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FAMILY MEDICINE CLERKSHIP HANDBOOKEffective 2018Department of Family Medicine Undergraduate Medical Education University of OttawaAbout the Authors:Victoria Gerber, Miki Lackman and Tyler Letain, third year medical students (MD 2019) at the University of Ottawa updated the handbook for 2018-2019 academic year. The handbook was originally created 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:MD 2018: Brendan Sanders, Iuliia Povieriena, Lawrence Yau, Monica Gad, Nickan Motamedi, Omar Anjum, Sarah Buttle & Sean Patrick MD 2017: Katherine Li & Olivia Margie MD 2016: Sarina Scaffidi Argentina & Kimberly Reiter MD 2015: Kelly Frydrych MD 2014: Bonnie TangPlease 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 \h \u \z Abdominal Pain PAGEREF _Toc355985255 \h 6Differential Diagnosis by Quadrant PAGEREF _Toc355985256 \h 6Red Flags PAGEREF _Toc355985259 \h 6Irritable Bowel Syndrome PAGEREF _Toc355985260 \h 7Alopecia PAGEREF _Toc355985261 \h 8Asthma PAGEREF _Toc355985269 \h 10Diagnosis PAGEREF _Toc355985270 \h 10Triggers PAGEREF _Toc355985271 \h 10Management PAGEREF _Toc355985272 \h 10Techniques13Monitoring PAGEREF _Toc355985278 \h 13COPD PAGEREF _Toc355985279 \h 14Targeted Screening PAGEREF _Toc355985280 \h 14Assessment PAGEREF _Toc355985281 \h 14Management PAGEREF _Toc355985282 \h 15Diabetes/Dysglycemia PAGEREF _Toc355985285 \h 18Screening/Diagnosis PAGEREF _Toc355985286 \h 18Diabetes Monitoring & Targets PAGEREF _Toc355985288 \h 20Gestational Diabetes PAGEREF _Toc355985289 \h 22Screening and Diagnosis PAGEREF _Toc355985290 \h 22Management PAGEREF _Toc355985291 \h 23Referral PAGEREF _Toc355985292 \h 23Prognosis PAGEREF _Toc355985293 \h 23Dizziness/Vertigo PAGEREF _Toc355985294 \h 24Approach to Dizziness PAGEREF _Toc355985295 \h 24Dyslipidemia PAGEREF _Toc355985296 \h 25Screening for Dyslipidemia PAGEREF _Toc355985297 \h 25Management of Dyslipidemia PAGEREF _Toc355985298 \h 25Dyspepsia/GERD PAGEREF _Toc355985300 \h 26Gout PAGEREF _Toc355985321 \h 30Headaches PAGEREF _Toc355985328 \h 34Primary Headaches PAGEREF _Toc355985345 \h 34 Secondary Headaches PAGEREF _Toc355985345 \h 35Red Flags PAGEREF _Toc355985346 \h 36Hypertension PAGEREF _Toc355985382 \h 37Valid BP PAGEREF _Toc355985383 \h 37Treatment40Fibromyalgia PAGEREF _Toc355985386 \h 40Lower Back Pain PAGEREF _Toc355985387 \h 41Acute Otitis Media PAGEREF _Toc355985392 \h 44Osteoarthritis PAGEREF _Toc355985398 \h 44Osteoporosis PAGEREF _Toc355985401 \h 46Pain PAGEREF _Toc355985403 \h 47Neuropathic Pain PAGEREF _Toc355985404 \h 47Nociceptive Pain PAGEREF _Toc355985405 \h 47Anxiety PAGEREF _Toc355985410 \h 48Depression50 Psychiatry51Skin Conditions PAGEREF _Toc355985417 \h 52Acne PAGEREF _Toc355985418 \h 52Eczema (Atopic Dermatitis) PAGEREF _Toc355985420 \h 52Actinic Keratosis (Solar Keratosis) PAGEREF _Toc355985423 \h 54Basal Cell Cacinoma PAGEREF _Toc355985427 \h 54Squamous Cell Carcinoma PAGEREF _Toc355985434 \h 55Red Eye PAGEREF _Toc355985438 \h 55Red Flags for Urgent Ophthalmology Referral: PAGEREF _Toc355985439 \h 56Problems in the Elderly PAGEREF _Toc355985440 \h 58Elder Abuse PAGEREF _Toc355985441 \h 58Assessment & Management of Falls PAGEREF _Toc355985443 \h 59 Dementia62 Pseudodementia PAGEREF _Toc355985448 \h 64Primary Care Pediatrics PAGEREF _Toc355985449 \h 65Well Child Visits PAGEREF _Toc355985450 \h 65Infant Feeding and Nutrition PAGEREF _Toc355985451 \h 66Pain Reduction Strategies for Immunizations: PAGEREF _Toc355985470 \h 67Health Promotion and Screening PAGEREF _Toc355985471 \h 68Periodic Health Examination PAGEREF _Toc355985472 \h 68Breast Cancer Screening PAGEREF _Toc355985473 \h 69Cervical Cancer Screening70Colorectal Cancer Screening PAGEREF _Toc355985476 \h 72Skin Cancer Screening PAGEREF _Toc355985477 \h 73Smoking Cessation Medications PAGEREF _Toc355985478 \h 74Smoking Cessation Flow Sheet PAGEREF _Toc355985479 \h 76Contraception Options PAGEREF _Toc355985481 \h 77Quick Reference Guide80Common Antibiotics80Common Antivirals PAGEREF _Toc355985484 \h 82Immunization Schedule PAGEREF _Toc355985485 \h 83Vaccine Contraindications PAGEREF _Toc355985486 \h 84Live Attenuated Vaccines: PAGEREF _Toc355985487 \h 84Developmental Milestones PAGEREF _Toc355985488 \h 85Dermatology Glossary PAGEREF _Toc355985489 \h 86Antenatal Care Timelines PAGEREF _Toc355985555 \h 87Abdominal PainDifferential Diagnosis by QuadrantRightCentreLeftRight HypochondriumGallbladder (colic, cholecystitis, cholangitis) Liver (hepatitis, abscess, PVT)RLL PneumoniaPerforated or penetrating duodenal ulcerEpigastricGERDPeptic Ulcer DiseasePancreatitis (acute vs chronic)Cardiac (i.e. MI)DyspepsiaGastritisLeft HypochondriumSpleen (splenomegaly, infarct, abscess, rupture)LLL pneumoniaCardiac (i.e. MI)PancreatitisAcute gastric distensionRight FlankKidney stoneRenalUmbilicalAbdominal aortic aneurysmEarly appendicitisLeft FlankKidney stoneRenalRight IliacAppendicitisGynecological (PID, ovarian, ectopic, endometriosis, torsion)Crohn’sInguinal herniaPelvis/hip fractureSuprapubicUrinary (UTI, retention, cystitis)Gynecological (PID, fibroid, menstruation)Left IliacConstipationDiverticulitisGynecologicalInguinal herniaPelvis/hip fractureColon cancer should be considered in all presentations of abdominal painDiffuse Abdominal Pain: Obstruction, perforation, ischemia, IBD, gastroenteritis, SBP, CRC, celiac, constipation. Life Threatening: acute bowel obstruction, acute mesenteric ischemia, perforation, acute myocardial infarction, ectopic pregnancyDifferential 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 sleepUnstable vitals Peritonitis Sources:Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-Hill Education; 2013.Charts. 8th ed. Saskatoon, SK: Saskatoon Heath Region; 2010; 43.Sam AH. Rapid Differential Diagnosis. Blackwell, 2003.Talley NJ, O’Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. MacLennan and Petty. 3rd edition, 1998 Bowel SyndromeRome IV CriteriaRecurrent abdominal pain or discomfort at least 1 day/week in the last 3 months. Associated with ≥2 of the following criteria: Related to defecationOnset associated with a change in stool frequencyOnset associated with a change in stool form (appearance)InvestigationsTypical history with no red flags, if red flags consider further imaging and an endoscopic evaluationObtain baseline labs (specific to patient’s symptoms) and begin treatmentDiarrhea predominant: ESR, CBC, TTG (celiac), TSH, O&PConstipation: CBC, TSH, lytes, Ca, X-ray Abdo pain: LFTs and amylaseTreatment resistant: further imaging and scopeManagementEducation and strong therapeutic allianceConservativeTrial of soluble fiber (psyllium)Increase fluid intakeDietary modifications (low FODMAP diet, exclusion of gas-producing foods, decrease caffeine and alcohol intake)Physical activityConstipation prone patients with IBS: if fail fiber considerBegin with PEGConsider Lubiprostone (chloride channel activator), or Linaclotide (guanylate cyclase agonist)Diarrheaprone patients with IBS: begin with antidiarrheals such as Loperamide Consider Bile acid sequestrants (many side effects such as bloating, flatulence, abdominal discomfort and constipation)Antispasmodic agents PRNDicetel (Pinaverium)Bentyl (Dicyclomine)Buscopan (Hyoscine)Sources: Kolodziejak L, Schuster B, Reiger L, Jensen B. Irritable bowel syndrome (IBS). RxFiles Drug Comparison: 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.e15Telogen Effluvium = increased sheddingHair has a bulb (club) end appearanceDiffuse non scarring hair loss.Anagen Effluvium = decreased growth of hairHair is tapered or broken off with