxime-axetil 30 mg/kg/day divided BID or TID x same durationIF NO IMPROVEMENT AFTER 2 DAYS: Amox-clav 45-60mg/kg/day divided TID x 10 daysIF TM PERFORATION: Ciprodex 4 drops BID x 5 daysSource: Saux, N. Le, Robinson, J. L. & Society, C. P. Management of acute otitis media in children six months of age and older. Paediatr Child Heal. 21, 39–44 (2016).Osteoarthritis Treatment of Osteoarthritis Indications for joint replacement: Continued pain and disability despite conservative treatmentsSource: Sinusas, K. Osteoarthritis: Diagnosis and Treatment. Am Fam Physician. 85(1)49-56 (2012).OsteoporosisIndications for BMD TestingOlder Adults (age ≥50 yr)Younger Adults (age <50 yr)All women and men age ≥65 yrMenopausal women, and men aged 50-64 yr with clinical risk factors for fracture:Fragility fracture after age 40Prolonged glucocorticoid useOther high-risk medication use (aromataseinhibitors, androgen deprivation therapy)Parental hip fractureVertebral fracture or osteopenia identifiedon x-rayCurrent smokingHigh alcohol intakeLow body weight (<60kg) or major weightloss (>10% of weight at age 25 yr_Rheumatoid arthritisOther disorders strongly associated withosteoporosisFragility fractureProlonged use of glucocorticoidsUse of other high-risk medications (aromatase inhibitors, androgen deprivation therapy, anticonvulsants)Hypogonadism or premature menopauseMalabsorption syndromePrimary hyperparathyroidismOther disorders strongly associated with rapid bone loss and/or fractureAssessment of 10-year fracture risk: CAROC or FRAX toolTreatmentLifestyle modifications:Elemental calcium 1000-1200 mg/d; Vit D 1000 IU/dExercise: 3x30 min weight-bearing exercises/wkCessation of smoking, reduce caffeine intakeStop/avoid osteoporosis-inducing medicationsDrug therapyBisphosphonateRANKL inhibitorsParathyroid hormoneCalcitonin (2nd line)Treatment specific to Post-Menopausal WomenSERMHRTPainNeuropathic PainStarting doseMaintenance doseFIRST LINETCAs10-25mg/day; increase by 10mg q1week50-150mg/dayGabapentinoidsPregabalin75-150mg/day; increase by 50-150mg q1week150-300mg BIDGabapentin300mg/day; increase by 300mg q1week300-1200mg TIDSECOND LINESNRIsVenlafaxine37.5mg/day; increase by 37.5mg q1wk150-225mg/dDuloxetine60mg/day60-120mg/dTopical Lidocaine5% patches or gel applied to painful area x 12hTHIRD LINETramadol50mg/day; increase by 50mg q1wk50-150mg QIDOpioidsMorphine15mg q12h30-120mg q12hOxycodone10mg q12h20-60mg q12hFentanyl25mcg/h patch25-100mcg/h patchFOURTH LINECannabinoidsMethadoneAnticonvulsants (Lamotrigene, Topiramate, Valproic Acid)SSRIsNociceptive PainStep 1: Acetaminophen and NSAIDAcetaminophen 75mg/kg (max) daily PO in divided dosesCan reduce the need for opioids by 50%Ibuprofen 600-2400mg daily PO in divideddoses TID-QIDNaproxen 500-1000mg daily PO in divided doses BID-TIDStep 2: Tramadol, Tapentadol, low dose step 3 medicationsTramadol 25-75mg PO q4hStep 3: Hydromorphone, Morphine, OxycodoneHydromorphone 2mg PO q4h or 1mg SC q4hOxycodone 5mg PO q4hMorphine 10mg PO q4h or 5mg SC q4hStep 4: Fentanyl and extended release step 3 medicationsAdjuvant Pain Medications:NMDA Antagonist (Ketamine, Memantine)Anti-depressants (SSRI, SNRI, TCs)Anticonvulsants (Gabapentin, pregabalin,valproic acid)Muscle relaxant (Cyclobenzaprine, baclofen)Sources:Moulin, D. E., Clark, A. J. & Gilron, I. Pharmacological management of chronic neuropathic pain – Consensus statement and guidelines from the Canadian Pain Society. 12, 13–21 (2007).Rosenquist, EWK. Overview of the treatment of chronic pain. Retrieved from . com/ contents/overview of-the-treatment-ofchronic-pain?source=search_result&search=chronic+pain&sele ctedTitle=1%7E150)Sullivan P. Ottawa Anesthesia Primer. 1st ed. Echo book Publishing; 2013.AnxietyDSM-V Criteria for Generalized Anxiety DisorderExcessive anxiety and worry most days >/=6 months about a number of events or activitiesWorry is difficult to controlAnxiety/worry associated with at least 3/6 symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, insomniaGAD Pharmacological TreatmentFirst-lineAgomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XRSecond-lineAlprazolam, bromazepam, bupropion XL, buspirone, diazepam, hydroxyzine, imipramine, lorazepam, quetiapine XR, vortioxetineThird-lineCitalopram, divalproex chrono, fluoxetine, mirtazepine, trazodoneAdjunctive therapySecond-line: pregabalinThird-line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidoneNot recommended: ziprasidoneNot recommendedBeta blockers (propranolol), pexacerfont, tiagabineCR = controlled release; XL = extended release; XR = extended release Consider BNZ first when looking at starting second line treatmentDepressionDSM-V Criteria for Major Depressive Disorder2 weeks including depressed mood OR anhedonia with functional impairment ANDAssociated with 5/9 symptoms: mood (depressed), sleep (insomnia or hypersomnia), interest (anhedonia), guilt/worthlessness, energy (decreased), concentration (decreased), appetite changes, psychomotor agitation or retardation, suicidal ideationFirst-lineSSRI, SNRI, NDRI, NaSSA, RIMAex. Escitalopram (Cipralex) 10mg PO daily, Venlafaxine (Effexor) 75mg PO dailySecond-lineTCA (Nortriptyline), SARI (Trazodone), Seroquel-XRThird-lineMAOI (Phenelzine)Adjunctive therapyLithium - 600 mg daily up to therapeutic serum levelAripiprazole (Abilify) 1-2 mg up to 10 mg Olanzapine (Zyprexa) 2.5-5 mg up to 7.5 mg qhs Risperidone (Risperdal) 0.5-1 mg up to 1.5 mg qhsPsychiatryCommon Psychiatric Medication Side EffectsMedication ClassSide EffectsSSRIHANDS: Headache, anxiety, agitation, nausea, diarrhea, sexual dysfunction, sleep disturbancesSNRISame as SSRI (HANDS) plus increased BPNDRIHeadache, rash, sleep disturbance (insomnia), shaking, anxiety, agitation, emesis, seizures (0.1% over 400mg)NaSSAWeight gain, increased cholesterol, anti-cholinergic (urinary retention, dry mouth, constipation, blurred vision), drowsiness, orthostatic hypotensionTrazodoneSedation, vivid dreams, headache, dry mouth, priapism (1/6000)TCAWeight gain, sedation, anti-cholinergic, dizziness, orthostatic hypotension, QTc prolongationMAOIOrthostatic hypotension, weight gain, sexual dysfunction, ankle edemaLithiumTremor, alopecia, GI upset, acne, weight gain, hypothyroid, muscle weakness, ECG changesSources:Katzman, M. A. et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 14, S1–S1 (2014).American Psychiatric Association. (2013). Major Depressive Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.).Canadian Network for Mood and Anxiety Treatments. Clinical Guidelines for the Management of Major Depressive Disorder in Adults. Retrieved from Psychiatric Association. (2013). Generalized Anxiety Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.).Canadian Psychiatry Association. Clinical Practice Guidelines – Management of Anxiety Disorders – Updated 2006. Retrieved from ConditionsAcneOptimizing topical Abx therapy (Tetracycline, Doxycycline, Erythromycin, Minocycline) with use of:topical retinoids: ↑ efficacybenzoyl peroxide: ↓ resistanceOther treatment options:Hormonal contraceptives:treatment of inflammatory and non-inflammatory acne in womenSpironolactone:consider as an alternative in women who cannot use isotretinoin. Potential teratogenSource: Titus, S. & Hodge, J. Diagnosis and Treatment of Acne. Am. Fam. Physician 86, 734–740 (2012).Eczema (Atopic Dermatitis)Clinical PresentationSubacute and chronic eczematous reaction associated with prolonged severe pruritusDistribution depends on ageInflammation, lichenification, excoriations are secondary to relentless scratchingAtopic palms: hyperlinearity of the palms (associated with ichthyosis vulgaris)Associated with: keratosis pillars (hyperkeratosis of hair follicles, “chicken skin”), xerosis, occupational hand drynessTreatment AlgorithmSource: Adapted from: Ellis C, et al. ICCAD II Faculty. International Consensus Conference on Atopic Dermatitis II (ICCAD II): clinical update and current treatment strategies. Br J Dermatol 2003;148(Suppl 63):3-10Actinic Keratosis (Solar Keratosis)Pre-malignant, common with increasing age. Risk of transformation from AK to SCC (~1/1000) but higher risk if AK is persistentClinical PresentationIll-defined, scaly erythematous papules or plaquesCommonly found in areas of sun exposure (face, ears, scalp if bald, neck, sun-exposed limbs)Sandpaper-like, gritty sensation. Easy to appreciate on palpation rather than inspectionInvestigationsBiopsy if resistant to treatmentManagementDestructive: cryotherapy, electrodessication and curettagePharmacotherapy: 5-FU cream for 2-3 weeks, Imiquimod cream for 8-10 weeks, photodynamic therapyExcisionBasal Cell CacinomaNon-melanoma skin cancer. Most common malignancy in humans.Clinical Presentationnoduloulcerative (typical)skin-coloured papule/nodule with rolled, translucent (“pearly”) telangiectatic border and depressed/eroded/ulcerated centre.pigmented variantflecks of pigment in translucent lesion with surface telangiectasiamay mimic MMsuperficial variantflat, tan to red-brown plaque, often with scaly, pearly border