associated shedding. Chemotherapy is the major cause. Interruption in hair growth leading to acute (within 2 weeks) extensive hair loss Androgenic Alopecia = male/female pattern hair lossMale-pattern hair loss Slow frontotemporal hair loss advancing to vertex and possibly entire scalp (most common type of hair loss in men)Female-pattern hair loss Less pronounced hair thinning affected anterior scalp with sparing of the occipital regionTreatment:Rogaine (Minoxidil) – topical solution applied to the scalp for use in both sexesHair growth stimulation secondary to vasodilation and increased cutaneous blood flowPropecia (Finasteride) – pill only recommended for use in menCompetitively inhibits type II- 5-alpha reductase resulting in decreased conversion of testosterone to dihydrotestosterone OthersSprinolactone (Aldactone) and Flutamide for womenEuflex (Dutasteride) for menTrichotillomania = compulsive hair pullingIndividuals compulsively pull hair from the scalp or other regions Irregular shapes areas of hair loss with hair at different lengths Alopecia Areata = autoimmune hair lossAutoimmune disorder resulting in total hair loss of the scalp, which can progress to involve any body hair but can also include any body hair Hair loss presents as a round bald patch or generalized thinning leading to total hair lossSpontaneous regrowth can occur, but frequent recurrence precipitated by emotional stressTreatment: Intra-lesional or topical corticosteroids (Triamcinolone 2.5-5 mg/mL q4-6weeks for 6 months) Topical immunotherapy Most effective for extensive scalp involvement (Performed by Dermatologists) Traction Alopecia = acquired hair lossResulting from prolonged or repetitive tension on the scalp of hair Hair loss due to scalp conditions (e.g., tinea capitis, psoriasis, seborrheic dermatitis)Sources: Alopecia – Canadian Dermatology Association [Internet]. Dermatology.ca. 2017 [cited 26 April 2017]. Available from: AL, Reed SW. Diagnosing and treating hair loss. American family physician. 2009 Aug 15;80(4).Oakley A. Hair loss. DermNet New Zealand [Internet]. . 2017 [cited 26 April 2017]. Available from: FeaturesWheezing, cough and dyspneaDiagnosisSymptoms + Spirometry findingsConfirming diagnosis with spirometry for patients >6yo is an important step in managementChildren (6-11yo)Adults (>12yo)Reduced FEV1/FVC<0.8<0.75ANDANDIncreased FEVI post-bronchodilator≥12%≥12%TriggersAllergen exposure (inhalants, food, occupational)Respiratory infections (viral, bacterial)Cigarettes Animal furCold/dry airExercise and emotional factors (stress/anxiety)B-Blockers/ASAManagementEnvironmental controlPatient educationWritten action planPharmacological managementVery 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 YearsAlways start with low dose ICS and then progress to medium and high doseNever give LABA as mono-therapy (ie. should always be given with ICS)Theophylline is reserved for near last-lineOmalizumab can be given to those with atopic asthma and poor control despite high dose ICSSource: 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 +/- Spacer TechniquesShake the inhaler well before use (3-4 shakes)Remove the cap from your inhaler, and from your spacer, if it has onePut the inhaler into the spacerBreathe out, away from the spacerBring the spacer to your mouth, put the mouthpiece between your teeth and close your lips around itPress the top of your inhaler onceStart 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 breath. If you hear a whistle sound, you are breathing in too fastRemove inhaler from your mouth. Hold breath for 1sec . ExhaleWait 30sec 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 controlPoor control may warrant dose increaseGood control for weeks-months warrants dose reduction consideration Lung function testsInhaler techniqueAdherence to asthma treatmentExposure to asthma triggers in the environmentPresence of co-morbiditiesSource: 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 recommended no evidence-based clinical criteria exist to help screen individuals at risk for COPDHowever, patients ≥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?Triggers for a COPD Exacerbation Respiratory Infection (viral or bacterial)StressAir pollution or changes in weatherIndications of a COPD ExacerbationChange in the amount or color of the sputumMore short of breath than usualPossible changes in mood (feeling down or anxious)Low energy of tiredness AssessmentCTS Disease SeverityClassification by symptoms (MRC Dyspnea Scale)Classification by impairment of lung functionNormalMRC 1: Dyspnea only with strenuous exerciseNormal spirometryMildMRC 2: Dyspnea when hurrying on level ground or walking up a slight hillFEV1 ≥80% predicted,FEV1/FVC <0.7ModerateMRC 3: Walks slower than people of the same age on level ground because of breathlessness, or has to stop for breath when walking at own pace on level groundMRC 4: Stops for breath after walking about 100m or after a few minutes walking on level ground50% ≤ FEV1 < 80% predicted,FEV1/FVC <0.7SevereMRC 5: Too breathless to leave the house, or breathless when dressing/undressing30% ≤ FEV1 < 50% predicted,FEV1/FVC <0.7Very SevereFEV1 < 30 % predicted,FEV1/FVC <0.7ManagementCOPD is treatable at any stage of the illnessGoals: alleviate symptoms; prevent acute exacerbationsEducationInhaler techniqueEarly recognition of exacerbationsAction planEnd-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 patients whose symptoms are well controlled but who do not exercise consider referral for pulmonary rehabilitationVaccinationAnnual influenzaPneumococcal vaccination (Pneumovax if <65, Prevnar if >65)Pharmacotherapy:Indications for Home Oxygen TherapySevere hypoxemia (PaO2 ≤55mmHg or SaO2≤88%)PaO2 <59mmHg + bilateral ankle edema or cor pulmonale (ECG) or Hct >55%Source:s2013 CTS COPD Action Plan. Canadian Respiratory Guidelines [Internet]. Respiratoryguidelines.ca. 2017 [cited 27 April 2017]. Available from: 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.Criner G, Bourbeau J. 2014 CHEST-CTS Guideline: Prevention of Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Presentation presented at; 2017.O’donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk DD, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Kaplan A. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease–2007 update. Canadian Respiratory Journal. 2007;14(Suppl B):5B-32B.Recommendations for the Management of Chronic Obstructive Pulmonary Disease 2008 Update [Internet]. 1st ed. Canadian Thoracic Society; 2008 [cited 27 April 2017]. Available from: of Drugs Used in Asthma and COPDDrug ClassCommon names + ColorsSide effectsSABASalbutamol (Ventolin)Terbutaline (Bricanyl)Fast heartbeat, irregular heartbeat, irritability (feeling cranky), difficulty sleeping, muscle cramps, shaky handsLABAFormoterol (Oxeze)Salmeterol (Serevent)Fast heartbeat, irregular heartbeat, irritability (feeling cranky), difficulty sleeping, muscle cramps, shaky handsICSBudesonide (Pulmicort)Fluticasone (Flovent)Beclomethasone (Ovar)Hoarseness, sore throat, thrush or yeast infectionICS + LABAFluticasone + Salmeterol (Advair)Pulmicort + Oxeze (Symbicort)Shaky hands, fast heartbeat, thrush, sore throat, hoarse voiceLTRAZafirlukase (Accolate)Montelukast (Singulair)Headache, dizziness, heart- burn, upset stomach, tirednessTheophyline(Uniphyll, TheoDur, Phyllocontin, TheoLair)Nausea, heartburn, restlessness, fast heartbeatShort-acting anticholinergicsIpratropium bromide (Atrovent)Dry mouth, urinary retentionLong-acting anticholinergicsTiotropium (Spiriva)Dry mouth, urinary retentionSource: Canadian Lung Association (2010). Medications for COPD. ( maladies/copd-mpoc/treatment-traitement/medications-medicaments_e.php. athme/treatment- traitement/medications-medicaments_e.php)Diabetes/DysglycemiaScreening/Diagnosis10g 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)Source:Screening [Internet]. Guidelines.diabetes.ca. 2017 [cited 27 April 2017]. Available from: Monitoring & TargetsTargetMonitorFasting Blood 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/1yr 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 dieticianSource: Adapted from Canadian Journal of Diabetes. 