and fine telangiectasia at marginleast aggressive subtypesclerosing (morpheaform) variantflesh/yellowish-coloured, shiny papule/plaque with indistinct borders, induratedInvestigations BiopsyManagementImiquimod 5% cream or cryotherapy is indicated for superficial BCCs on the trunkShave excision+electrodessication and curettage for most types of BCCs, not including morpheaformMohs surgeryRadiotherapy in advised casesVismodegib for metastatic BCCLife-long follow-up95% cure rate if lesion <2cm in diameter or if treated earlySquamous Cell CarcinomaNon-melanoma skin cancer. Second most common cutaneous neoplasm.Clinical Presentationindurated erythematous nodule/plaque with surface scale/crust ± ulcerationmore rapid enlargement than BCCCommonly found on face, ears, scalp, forearms, and dorsum of handsInvestigationsBiopsyManagementsurgical excision with primary closure, skin flaps or graftingMohs surgerylifelong follow-up (more aggressive treatment than BCC)Red EyeConjunctivitsHistorySymptomsSignsTreamtentAllergicAtopy or allergiesItching, rhinitisBilateral watery eyes, papillaeCool compression, oral/ topical antihistamine, artificial tearsBacterialBurning, tearing, foreign body sensation, mild photophobia, blurry visionPurulent discharge, papillae, “may progress to periorbital cellulitis”Topical antibiotic x1 weekGonococcal/ ChlamydiaSexual contact, possible vertical transmission in neonatesChronic, unilateral conjunctivitis not responsive to drops. Tearing, foreign body sensation. LUTS+new sexual partnerMucoid discharge. FolliclesTreat for both gonococcal and chlamydial infection. Ceftriaxone=1g IM once AND azithromycin 1g PO +/- topical abc. Ophthalmology referralViral (adenovirus most common)Sick contactRecent URTI, burning, itching, foreign body sensation. Mild photophobia. Typically affects one eye first, with spread to other eye after a few daysClear mucoid discharge. Follicles. Tender pre-auricular lymphadenopathySelf-limiting (resolves in 2-3 weeks). Contagious forweeks after sx onset. Cold warm compresses. Artificial tears. Proper hand hygieneRed Flags for Urgent Ophthalmology Referral:Decreased visual acuity (infectious keratitis, iritis, angle closure glaucoma)Ciliary flush (infectious keratitis, iritis, angle closure glaucoma)Photophobia (infectious keratitis, iritis)Corneal Opacity (infectious keratitis)Fixed Pupil (angle closure glaucoma)Severe headache with nausea (angle closure glaucoma Sources:Anti-infective Review Panel. Anti-infective Guidelines for Community Acquired Infections. Toronto: MUMS Guideline. Clearinghouse; 2013.Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw- Hill Education; 2013.Jacobs, DS. Conjunctivitis. Uptodate. Retrieved from conjunctivitis?source=search_result&search=conjunctivitis&selectedTitle=1 7E150. Accessed June 2, 2014 Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: The McGraw- Hill Companies; 2012.Problems in the ElderlyElder Abuse Suspicion Index (EASI)Screening Tool: Validated tool for use by family practitioners in ambulatory, cognitively intact elderly patients.Within the last 12 months:Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?YesNoDid not answerHas anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?YesNoDid not answerHave you been upset because someone talked to you in a way that made you feel shamed or threatened?YesNoDid not answerHas anyone tried to force you to sign papers or to use your money against your will? YesNoDid not answerHas anyone made you afraid, touched you in ways that you did not want, or hurt you physically? YesNoDid not answerDoctor: elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. did you notice any of these today or in the last 12 months?YesNoDid not answer“Yes” to ≥1 of Q2-Q6 establishes concern for elder abuseSources:Ya e MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: The Elder Abuse Suspicion Index (EASI) ?. Journal of Elder Abuse and Neglect 2008; 20(3) 276-300. Haworth Press Inc: ? The Elder Abuse Suspicion Index (EASI) was granted copyright by the Canadian Intellectual Property Office (Industry Canada) February 21, 2006. (RegistrationAssessment & Management of Falls No. 1036459)Sources:Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society (2010). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc (2010). DOI: 10.1111/j.1532-5415.2010.03234.x ( health_care_pros/ JAGS.Falls.Guidelines.pdf)Can also refer to Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society (2010). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc (2010). DOI: 10.1111/j.1532-5415.2010.03234.x ( health_care_pros/DementiaComparison of types of DementiaTypeFeaturesAlzhemier’s Disease (AD)Insidious onset, gradual progressionDecreased short term memory (encoding deficit, will notrespond to cues)Word finding and way finding difficultiesLimited insightVascular Dementia (VD)Presence of vascular risk factors OR established arterial disease OR neuroimaging evidenceMemory loss (recall deficit, responsive to cues)Executive skills deficitsEarly apraxia and agnosiaDepression, apathyLewy Body Dementia (LBD)Fluctuating presentationVisual hallucination, parkinsonism, REM sleep behaviourdisorderFrontal Temporal Dementia (FTD)Early onset (45-64)Personality change, disinhibition, executive skills deficitsMemory and visualspcial skills presented earlyManagement“Dr. Dalziel’s Triple Therapy”Prevent the Preventable (as applicable)Lifestyle changes; improve sensory deficitsTreat the TreatableMild – moderate AD: Any of the 3 cholinesterase inhibitors (Donezepil, Galantamine, Rivastigmine)Moderate-severe AD: Memantine (NMDA Antagonist)VD: DonepezilMixed dementia (AD + VD): GalantamineCare for the CaregiversReferral to Alzheimer’s societyRecognize and address caregiver burden/stress/depressionSources:Huntington, Kate. “Clerkship Overview of Geriatric Psychiatry.” Powerpoint presentation. Chun, Soojin. “Neurocognitive Disorders (Dementia).” Psychiatry Clerkship Bootcamp. 2016.Powerpoint presentation.PseudodementiaPseudodementia: a term used to describe dementia-like features seen in depressed elderly patients. The underlying cause of the cognitive change is depression, not dementia.DementiaDepressionOnsetInsidiousSubacuteMoodLabileConsistently depressedMood reactivity (able to enjoy things)YesNoMood or cognition affected firstCognition affected firstMood affected firstCooperativeYesNoAphasiaYesNoHistory of depressionNoYesSource: National Guidelines for Seniors’ Mental Health. The Assessment and Treatment of Depression. (2006)Health Promotion and ScreeningPeriodic Health ExaminationLabs/InvestigationsImmunizationsMaleFasting lipid profileq3 years at age 40 (earlier if high risk)Fasting blood glucoseq3 years at age 40 (more often if high risk)Hemoccult Multiphaseq1-2 years at age 50 OR Colonoscopy q10 years OR Sigmoidoscopy q5 years if normal and no polypsBone Mineral Densityq1-3 years if moderate risk, q5 years if low risk at age 65 (earlier if at risk)Tetanus vaccine q10 yearsInfluenza vaccine q1 yearHerpes zoster vaccine (age 60)Pneumococcal vaccine (age 65 or earlier if high risk)Acellular pertussis vaccineVaricella immunityRubella ImmunityMeningococcal vaccine (if high risk age 2-25)FemalesSame as males except:Fasting lipid profile at age 50Mammographyq1-2 years from ages 50-69Cervical Cytologyq3 years from ages 21-69Same as males plus:Human papilloma virus (HPV) vaccine 3 doses (aged 9-26)Breast Cancer ScreeningAge </= 49Age >50Average RiskRoutine mammography not recommendedMammography every 2-3 yearsHigh Risk (i.e. genetic mutation in self or family, family history of hereditary breast cancer, or radiation therapy to chest before age 30)Breast MRI and mammography yearlyBreast MRI and mammography yearlySources:Government of Ontario. Ontario Breast Cancer Screening Program ( public/programs/breastcancer/screened.aspx#2) ? Queen’s Printer for Ontario, 2008The Canadian Task Force on Preventive Health Care (2011). Recommendations on screening for breast cancer in average-risk women aged 40–74 years. CMAJ, 183 (17), 1991-2001. (http:// cmaj.ca/content/183/17/1991)Cervical Cancer ScreeningRecommendationsScreening InitiationAge 21Postpone to initiation of sexual activity* if not sexually active at age 21Screening Intervalq3years unless result dictates otherwiseScreening CessationAge 70 if last 3 pap tests have been normal*includes intercourse, digital or oral contact of the genital area with a partners of all gendersSpecial CircumstancesWomen who:Screening IntervalAre immunocompromisedq1yRetained their cervix after subtotal hysterectomyq3y (regular screening guidelines)Are pregnantHave sex with womenHave received the HPV vaccineAny visual cervical abnormalities and/or abnormal symptoms must be investigated regardless of cytology findings.See link below for recommended management of different Pap test results.Source:Cancer Care Ontario. Ontario Cervical Screening Cytology Guidelines Summary - Updated May 2012 ()Colorectal Cancer ScreeningAverage risk: Individuals aged 50 - 75 with a negative family history should undergo screening with one of the following strategies:FOBT every two yearsFlexible Sigmoidoscopy every ten yearsFlexible Sigmoidoscopy Combined with FOBT every ten yearsHigh risk: see below for description on left and specific guideline on rightFirst degree relative with the disease diagnosed before age 60Colonoscopy q5 yrs to begin at age 40OR 10 yrs earlier than the youngest diagnosis ofpolyp or cancer in the familyIf diagnosed after age 60, then employ average risk screening to begin at age 40Family history of HNPCCColonoscopy q1-2 yrs beginning at age 20OR 10 yrs younger than the earliest case in thefamilyFamilial Adenomatous Polyposis (FAP)Sigmoidoscopy annually to begin at age 10-12Long standing colonic inflammatory bowel disease (Crohn’s or Ulcerative Colitis)For pancolitis: begin screening at 8 yrs after onset of disease, continue with colonoscopy q3 yrs in the second decade, colonoscopy q2 yrs in thethird decade and colonoscopy annually in the fourth decadeFor left sided colitis, begin screening at 15 years after onsetSources:Canadian Association of Gastroenterology position statement on screening individuals at average risk for developing colorectal cancer: 2010. This information was originally published in Can J Gastroenterol 2010;24(12):705-714. (? sCurrPg=abstract&jnlKy=2&atlKy=9870& isuKy=954&isArt=t)Colorectal Cancer Association of Canada. Canadian Association of Gastroenterology issued Guidelines on Colon Cancer Screening 2004 ( screening-tests/#II)Cancer Care Ontario: Colorectal Cancer Screening ( coloscreening/)Skin Cancer ScreeningTargetRecommendationsVery high risk populationIndividuals with ANY of the following risk factors:on immunosuppressive therapy after organ transplantationpersonal history of skin cancer2 or more first-degree relatives with melanomamore than 100 nevi in total or 5+ atypical nevihave received more than 250 treatments ofpsoralen ultraviolet A radiation (PUVA) forpsoriasisreceived radiotherapy for cancer as a childYearly total body skin examinationCounselling on skin self- examination and skin cancer preventionIn the case of childhood cancer survivors, the site of radiation therapy should be monitoredIndividuals with TWO OR MORE of the following risk factors:a first-degree relative with melanomamany (50-100) nevione or more atypical (dysplastic) nevinaturally red or blond haira tendency to freckleskin that burns easily and tans poorly or not at allCounselling on skin self-examinationShould be seen once a year by a health care provider trained in screening for skin cancersNote: The general population is not at increased risk of skin cancerAt this time there is no evidence for or against skin cancer screening of the general population at average risk of developing skin cancerBased on limited evidence available at present, routine total body examination or routine counselling on skin self-examination by primary care providers is NOT RECOMMENDED for individuals at AVERAGE OR LOW RISK for skin cancerSource:From, L., Marrett, L., Rosen, C., Zwaal, C., Johnston, M., Bak, K., Sibbald, G., Fong, J., & Mai, V. (2007) Screening for Skin Cancer : A Clinical Practice Guideline A Quality Initiative of the Program in Evidence-based Care (PEBC), Cancer Care Ontario (CCO). (http:// cancercare.on.ca/common/pages/UserFile. aspx?fileId=13942)Smoking Cessation MedicationsMedicationDosingAdverse EffectsNICOTINE REPLACEMENT THERAPYGum1st cigarette ≤30 minutes after waking: 4mg1st cigarette >30 minutes after waking: 2mgWeeks 1-6: 1 piece q1-2 hoursWeeks 7-9: 1 piece q2-4 hoursWeeks 10-12: 1 piece q4-8 hoursMaximum 24 pieces/dayMaximum 24 pieces/dayChew and parkChew and paChew and parkMouth/jaw sorenessHiccupsDyspepsiaHypersalivationEffects associated with incorrect chewing technique:LightheadednessNausea/vomitingThroat and mouth irritationLozenge1st cigarette ≤30 minutes after waking: 4mg1st cigarette >30 minutes after waking: 2 mgWeeks 1–6: 1 lozenge q1–2 hoursWeeks 7–9: 1 lozenge q2–4hours Weeks 10–12: 1 lozenge q4–8 hoursMaximum, 20 lozenges/dayMaximum, 20 lozenges/dayNauseaHiccupsCoughHeartburnHeadacheFlatulenceInsomniaTransdermal Patch>10 cigarettes/day:-21 mg/day x 4 weeks-14 mg/day x 2 weeks-7 mg/day x 2 weeks≤10 cigarettes/day:-14 mg/day x 6 weeks-7 mg/day x 2 weeks- Local skin reactions (erythema, pruritus, burning)- Headache- Sleep disturbances (insomnia, abnormal/vivid dreams): associated with nocturnal nicotine absorption *May wear patch for 16 hours if patient experiences sleep disturbances (remove at