2013 Clinical Practice Guidelines Sample Diabetes Care Flow Sheet for AdultsManagement of Hyperglycemia in Type 2 DiabetesSource: Lorraine Lipscombe MD, Sonia Butalia MD, Kaberi Dasgupta MD, Ronald Goldenberg MD, Nadia Khan MD, Baiju Shah MD. Pharmacologic management of type 2 diabetes: 2016 interim updateGestational DiabetesRisk FactorsHistory of GDM or macrocosmic infantFamily history of DMCurrent fetal macrosomia or polyhydramnios [Grade D recommendation] Age ≥35yoHigh risk population (Aboriginal, Hispanic, South Asian, Asian, African)BMI ≥30kg/m2PCOS, acanthosis nigricans, metabolic syndrome Essential HTN or pregnancy-related HTNCorticosteroid useMultiple gestationsGlycosuria at first prenatal visit Screening and DiagnosisIf patient has multiple clinical factors and is at high risk for GDM, screening should be offered at any stage in pregnancy [Grade D recommendation]If screening is performed prior to the recommended 24-28 week window, the patient should be rescreened during the recommended timeTwo step: 1hr glucose challenge test (GCT), if positive then 2hr GCT—Canadian Diabetes Association recommendation One step: Only 2 hr GCTManagementFirst 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 postpartumReferralRefer to high-risk pregnancy clinic once patient requires insulin Prognosis50% risk of developing type 2 DM in the next 20 years in patients with GDMSources: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. to DizzinessSource: Post, R.E., & Dickerson, L.M. (2010) Dizziness: A Diagnostic Approach. Am Fam Physician, 82(4), 361-368. ()DyslipidemiaScreening for DyslipidemiaManagement of DyslipidemiaStain indicated conditions: Clinical atherosclerosis, AAA, Diabetes, CKD, LDL > 5.0 mmol/LSource: Anderson, Todd J.,"2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult." Canadian Journal of Cardiology 32.11 (2016): 1263-1282.Dyspepsia/GERDDyspepsiaDefinition: According to the Rome IV criteria, dyspepsia is defined as one or more of the following symptoms:Postprandial fullness (classified as postprandial distress syndrome)Early satiation (inability to finish a normal sized meal, also classified as postprandial distress syndrome)Epigastric pain or burning (classified as epigastric pain syndrome)Approximately 25 percent of patients with dyspepsia have an underlying organic cause. However, up to 75 percent of patients have functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation.Red Flags in dyspepsia:Age >55 with new onset dyspepsiaFamily history of upper GI cancerProgressive dysphagiaOdynophagiaUnexplained iron deficiency anemiaPersistent vomitingPalpable mass or lymphadenopathyJaundiceGERDGastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The diagnosis of GERD can be based upon clinical symptoms alone.GERD is classified based on the appearance of the esophageal mucosa on upper endoscopy into the following:Erosive esophagitis?— Erosive esophagitis is characterized by endoscopically visible breaks in the distal esophageal mucosa with or without troublesome symptoms of GERD. Nonerosive reflux disease?— Nonerosive reflux disease or endoscopy negative reflux disease is characterized by the presence of troublesome symptoms of GERD without visible esophageal mucosal injury.InvestigationRecognize the symptoms of GERD: heartburn and acid regurgitation. Extraesophageal manifestations can include bronchospasm, laryngitis, and chronic cough. Other symptoms of GERD include chest pain, water brash (relatively unusual symptom in which patients can foam at the mouth, secreting as much as 10 mL of saliva per minute in response to reflux), globus sensation, odynophagia, and nausea.Look for alarm features: vomiting, evidence of GI blood loss, anemia, involuntary weight loss, dysphagia, or chest painEndoscopic evaluation is not routinely done to diagnose GERDUse endoscopy to:Investigate atypical or alarm features Detect Barrett’s esophagusInvestigate dysphagia that has not resolved within 2-4 weeks of adequate twice daily 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 of GERDA. Mild Symptoms and intermittent symptoms: (fewer than two episodes per week) and no evidence of erosive esophagitis on upper endoscopy ( if it was performed):1. Routine follow-up to facilitate incremental changes in therapy at 2-4 week intervals.First begin with lifestyle and dietary modification Weight loss, head elevation at night if night-time symptomsAvoidance of dietary trigger foods if patient noticed any associationsAvoid alcohol, tobacco, and caffeineEncourage salivation through chewing gum, Attempt using antacids if symptoms occurring less than twice a weekConsider stating low-dose histamine 2 receptor antagonists (H2RAs) PRN2. If symptoms despite these measures.Increase the dose of H2RAs to standard dose, twice daily for a minimum of two weeks. If symptoms of GERD persist, discontinue H2RAs and initiate once-daily PPIs at a low dose Increase doses if required.Once symptoms are controlled, treatment should be continued for at least eight weeks.B. Severe or frequent symptoms (two or more episodes per week, impact quality of life) or erosive esophagitis Begin with standard-dose PPI once daily for 4-8 weeks in addition to lifestyle and dietary modification.If symptoms improve decrease acid suppression to low-dose PPIs and then to H2RAs Discontinue acid suppression in all asymptomatic patients with the exception of patients with severe erosive esophagitis or Barrett's esophagus, in whom maintenance PPI therapy is suggested. Diagnostic testing for H. pylori Non invasiveUrea breath test, stool antigen assay, serology (IgG)EndoscopicBiopsy urease testing, histology Treatment: H. pylori EradicationTriple therapy for 7-14 d (Hp-Pac): PPI bid (e.g. lansoprazole 30mg bid) + amoxicillin 1g bid + clarithromycin 500mg bidLess than 80% success rate due to Clarithromycin resistance Quadruple therapy for 10-14 d: PPI bid + bismuth 525mg qid + tetracycline 500mg qid + metronidazole 250mg qidFirst 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 G14 is defined as arthritis due to precipitation of monosodium urate crystals in the joint space.Risk 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 6 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 goutTreatmentTreatment principles in Acute Gout: Treatment of acute gout should commence within 24 hours of symptom onset to achieve rapid & complete resolution of symptomsMedical ManagementMild - Moderate attack (few small joints or two large joints) includes monotherapy with: NSAIDS (first-line treatment) orColchicine orCorticosteroidsSevere attack (many joints) include combination therapy with:Colchicine + NSAIDsColchicine + Oral CorticosteroidsIntra-articular steroids + all other modalities*see further detailed management algorithm and medication recommendations belowPrevention of GoutSerum urate - lowering therapyDietary Modifications (reduce high fructose corn syrup, beef, lamb, pork, shellfish, alcohol and increase vegetable & low-fat dairy products) Pharmacologic options (NSAID, colchicine and low-dose steroid in addition to urate-lowering therapy (Allopurinol or Febuxostat))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).