bedtime)Nasal Spray1–2 doses/hour (8–40 doses/day)*One dose = 2 sprays (one in each nostril)- Maximum: 5 doses/hour or 40doses/day- Duration: 3–6 monthsDuration: 3–6 monthsNasal and/or throat irritation (hot, peppery, or burning sensation)RhinitisTearingSneezing - CoughHeadacheOral Inhaler6–16 cartridges/day Individualize dosing; initially use 1 cartridge q 1–2 hoursBest effects with continuouspuffing for 20 minutesDo NOT inhale into the lungs(like a cigarette) but “puff” as if lighting a pipeDuration: 3–6 monthsMouth and/or throat irritationCoughHeadacheRhinitisDyspepsia- HiccupsOTHERBupropion150 mg PO qAM x 3 days, then 150 mgPO BIDDo not exceed 300 mg/dayBegin therapy 1–2 weeksprior to quit dateInsomniaDry mouthNervousness/difficulty concentratingVareniclineDays 1–3: 0.5 mg PO qAMDays 4–7: 0.5 mg PO BIDWeeks 2–12: 1 mg PO BIDBegin therapy 1 week prior toquit dateDuration: 12 weeks (+/-additional 12-weeks)NauseaSleep disturbances (insomnia,abnormal/vivid dreams)ConstipationSources:Rx for Change. Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation.Updated March 1, 2012. Copyright ? 1999–2012 The Regents of the University of California. Smoking Cessation Flow SheetSmoking Cessation Flow SheetSource: CTI (2008). Smoking Progress Notes – Annual Patient Profile. ( Cessation_Guideline_Flow_Sheet_updated_Jan2008.pdf)Family PlanningContraception OptionsMethodAdvantagesDisadvantagesCombined OCP (Daily)Effectiveness (99.7% - perfect use,92% - typical use)Cycle control↓ dysmenorrhea,↓ menstrual flow↓ perimenopausal and PMS symptoms↓ risk of ovarian, endometrial,possibly colorectal cancer↓ ovarian cysts↓ acne and hirsutism↑ bone densityIrregular bleeding/spottingBreast tenderness, nausea, headache↑ VTE riskSlight ↑ risk of breast cancerTransdermal Contraceptive Patch (Weekly)Effectiveness (99.7% – perfect use,92% - typical use)Same as OCP48-hour “window of forgiveness”Same as OCP Skin irritationPatch detachment (uncommon) Less effective if >90kgVaginal Contraceptive Ring(Monthly)Effectiveness (99.7% - perfect use,92% - typical use)Same as OCP1-week “window of forgivenessSame as OCP VaginitisVaginal discomfortExpulsion (uncommon)Progestin Only Pill(Daily)Effectiveness (99.7% - perfect use,92% - typical use)Can be used post-partumIrregular bleedingHeadache, bloating, acne, breasttendernessMust take at same time everydayNo pill-free intervalDepot medroxy- progesterone acetate (DMPA)(IM progesterone injection every 12-13 weeks)Effectiveness (99.7% - perfect use,97% - typical use)↓ menstrual flow orAmenorrhea↓ risk of endometrial cancer↓ endometriosis symptoms↓ PMS and chronic pelvic pain symptoms↓ SeizuresPossible ↓ risk of PID and sickle-cell crises6-day “window of forgiveness”Irregular bleeding Delayed return of fertility Headache, ↓ libido, nausea, breasttenderness, weight gain, mood effectsWeight gain↓ Bone mineral densityCopper IntrauterineDevice (5 years)Effectiveness (99.4% - perfect use,99.2% - typical use)Possible ↓ risk of endometrial cancerCan be used as emergencycontraceptionIrregular bleeding↑Menstrual flowDysmenorrheaPerforationExpulsionIncreased risk of PID for first 20 daysHormonal Intrauterine Device (5 years)Effectiveness (99.9% - perfect use,99.9% - typical use)↓ Menstrual flow/ Amenorrhea↓ dysmenorrheaMay protect against endometrialhyperplasiaIrregular bleedingSystemic hormonal side effectsFunctional cystsPerforationExpulsionIncreased risk of PID for first 20 daysMale Condom (one-time use)Effectiveness (98%- perfect use,85% - typical use)Protects against STIsNo prescription requiredFemale Condon (one-time use)Effectiveness (95%- perfect use,79% - typical use)Same as male condomFemale controlledCan be noisy during intercourseCan be difficult to insertCan cause discomfort during intercourseDiaphragm (one-time use)Effectiveness (94%- perfect use,84% - typical use)Some protection against STIsCan be used during mensesCan be difficult to insertMust be left in for 6 hours after intercourseMust be used with spermicideDoes not protect against HIVLatex or spermicide allergyMust be fitted by health care providerMay ↑ risk of UTI,Sponge (one-time use)Effectiveness (Nulliparous:91% - perfect use, 84% - typical use;Parous: 80% - perfect use, 68% -typical use)One size fits allNo prescription requiredCan be difficult to insert and removeMust be left in 6 hours after intercoursePossible spermicide sensitivityShould not be used during menstruationLess effective in multiparous womenFertility Awareness and Symptothermal MethodEffectiveness (91-99% - perfect use,80% - typical use)Greater awareness of gynaecologicalhealthHigh probability of failure if not used consistently and correctlyLactational Amenorrhea MethodEffectiveness 98%Menses must have not returnedMust be fully/nearly fully breastfeedingBaby must be < 6 months of ageAbstinenceEffectiveness 100%No STI risk if no exchange of bodyfluidsMay be too restrictive for some couplesCan cause frustrationDoes not encourage use of other methods of contraception, if behaviour changesSource: Fisher, W.A., Black, A (March 27, 2007). Contraception in Canada: a review of method choices, characteristics, adherence and approaches to counseling. CMAJ. 176(7), 953-961.(http:// cmaj.ca/content/176/7/953.full.pdf)Quick Reference GuideCommon AntibioticsConditionMicroorganismFirst Line Antibiotic RegimenCommunity Acquired Pneumonia - Adult(outpatient without comorbidities)S. pneumoniaeM. pneumoniaeC. pneumoniaeClarithromycin 500mg BID or 1000mg(extended release) once daily x 7-14 daysAmoxicillin 1g TID x7-14 daysAzithromycin 500mg on first day then 250mg x 4 dayCommunity Acquired Pneumonia– Children (outpatient without comorbidities)1 – 3 months: RSV, viruses3 months – 5 years:S. pneumo, S. aureas, GAS, H. influenza5 – 18 years: M. pneumonia, C. pneumonia, S. pneumonia, influenza A or B1-3 months: no antibiotic indicated 3 months – 5 years: Amoxicillin80mg/kg/day divided TID x 7-10days5 – 18 years: Clarithromycin 15mg/kg/day divided BID x 7-10 daysAcute PharyngitisGroup A StrepAdults: Penicillin V 600mg BID x 10 dayErythromycin 250mg QID x 10dChildren: Pen V 40mg/kg/d divided BID-TID x 10d, max 750mg/d (use adult dosing if>27kg)Erythromycin estolate 40mg/kg/d divided BID-TID x 10dOtitis MediaS. pneumoniaeH. InfluenzaM. catarrhalisAdults: Amoxicillin 500mg TID x 5 d Cefprozil 250-500mg BID x7-10dChildren: Amoxicillin 80-90mg/kg/ day divided BID or TID (max 3g/day) x5 or 10 daysCefprozil 30mg/kg/d divided BID (see acute otitis media p.x for details)Otitis ExternaP. aeruginosa ColiformsS. aureusCiprodex 4 drops BIDBacterial SinusitisS. pneumoniaeH. influenzaM. catarrhalisS. aureusAdults: Amoxicillin 500mg TID x 5-10 dAmoxicillin/Clavulanate 500mg BID x 5-10 daysCefurozime-AX 250-500mg BID x 5-10dChildren: Amoxicillin 80-90mg/kg/ day divided BID or TID (max 3g/day) x 10-14 daysAmoxicillin/Clavulanate 40-80mg/ kg/day divided BIDCefprozil 30mg/kg/d divided BID x10-14dBacterial ConjunctivitisS. aureusS. pneumoniaeH. influenzaM. catarrhalisErythromycin 0.5 ointment 1/2 inch QID x5-7 dayContact lens users: Ciprofloxacin 0.3% drops1-2 drUrinary Tract InfectionE.coliS. saprophyticus Other gram –ve bacilliTMP/SMX 1DS tab BID x 3 days Nitrofurantoin 100mg BID x 5 days (CI in pregnancy after 36wk) Cephalexin 250-500 mg QID x 7 days (if pregnant)PyelonephritisE. coliK. pneumoniaP. mirabilisCiprofloxacin 500mg BID x 7 daysUrethritisN. gonorrheaC. trachomatisCeftriaxone 250mg IM x 1 AND Azithromycin 1g PO onceBacterial VaginosisOvergrowth of:G.vaginalisM. hominis AnaerobesMetronidazole 500mg BID PO x 7 daysPeptic Ulcer Disease (non- NSAID)H. pylori“HP-PAC” BID x7dP: PPI (eg. omeprazole 20mg BID x 7d)A: Amoxicillin 1000mg BID x 7 d C: Clarithromycin 500mg BID x 7dCommon AntiviralsConditionMicroorganismAntiviral RegimenMucocutaneous herpes (>3/year)Herpes Simplex type 1 or 2Valacyclovir 2g BID onceFamciclovir 500mg BID x 7 daysGenital HerpesHerpes Simplex type 1 or 2Acyclovir 400mg TID x 5-7 daysShingles (initiate within 72 hours of rash onset)Varicella ZosterValacyclovir 1g TID x 7 daysFamciclovir 500mg TID x 7 daysChicken Pox (initiate within 24 hours of rash onset)Varicella ZosterValacyclovir 1g TID Famciclovir 500mg TID Prevention: Chickenpox vaccineGenital WartsHuman Papilloma VirusCryotherapy (liquid nitrogen q1-2 weeks)InfluenzaInfluenza A or BOseltamivir (Tamiflu) 75mg daily x 10 days (must begin within 48 hours of exposure/ symptoms)Source: Anti-infective Review Panel. Anti-infective Guidelines for Community Acquired Infections. Toronto: MUMS Guideline Clearinghouse; 2013.Immunization ScheduleVaccine ContraindicationsAnaphylaxis to a previous dose or constituent (e.g. neomycin)Significant Immunosuppression (live vaccines)Pregnancy (live vaccines)Live Attenuated Vaccines:BCGMeaslesMumpsRubellaVaricellaYellow feverTyphoid Ty21aVacciniaSources:Sur, D., Wallis, D. & O’Connell, T. Vaccinations in Pregnancy. Am. Fam. Physician 68, E299–309 (2003).MacDonnell, Heather, “Immunizations in Canada.” CHEO. Paediatric Clerkship. 