*Note: Oral/IV corticosteroids, NSAIDS, and colchicine are all 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 flaresIndications for long-term therapy:≥2 flares/year≥1 flare/year in persons with CKD stage 2 or greaterTophiHistory of nephrolithiasisAgents used:First line: Xanthine Oxidase Inhibitor: Allopurinol, Febuxostat , or 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)Dietary Modifications (reduce high fructose corn syrup, beef, lamb, pork, shellfish, alcohol and increase vegetable & low-fat dairy products)Duration of treatment:No ongoing symptoms: continue for 3-6 months after a flareOngoing signs or symptoms (e.g., tophi on examination): continue indefinitelyCurrent evidence suggests there is uncertainty about the value of a treat-to-target strategy compared with a strategy of basing treatment intensity on minimizing symptoms.*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).Qaseem, Amir, Russell P. Harris, and Mary Ann Forciea. "Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians." Annals of Internal Medicine 166, no. 1 (2016): 58. doi:10.7326/m16-0570Anti-inflammatory Prophylaxis Source: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 Primary headaches: Migraine, cluster, tension, medication overuseMigraine HeadachesSymptoms: throbbing, unilateral, photophobia, phonophobia, nausea, debilitating, +/- aurasTriggers: stress, physical activity, poor sleep, fatigue, EtOH, chocolate, cheese, MSG, aspartame, caffeine, nuts, nitratesAcute Treatment: NSAIDs = first line (ASA 1000mg q4h or Advil 200-800mg), triptans, ergotamines, prochlorperazine 5-10mg IM/IV +/- antiemetics (for nausea)Prevention: B-blockers = first line (propranolol 40-240mg/day), CCB (verapamil 240-320mg/day), anticonvulsants (topiramate 25-100mg/day), TCAs (amitriptyline 50-150mg/day)Diagnostic criteria for migraine without aura: A. At least five attacks fulfilling criteria B through DB. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)C. Headache has at least two of the following characteristics: Unilateral locationPulsating qualityModerate or severe pain intensityAggravation by or causing avoidance of routine physical activity (eg. Walking or climbing stairs)D. During headache at least one of the following:Nausea, vomiting or bothPhotophobia and phonophobiaE. Not better accounted for by another diagnosisDiagnostic criteria for migraine with aura:At least two attacks fulfilling criterion B and COne or more of the following fully reversible aura symptomsVisualSensorySpeech and/or languageMotorBrainstemRetinalAt least three of the following six characteristics At least one aura symptom spreads gradually over >5 minutesTwo or more symptoms occur in successionEach individual symptom lasts 5-60 minutesAt least one aura is unilateralAt least one aura symptom is positiveThe aura is accompanied or followed within 60 minutes by headacheNot better accounted for by another diagnosisCluster HeadachesDiagnosis: episodes lasting 15-180 mins, frequency 8x/day to q2d, unilateral (orbital/temporal), autonomic ipsilateral sx (conjunctival injection, tearing, pseudo Horner’s syndrome)Triggers: often alcoholAcute Treatment: 100% O2 = first line (high flow >7L/min x10min), sumatriptan 6mg sc, lidocaine 1mL 4% intranasal, octreotide 100mcg scPrevention: prednisone 40-80mg x7d, then taper over 5 days (bridging prophylaxis), verapamil SR 120-360 mg/day= first line, lithium, methysergide, topiramate, melatonin, ergotamineTension HeadachesSymptoms: bilateral, fronto-occipital band-like pain, contracted neck/scalp musclesTriggers: stressful eventsAcute Treatment: rest and relaxation, NSAIDs or acetaminophenPrevention: physical activity, rest, biofeedbackMedication Overuse HeadachesDiagnosis: Episodic headache disorder, migraine or tension-type. Headache occurring on 15 or more days per month, developing as a consequence of regular overuse of acute or symptomatic headache medication for more than three months. Triggers: regular intake, for ≥10 days per month for >3 months, of ergotamines, triptans, opioids, or combination analgesics, or any combination of ergotamines, triptans, simple analgesics, nonsteroidal anti-inflammatory drugs (NSAID)?and/or?opioidsTreatment: Most experts regard withdrawal of the overused medication as the treatment of choice.Secondary headaches: Extracranial: carotid or vertebral artery dissection, dental disorders, glaucoma, sinusitisIntracranial: brain tumor/mass, Chiari type I malformation, CSF leak with low-pressure headache, hemorrhage (intracerebral, subdural, subarachnoid), idiopathic intracranial hypertension, infections (meningitis, encephalitis, subdural empyema), obstructive hydrocephalus, vascular disordersSystemic disorders: hypertensive crisis, bacteremia, Giant cell arteritis, hypercapnea, hypoxiaDrugs and toxins: analgesia overdose, caffeine withdrawal, carbon monoxide, hormones (ie. estrogen), nitrates, PPIsRed FlagsRed FlagsDifferential DiagnosisPossible work-upNew headache (>50 yrs)? Temporal arteritis? Mass lesionAngle closure glaucomaESR, CT neuroimagingSudden onset (exertion)? Subarachnoid hemorrhage? Carotid/vertebral artery dissection? Mass lesion (esp. posterior fossa mass)CT neuroimagingLP if neuroimaging negativeIncreasing frequency and severity? Mass lesion? Subdural hematoma? Medication overuseCT neuroimaging, drug screenHeadache with signs of systemic illness (fever, stiff neck, rash)? Meningitis? Encephalitis (Lyme disease)? Systemic infection? Collagen vascular diseaseCT neuroimaging, LP, serologyFocal neurological signs or symptoms of disease (other than typical aura)? Mass lesion? Vascular malformation? Stroke? Collagen vascular diseaseCT neuroimagingCollagen vascular evaluation (including anti-phospholipid antibodies)Papilledema? Mass lesion? Pseudotumor? Cerebri meningitisCT neuroimagingLPHeadache subsequent to head trauma? Intracranial hemorrhage? Subdural hematoma? Epidural hematoma? Post-traumatic headacheNeuroimaging of brain, skull and possibly cervical spineRed eye, cloudy cornea, mid fixed dilated pupil? Angle closure glaucomaOphthalmoscopy, tonometrySource: Clinch,C.R.(2001). Evaluations of Acute Headaches in Adults. Am Fam Physician, 63(4),685-693. (. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38:1Hypertension Hypertension: HTN is defined as the BP at which the introduction of therapy reduces BP-related morbidity and mortality. There are two main hypertensive descriptive categories: Essential hypertension: BP elevation with an unknown cause. EH represents >90% of HTN cases. Secondary hypertension: Secondary HTN is an elevation in BP that can be attributed to a definable cause and represents the remaining 10% of hypertensive cases.? ?Valid BP exam in clinicPATIENT: Back and arm supported, bladder emptied, seated comfortably with legs uncrossed X 5 min, no talking prior to or during measurement.CUFF: Over bare arm, 3 cm above elbow crease, width & length of cuff bladder should be 40% & 80-100% of arm circumferenceMEASUREMENT: Inflate 30 mmHg beyond radial pulse obliteration, deflate slowly & take avg. of 2 readings at least 60 seconds apart.Diagnosis: Source: A New Algorithm for the Diagnosis of Hypertension in?Canada Cloutier, Lyne et al. Canadian Journal of Cardiology , Volume 31 , Issue 5 , 620 - 630Routine laboratory investigations: Electrolytes, creatinine , fasting blood glucose, fasting lipid panel, urinalysis (blood and protein), ECG (LVH). Consider ACR if diabetic.Red Flags for Secondary HypertensionEtiologyPresentationTests to considerHyperthyroidismPalpitations, sweating, tremor, anxiety, frequent bowel movements, weight loss, vision changes, goiterTSHAortic coarctationInterscapular murmur, delayed femoral pulses, asymmetric BPCXR, CT angiogramCushing syndromeEasy bruising, psychiatric disturbance, hyperglycemia, truncal obesity, proximal muscle weakness, hirsutism, thin skin, ecchymosis, rounded face, buffalo hump24-hr urine cortisol excretionObstructive sleep apneaSnoring, witnessed apneas, daytime drowsiness, AM headache, impaired concentrationSleep study with O2 saturation monitoringRenal disease (renal artery stenosis)Hx of UTIs/obstruction, hematuria, NSAID abuse, FHx of PCOS, abdominal massRenal U/SPheochromocytomaEpisodes of headaches, sweating and increased heart ratePlasma fractionated metanephrinesMeds/herbsNSAIDs, OCP, steroids, pseudoephedrine, cocaine Treatment Target BP is <140/90 mmHg, <130/80 mmHg if DM, <150 SBP if very elderly Lifestyle 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-hypertensivesFibromyalgiaDefinition: Chronic (>3mo), widespread non-articular pain with characteristic tender points 2010 ACR Diagnostic Criteria for FibromyalgiaWidespread Pain Index (WPI) = # of areas in which patient had pain over last week (max score = 19)·L and R: shoulder girdle, upper arm, lower arm, hip, upper leg, lower leg, jaw·One Area: chest, abdomen, upper back, lower back, neckSymptom Severity Score (SSS) = sum of (all rated on 0-3 scale; 0 = no problem, 1 = mild, 2 = moderate, 3 = severe):·Severity of fatigue·Waking unrefreshed·Cognitive symptoms over the past week·Extent of somatic symptoms (IBS, H/A, abdominal pain/cramps, dry mouth, fever, hives, ringing in ears, vomiting, heartburn, dry eyes, SOB, loss of appetite, rash hair loss, easy bruising, etc.) Fibromyalgia Diagnosis (all criteria need to be met)1. WPI ≥ 7 and SSS ≥ 5 OR WPI 3-6 and SSS ≥ 92. Symptoms present at similar level for at least 3 mo3. Patient does not have a disorder that would otherwise explain the pain InvestigationsBloodwork is usually normalDo not order ANA or RF unless clinical suspicion for connective tissue diseaseLaboratory sleep assessment ManagementBio: Duloxetine and Pregabalin approved by Health Canada for fibromyalgia treatment; low dose TCA for sleep restoration, cannabinoidsPsycho: CBT, coping skills, stress reductionSocial: exercise program (20-30min 2-3x/week), physical therapy (posture, stretching, muscle strengthening, massage)Lower Back PainDifferential Diagnosis of Chronic Low Back Pain1. Nonspecific/idiopathic (70%)lumbar sprain or strain2. Mechanical (27%)Degenerative processes of disks and facetsHerniated diskOsteoporotic fractureSpinal stenosisTraumatic fractureSevere kyphosisSevere scoliosisTransitional vertebraeSpondylosisInternal disk disruption or discogenic painPresumed instability3. Referred pain (2%)Aortic aneurysm Diseases of the pelvic organs (prostatitis, endometriosis, PID)GI diseases (pancreatitis, cholecystitis, penetrating ulcer)4. Renal diseaseHistory Figure: Features on history to differentiate various patterns of lower back painHistory considerations:Vascular: AA risk factorsInfection: fevers/chills, IDU, STIsNeoplastic: history of cancer, weight loss, pain >1 month, failure to improveDegenerative: older age, family history, previous imaging, smoking, steroidAutoimmune: younger age, insidious onset, >3 months, ++ AM stiffness, worse with rest, SI joint involvement, IBD presentationTraumaGI/GU/pelvisRed Flags (NIFTI acronym)IndicationInvestigationsNeurological: diffuse motor/sensory loss, progressive neurological deficits, cauda equina syndrome (urinary retention, fecal incontinence, saddle paresthesia)Urgent MRIInfection: fever, IV drug use, immunosuppressionX-ray and MRIFracture: trauma, osteoporosis risk, fragility fractureX-ray and may require CT scanTumor: hx of cancer, unexplained weight loss, significant unexpected night pain, severe fatigueX-ray and MRIInflammation: chronic low back pain >3 mo, age of onset <45, morning stiffness > 30 mins, improves with exercise, disproportionate night painRheumatology consultation and guidelinesPhysical Exam1. Gait: Heel walking (L4-L5) and toe walking (S1)2. Standing: movement testing in flexion and extension, Trendelenburg test (L5), repeated toe raises (S1)3. Sitting: patellar reflex (L3-L4), quadriceps power (L3-L4), ankle dorsiflexion power (L4-L5), great toe extension (L5) and flexion (S1) power, plantar response4. Lying supinea. Passive straight leg raiseb. Passive hip range of motion5. Lying prone:a. Femoral nerve stretch (L3-L4)b. Gluteus maximus power (S1)c. Saddle sensation testing (S2-S4) ManagementPattern 1Disc PainPattern 2Facet Joint PainPattern 3Compressed Nerve PainPattern 4Symptomatic Spinal StenosisMedicationsAcetaminophenNSAIDsAcetaminophenNSAIDsMay require opiods if 1st line pain meds insufficientAcetaminophenNSAIDsStarter ExercisesRepeated prone lying passive extensionsSitting in chair, bend forward, and stretch in flexion. Use hands on knees to push trunk upright.“Z” lieRest in seated or other flexed position to relieve leg Functional ActivitiesShort frequent walking, reduce sitting activitiesEncourage sitting or standing with foot stool, reduce back extensionChange positions frequently from sit to stand to lie to walkUse support with walking or standing, use frequent sitting breaksReference: Reprinted from Centre for Effective Practice (March 2016). CORE Back Tool. Toronto. Centre for Effective Practice.Acute Otitis MediaDiagnosisAcute onset of symptoms ANDOne or more signs of middle ear effusion (bulging TM, limited TM mobility, air fluid levels behind TM, or otorrhea) ANDOne or more signs of middle ear inflammation (TM redness, otalgia)Middle 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 months years old Fever >38.5°CPerforated TM with purulent drainageSignificant comorbidities (eg. immune deficiency, cardiac/pulmonary disease, anatomicabnormalities of head & neck, Down syndrome)current or previous complicated otitis mediaIndications for 48 h observation:age > 2 years oldreliable 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: Clarithromycin, Azithromycin, TMP/SMX (but significant resistance)IF 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 Definition: Inflammatory arthritis due to articular cartilage degenerationMost common polyarthritisClinical PresentationAsymmetric joint painWorsens with activity Relieved by restMorning stiffness (<30 min or none)Joint swelling (d/t osteophyte & synovial fluid)Bouchards nodes (PIP)Herbender nodes (DIP)Risk FactorsAge (older)Gender (if <50 M>F, if >50 F>M)TraumaObesity Endocrine disordersInvestigationsImaging (XRay)Joint space narrowingProductive changes (subchondral sclerosis)Subchondral cysts OsteophytesNote that majority of population >65 years of age have signs of OA on x-ray imaging, however only 33% of these individuals will be symptomatic. DiagnosisClinicalTreatment 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).Toronto Notes 2016OsteoporosisIndications for BMD Testing2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada:Obtained from Osteoporosis Canada (osteoporosis.ca)Assessment 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 Pain1st LineTricyclic Antidepressants (eg: amitriptyline), Gabapentinoids (gabapentin, pregabalin), SNRIs (venlafaxine, duloxetine)2nd LineTramadol, Opioid analgesics3rd LineCannabinoids4th LineMethadone, anticonvulsants with lesser activity (eg: lamotrigine, topiramate, valproic acid), tapentadol, topical lidocaine, capsaicinSource: Canadian Pain Society Pharmacological Treatment Guidelines for Neuropathic Pain, 2017Nociceptive 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 divided oses 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)Other Recommendations1First line therapy for chronic non-cancer pain: optimize non-opioid pharmacotherapy and non-pharmacological therapy, rather than a trial of opioidsPatients with chronic non-cancer pain with an active substance use disorder and chronic non-cancer pain: avoid the use of opioidsRestrict the prescribed dose to under 90mg morphine equivalents daily rather than no upper, or a higher limit on dosingPatients with chronic non-cancer pain using opioids and experiencing serious challenges in tapering: refer to a formal multidisciplinary opioids reduction program or use coordinated multidisciplinary collaboration (eg. primary care physician, pharmacist, physical therapist, kinesiologist, psychiatrist, and psychologist)Sources:1McMaster National Pain Center. The 2017 Draft Recommendations for Use of Opioids in Chronic Non-Cancer Pain. DRAFT January 30, 2017. , 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 Anxiety Disorders:Separation Anxiety DisorderSelective MutismSpecific PhobiaSocial Anxiety Disorder (Social Phobia)Panic DisorderAgoraphobiaGeneralized Anxiety Disorder Substance/Medication Induced Anxiety DisorderAnxiety Disorder due to another Medical ConditionUnspecified Anxiety DisorderDSM-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 Treatment1st line2nd line3rd lineAdjunctPanic disorderSSRI, VENBDZ, TCA, other ADMAOI, other AD, AC, AAPBDZ, AC, AAP, PINSocial Anxiety DisorderSSRI, VEN, PREBDZ, GAB, PHEOther AD, AC BUS, AAPGeneralized Anxiety DisorderSSRI, SNRI, PREBDZ, BUS, other AD, QUEOther AD, ACPRE, AAPVEN venlafaxine, PRE pregabalin, GAB gabapentin, PHE phenelzine, BUS buspirone, QUE quetiapine, PIN pindolol, AC anticonvulsants, AD antidepressant AAP atypical antipsychoticsSource: Stein MB, Craske MG. Treating Anxiety in 2017Optimizing Care to Improve Outcomes.?JAMA.2017;318(3):235–236. doi:10.1001/jama.2017.6996DepressionDSM-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 level Aripiprazole (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 Presentation:Subacute and chronic eczematous reaction associated with prolonged severe pruritusDistribution depends on age.Infants and young children (zero to two years): pruritic, red, scaly, and crusted lesions on the extensor surfaces and cheeks or scalp. Usually sparing of the diaper areaIn older children and adolescents (2 to 16 years): less exudation and often demonstrates lichenified plaques in a flexural distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists, ankles, and neck (pictureIn adults: atopic dermatitis is considerably more localized and lichenified. The areas involved are in most cases the skin flexuresInflammation, 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 CarcinomaNon-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 EyeHistorySymptomsSignsTreatmentAllergicAtopy or allergiesItching, rhinitisBilateral watery eyes, papillaeCool compression, oral/ topical antihistamine, artificial tearsBacterialConjunctivitisBurning, 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 hygieneHerpes Simplex KeratitisMay be triggered by stress, fever, sun exposure, immunosuppressionPain, tearing, foreign body sensation, red eye, +/- decreased vision, eyelid edemaDendritic lesion in epithelium that stains with fluorescein;Corneal hypoesthesiaTopical antiviral such as trifluridine, consider systemic such as acyclovir;No steroids;Ophthalmology referral for possible dendritic debridementRed Flags for Urgent Ophthalmology Referral:Decreased visual acuity (infectious keratitis, iritis, angle closure glaucoma) or sudden painless vision loss (CRAO)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)Trauma: lid/globe locations and intraocular foreign body, chemical burnGonococcal conjunctivitisOrbital cellulitisTemporal arteritisAbsent red reflex (white reflex, leukocoria) - r/o retinoblastomaCN III palsy with dilated pupil (IC aneurism or neoplasm)Proptosis (r/o cavernous sinus fistula or thrombosis)Common Lids and Lashes ConditionsConditionHordeolum (Stye)ChalazionBlepharitisXanthelasmaDefinition and manifestationDefinition: acute inflammation of eyelid gland, usually caused by infection (S. aureus)Manifestation: painful, red swelling of a lid Definition: chronic granulomatous inflammation of Meibomian gland often preceded by an internal hordeolumManifestation: Usually no acute inflammatory signsInflammation of lid margins.Two main types:1. S. aureus: ulcerative, dry scales2. Seborrheic: no ulcers, greasy scalesManifestation: itching, tearing, foreign body sensation; thickened, red lid margins, crusting, “toothpaste sign” (discharge with pressure on lids)Definition: eyelid xanthoma (lipid deposits in dermis of lids).Manifestation: pale, slightly elevated yellowish plaques or streaks, most commonly in the medial upper lids, often bilateral.Associated with hyperlipidemia. Common in elderly, concerning in youngTreatment Warm compress,· Gentle massage· Topical antibiotic (erythromycin ointment bid)· Usually resolves in 2-5 daysWarm compressIf no improvement in 1 mo, consider incision and curettage. If chronic recurrent – biopsy to r/o malignancy Warm compresses and lid scrubs with diluted baby shampoo Topical or systemic antibiotics PRN If severe – ophthalmologist may prescribe short term corticosteroidExcision for cosmesis onlyCommonly recur 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 WHO definition: Single or repeated act or lack of appropriate action, occurring in any relationship where there is an expectation of trust that causes harm or distress to an older personType of AbusePhysicalEmotionalFinancialNeglectScreening for Elder AbuseConflicting evidence if should screen for elderly abuseno uniformly accepted minimum standard of care making it difficult to say when screening becomes positivecan use elder abuse suspicion index (EASI)other resourcesONPEASeniors Health Research Transfer Network (SHRTN)Canadian Network for the Prevention of Elder Abuse (CNPEA)National initiative for care of the elderly (NICE)Brief Abuse Screen for the Elderly (BASE) Conflict Tactics Scale (CTS) Suspicion Index (EASI)Screening Tool: Validated screening tool for elder abuse 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. (Registration No. 1036459)World Health Organization.?The Toronto declaration on the global prevention of elder abuse.?Geneva, Switz:?World Health Organization;2002.Yaffe, Mark J., and Bachir Tazkarji. "Understanding elder abuse in family practice."?Canadian Family Physician?58, no. 12 (December 2012): 1336-340. Assessment & Management of FallsFalls are common among older people and can have devastating consequences.Key Points from CMAJ Review 2014A targeted history and physical examination, covering potential home hazards, cognitive and visual impairment, functional limitations, medications, orthostatic hypotension, and gait and balance abnormalities, can be used to identify risk factors for falls. No specific assessment tools have been shown to accurately predict the risk of falls. Numerous interventions (single and multicomponent) have been shown to decrease the risk of falls. At a minimum, patients who have experienced a fall should be encouraged to participate in an approved exercise program to help prevent further falls Pocket Reference obtained from: Lee, Aimee; Lee, Kuo-Wei;and Khang. Peter (2013). Preventing Falls in the Geriatric Population. Perm J; 17(4): 37-39.