2015. Lecture. Government of Ontario. Publicly Funded Immunization Schedules for Ontario – October 2015. ? Queen’sPrinter for Ontario, 2015 ( immunization_schedule.pdf)60Developmental MilestonesAgeGross MotorFine MotorLanguageSocial/Cognition1 monthLifts head to 45 degreesFollow to midlineStartles to loud noiseSmiles spontaneously2 monthsLifts head up when on stomachFollows past midlineCoos (gurgly sounds), squeals, laughsSmiles responsively, recognizes caregivers6 monthsSits without support, rolls from back to sideTransfers between handsBabbles, uses dada/ mama non specificallyFeeds self, stranger anxiety9 monthsPulls to standThumb-finger grasp, bangs 2 cubes held in handUses dada/mama specificallyWaves bye, plays pat-a-cake, indicates wants12 monthsStands alone, walksPuts block in cup, scribbles2-3 wordsImitates activity, play ball18 monthsWalks up steps, kicks ballBuilds tower of 4 cubesCombines words, speech half understandableWash and dry hands, brush teeth with help2 yearsJumps, throws ball overhandBuilds tower of 6 cubesKnows 6 bodyparts, names 1 pictureNames friend, puts on clothingSources:Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-Hill Education; 2013.Frankenburg, W.K., et al.: The DENVER II: A major revision and restandardization of the Denver Developmental Screening Test.Pediatrics, 89:91-97, 1992Frankenburg, W.K., et al.: The DENVER II Technical Manual 1996, Denver Developmental Materials, Denver, Co.Rourke, L., Leduc, D., Rourke, J. (2014). Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance. Retrieved from GlossaryTermCharacteristicsDiameterExampleMaculeFlat, non-palpable, change in color of skin<1cmFrecklesPatchFlat, non-palpable, change in color of skin>1cmVitiligoPapuleSolid raised lesion, well circumscribed<1cmNeviPlaqueSolid raised lesion, well circumscribed, superficial, may be flat topped or rounded>1cmPsoriasisNoduleSolid palpable lesion, height>width, appreciable depth.<1cmDermatofibromaTumourUsually found in dermal or subcutaneous tissue and the lesion may be above level with or below the skin surface>1cmLipomaVesicleRaised, pus-filled lesion<1cmHSVBullaRaised, pus-filled lesion>1cmBurnsPustuleRaised, pus-filled lesion<1cmPustullar psoriasisWheal (Hive/ Urticaria)Transient, circumscribed elevated papules or plaques often with erythematous borders and pale centres. Often pruritic, formed by edema in the dermisAllergic reactionErosionSuperficial break in the skin due to loss of part or all of the epidermis; heals without scarringUlcerLoss of epidermis and at least part of dermis; heals with scarringFissureBreak in the skin extending from epidermis to dermisTelegiectasiaFoci of visibly dilated capillariesRosaceaPurpuraRed or purple macule or patch that is non-blancheable; area of hemorrhageCoagulopathiesLichenificationDiffuse thickening of the epidermis, accentuating normal skin markingsEczemaCrustDried exudate of serum, pus or blood originating from a lesionImpetigoScalesA dry build-up of dead skin cellsPsorasisAtrophyThinning of the skinChronic sun exposureSource: MacNeal, RJ. (2015). Description of Skin Lesions ()Antenatal Care TimelinesFrequency of visits:Advise 1st visit 8-10 weeks GAEvery 4 weeks for the first 28 weeksEvery 2-3 weeks until 36 weeks GAWeekly after 36 weeks GA?Add to Antenatal Form 2 at each subsequent visit following initial visitInitial Visit (Recommended 8-10 weeks GA)Complete Antenatal Form 1 and 2Initiate antenatal bloodworkCBC, Type + Screen, VDRL, Hepatitis B, Rubella, HIVPap (if indicated), Chlamydia/Gonorrhea swab? Urine C+S and dipInitiate prenatal vitamins if not yet started11-14 weeks GAIntegrated Pregnancy Screening (IPS) U/S and 1 bloodwork (PAPP-A)11-13 weeks GAChorionic Villous Sampling (if indicated)12 weeks GA +Fetal heart rate (FHR) with doppler15-20 weeks GA2nd set of IPS bloodwork (MSS)15-22 weeks GAAmniocentesis (if indicated)18-20 weeks GAU/S for fetal morphology recommended20 weeks GA+Symphysial fundal height (SFH)24-28 weeks GAGestational diabetes screen: Glucose tolerance test (50-gram)If >7.8 a 2nd28 weeks GAWinRho injection for Rh(-) patients32-34 weeks GAU/S for fetal growth is recommended35-37 weeks GAGroup B Strep (GBS) swabDetermine fetal lie by palpation40 weeks GA+U/S for fetal growth and BPPSource: Summary of ACOG Guidelines for Perinatal Care 7th Edition. (2012).Pediatric Visit ScheduleNewbornWithin 1 week of discharge,Then at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months2-6 years oldAnnually6-11 years oldEvery other year ................
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