*Note: Timed up & go test has conflicting evidence as accurate assessment tool for risk of future fallsSources: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/DementiaCanadian Task Force on Preventive Health Care (2015) Key Points:No randomized trials have evaluated the benefits of screening for cognitive impairment. Available data suggest that pharmacologic treatments are not effective in people with mild cognitive impairment and that nonpharmacologic therapies (e.g., exercise, cognitive training and rehabilitation) produce only small benefits, which do not appear to be clinically significant.Existing studies suggest that about 1 in 10 people without cognitive impairment may erroneously screen positive for mild cognitive impairment using the Mini-Mental State Examination and that 1 in 4 people may incorrectly be classified as positive using the Montreal Cognitive Assessment tool. The task force recommendation against screening asymptomatic adults 65 years of age and older for cognitive impairment is based on the lack of high-quality studies evaluating the benefits and harms of screening for cognitive impairment, on evidence showing that treatment of mild cognitive impairment does not produce clinically meaningful benefit and on the potentially high rate of false-positive screens that may occur. The strong recommendation against screening asymptomatic adults 65 years of age and older for cognitive impairment implies that the task force is confident that most individuals will be best served by the recommended course of action. Practitioners should consider cognitive assessment for patients with signs and symptoms of impairment or when family members or patients express concerns about potential cognitive decline.Source: Pottie, Kevin, et al. Canadian Task Force “Recommendations on screening for cognitive impairment in older adults."?Canadian Medical Association Journal?(2015): cmaj-parison of types of DementiaTypeFeaturesAlzheimer’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 depressionNoYesNote there is some evidence suggesting that pseudodementia is possibly a prodrome or risk factor for the development of dementia. Source: National Guidelines for Seniors’ Mental Health. The Assessment and Treatment of Depression. (2006)Kennedy, James. "Depressive pseudodementia–how ‘pseudo’is it really?."?Old Age Psychiatrist?62 (2015): 30-37.Primary Care PediatricsWell Child VisitsFollow the Rourke Baby Record from 0-5 years.Includes information on normal growth and development, nutrition, anticipatory guidance regarding safety and common complaints, suggested physical examination and incorporates the Immunization Schedule recommended by the National Advisory Committee on Immunization.Timing of visits:o Within 1 weeko 2 weeks (optional visit)o 1 montho 2 monthso 4 monthso 6 monthso 9 months (optional visit)o 12-13 monthso 15 months (optional visit)o 18 monthso 2-3 yearso 4-5 yearsVisits are recommended every 1-2 years from ages 6-17.For well-child visits of older children and adolescents, the Greig Health Record can be used to guide visits.The Greig is formatted similarly to the Rourke, and includes age-specific additional information on psychosocial issues and education regarding safety, injury prevention, and family issues.Additional resources are provided that can beThere are three Greig Health Record forms available, for ages 6-9, 10-13, and 14-17.Greig, A., Constantin, E., Carsley, S., & Cummings, C. (2010). Preventive health care visits for children and adolescents aged six to 17 years: The Greig Health Record–Executive Summary. Paediatrics & child health, 15(3), 157. () linkRourke, L., Leduc, D., & Rourke J. (last updated 20-02-2014). The Rouke Baby Record. () linkGrowth should be tracked using the WHO growth charts. Each visit should include measurement of height, weight, and head circumference (up to 2 years of age).o If there is a failure to gain weight but normal height velocity, consider failure to thrive.o If weight gain is normal but height velocity is slowed (<5cm/year), consider constitutional delay, genetic short stature, or an endocrine cause.o If both height and weight are small, consider chronic disease. Source: Canadian Pediatric Society. (last updated 05-08-2014). Promoting optimal monitoring of child growth in Canada: Using the WHO growth charts. () LinkInfant Feeding and NutritionExclusive breastfeeding for healthy term infants is recommended until 6 months of age and can be continued up to 2 years of age or longer with appropriate complementary feeding. Breastfeeding reduces gastrointestinal and respiratory infections and helps to protect against SIDS.o Newborns require 150 cc (5oz) breast milk or formula equivalent per kg per dayo Infants 2-4 months require 600-900 cc (20-30 oz) per dayo Infants 4-8 months require 750-1080 cc (25-36 oz) per dayo Infants 9 months up to one year require 720-960 cc (24-32 oz) per dayo Supplementation with 400IU Vitamin D is recommended if exclusively breastfeedingMedications and breastfeeding tool from the Hospital for Sick Children endorsed by CFPC: Mother Risk, available at: linkCommunity lactation consultants are available to meet with mothers and their babies and can assist with many issues including poor latch, nipple pain, cracked nipples, infections, poor infant weight gain, and insufficient milk supply. Many community health centres also have breastfeeding accessories like pumps available to rent on a weekly or monthly basis.For infants with tongue-tie (ankyloglossia), the CPS does not recommend routine frenotomy (surgical division of the tongue tie). There may be an association between ankyloglossia and breastfeeding difficulties; the choice to intervene surgically should be made jointly by the family and clinician after consideration of the individual situation.Introduction of solid foods is recommended at 6 months of age. The recommended order of introduction is iron rich foods (meats, legumes, fortified cereals) > vegetables > fruits. Delayed introduction of allergenic foods is not recommended. Lumpy textures should be offered by 9 months of ageConsumption of fruit juices should be limited. Water should be offered to satisfy thirstHomogenized cow’s milk can be introduced after 9-12 months of age, not earlier. Cow’s milk should be limited to less than 750 cc per day. Skim milk can be introduced after 2 years of age with the gradual transition to a lower fat dietNo bottles in bedAn open cup should be introduced approximately 1 year of ageIntroduction of honey should be avoided until 1 year of age due to risk of botulismInquire regarding vegetarian/vegan dietsSources: Health Canada Infant Feeding Joint Working Group. (last updated 2015-08-18). Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. () HYPERLINK "" linkHealth Canada Infant Feeding Joint Working Group. (last updated 2015-01-19). Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months. () linkRowan Legg, A.(2015). Position Statement: Ankyloglossia and breastfeeding. Canadian Paediatric Society 20(4):209-13. ()Pain Reduction Strategies for Immunizations Infants:Breastfeeding during the immunizationUse of sweet-tasting solutions e.g. TootsweetUsing the least painful vaccine brandConsideration of topical anaesthetics Children:Use the least painful brand of vaccineKeep the child in a non-supine positionRapid injection without aspirationInject the most painful vaccine lastRub/stroke the skin of the injection site with moderate intensity before and during vaccinationMake use of physician or parent-led distraction or coachingEncourage the child to use slow deep breathing or blowingAvoid telling the child “it won’t hurt” Source: Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., … Shah, V. (2010). Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ?: Canadian Medical Association Journal, 182(18), E843–E855. ()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 Flexible sigmoidoscopy q10 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 diphtheria, acellular pertussis vaccine q10 years until age 34Tetanus, diphtheria vaccine q10 years age >34Influenza vaccine q1 yearHerpes zoster vaccine (age 65)Pneumococcal Pneu-P-23 vaccine (age 65 or earlier if high risk)Acellular pertussis vaccineVaricella immunityRubella ImmunityHuman papilloma virus (HPV) vaccine (2-3 doses, Grade 7)FemalesSame as males except:Fasting lipid profile at age 50Mammography q1-2 years from ages 50-74Cervical Cytology q3 years from ages 21-69Same as males plus:Breast Cancer ScreeningOntario Breast Screening Program1, 2Average RiskHigh RiskScreening RecommendationMammogram every two years for most womenMammogram and screening breast MRI every year (or, if MRI contraindicated, screening breast ultrasound)Screening PopulationWomen ages 50 to 74Women ages 30 to 69 identified as high risk*Eligibility? Healthcare provider referral or self-referral ? No acute breast symptoms ? No personal history of breast cancer ? No current breast implants? No screening mammogram within the last 11 months? Physician referral ? Valid Ontario Health Insurance Plan number ? No acute breast symptoms? Meets one of the high risk* criteria*High Risk Criteria? Are known to be carriers of a deleterious gene mutation (e.g., BRCA1, BRCA2)? Are the first degree relative of a mutation carrier (e.g., BRCA1, BRCA2) and have declined genetic testing? Are determined to be at ≥ 25% lifetime risk of breast cancer -- must have been assessed using either the IBIS or BOADICEA risk assessment tools, at a genetics clinic? Have received chest radiation treatment (not chest x-ray) before age 30 and at least 8 years previously.Other RecommendationsBreast Aware – Patients should be encouraged to be aware of how their breasts normally look and feel so they can identify changes (lumps, dimpling, discharge, skin redness, other changes)2Women Aged 40-49, Average Risk – Routine screening with mammography may be considered, but is not recommended (weak recommendation - moderate quality evidence)3. Mammography is associated with reduction in relative risk of death from cancer in this age group, both the number needed to screen and the risk of false positive tests are higher.3 Patients in this group may make personal decisions about mammography after discussion with their health care provider.2Women Aged 75 and over – Limited data is available for this age group. Assess on an individual basis, taking into account life expectancy.3Sources:1Cancer Care Ontario: Cancer Screening Guidelines. Revised October 2016 ()2Government of Ontario: Ontario Breast Cancer Screening Program. Revised September 2016. () 3The 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. ()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 hysterectomyAre pregnantq3y (regular screening guidelines)Have 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. Ontario Cervical Screening Cytology GuidelinesSource:Cancer Care Ontario. Ontario Cervical Screening Cytology Guidelines Summary – Revised October 2016, based on 2012 Guidelines Notes, Adapted from: Ontario Cervical Screening Cytology Guidelines. May 2012Colorectal Cancer ScreeningAverage risk: Individuals aged 50 - 74 with no family history of colorectal cancer and no personal history of polyps or inflammatory bowel disease should undergo screening with one of the following strategies1:FOBT (either gFOBT or FIT) every two yearsFlexible Sigmoidoscopy every ten yearsHigh risk: family history1First degree relative with the disease diagnosed before age 60Colonoscopy q5 yrs to begin at age 40OR 10 yrs earlier than the youngest diagnosis of polyp or cancer in the familyIf diagnosed after age 60, then employ average risk screening to begin at age 40High risk: hereditary colorectal cancer syndrome and IBD3Family history of HNPCCColonoscopy q1-2 yrs beginning at age 20OR 10 yrs younger than the earliest case in the familyFamilial 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 the third decade and colonoscopy annually in the fourth decadeFor left sided colitis, begin screening at 15 years after onsetOther RecommendationsAbnormal FOBT should be followed up with a colonoscopy within 8 weeks1If symptomatic, refer to specialist for evaluation (no role for FOBT at this point)1There is insufficient evidence to support screening with using metabolomic (blood or urine) tests, DNA (blood or stool) tests, computed tomography colonography, capsule colonoscopy and double contrast barium enema1Surveillance after polypectomy is based on the number, size, and pathological features of polyp as well as other clinical features such as family history and previous colonoscopy findings2Sources:1Cancer Care Ontario: Colon Cancer Screening Guidelines. August 2016 for surveillance after polypectomy. Gastroenterology 2006. link3ASGE guideline: colorectal cancer screening and surveillance. Gastrointestinal Endoscopy 2006. 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 monitoredHigh risk populationIndividuals 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:Source currently on CCO webpage under Education and Information rather than under the current Evidence Based Series recommendations: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/dayChew and parkMouth/jaw sorenessHiccupsDyspepsiaHypersalivationEffects associated with incorrect chewing technique:Light-headednessNausea/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/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, 2015. Copyright ? 1999–2015 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 (mild, resolve within a few months usually)↑ VTE risk (9-10/10 000 women/years, 4-5/10 000 at baseline)Slight ↑ risk of breast cancerDoes not increase breast cancer risk(Vessey M, Painter R. Oral contraceptive use and cancer. Findings in a large cohort study, 1968-2004. Br J Cancer 2006;95(3):385–9.)Transdermal 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-partum~3-hour window of forgivenessIrregular 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 density (just monitor and give Calcium + Vit D)Copper 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 (first 20 days)Failure (if fails, must exclude ectopic)Increased 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 TID x 5-10 daysCefuroxime-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% 1-2 drops QID 5-7 days1-2 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. ernment of Ontario. Publicly Funded Immunization Schedules for Ontario – October 2015. ? Queen’sPublicly Funded Immunization Schedules for Ontario – December 2016. ? Queen’s Printer for Ontario, 20152016 ()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 cellsPsoriasisAtrophyThinning of the skinChronic sun exposureSource: MacNeal, RJ. (2015). Description of Skin Lesions ( dermatologic-disorders/approach-to-the-dermatologic-patient/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 bloodwork (CBC, Type + Screen, VDRL, Hepatitis B, Rubella, HIV, Pap (if indicated), Chlamydia/Gonorrhea swab, Urine C+S and dip)Initiate 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). ................
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