10 - toronto notes 2011 - family medicine

FM

Family MedicineNicole Coles, Melisssa Loh and Mitch Vainberg, chapter editors Christophel' Kitamura and Michelle Lam, associate editors Janine Hutson, EBM editor Dr. Ruby Alvi, staff editorFour Principles of Family Medicine ......... 2 Periodic Health Examination (PHE) . 2Purpose ofthe PHE Sore Throat (Pharyngitis) ................. 47

Complementary and Altemative Medicine (CAM) .. 49 Primary Care Models .................... 50 Antimicrobial Quick Reference ........... 50 Referenceso

Health Promotion and CounsellingMotivational Strategies for Behavioural Change ................................ 3 Nutrition ............................... 4 Obesity ................................ 5 Dyslipidemia ............................ 6 Exercise................................ 7 Smoking Cessation ..... 8 Alcohol. 100 0 0 0 0 0. 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0.

52

Common Presenting ProblemsAbdominal Pain ........................ Allergic Rhinitis .. o...... o.. o... o...... o . Amenorrhea ........................... Anxiety. o...... o...... o.. o... o...... o. Asthma/COPD .......................... Benign Prostatic Hyperplasia (BPH)o .. o... o . Bronchitis (Acute) ....................... Chest Pain Common Cold (Acute Rhinitis) ... Contraception .......................... Cough .. Dementia.............................. Depression ..... o...... o.. o... o...... o . Diabetes Mellitus (DM) ................... Diarrhea o...... o...... o.. o... o...... o . Dizziness .............................. Domestic Violence/Elder Abuse .. o...... o . Dyspepsia ............................. Dyspnea Dysuria. Epistaxis .............................. Erectile Dysfunction (ED) . Fatigue ............................... Fever o.. o...... o...... o.. o... o...... o. Joint Pain ............................. Headache ...... Hearing Impairment ..................... Hypertension ... o...... o.. o... o...... o . low Back Pain .......................... Menopause/HRT. Osteoarthritis ... Osteoporosis .......................... Rash Rhinorrhea ............................ Sexually Transmitted Infections (STis) o... o . Sinusitis............................... Sleep Disorders . o...... o.. o... o...... o .0 0 0. 0 0 0. 0 0. 0 0 0. 0 0. 0 0 0. 0 0. 0 0

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11 11 12 13 14 15 16 17 18 19 20 20 20 21 25 25 26 28 28 28 29 30 31 32 33 34 35 35 39 41 41 42 42 43 43 45 45

Toronto Notes 2011

Famlly Medicine FMI

FM2 Family Medicine

Four Principles ofFamlly Medidne/Perlodic: Health Eum.ination

Toronto Notes 2011

--"(.,l'ltiont-(ontrld CUnical Mltllod Explora'define patient problems and decide on m1111gamant togathlll' Consiur bath ndas and lind

Four Principles of Family MedicineCollege of Family Physicians of Canada Guidelines I. The family physician ia a skilled clinician in diagnosing and managing diseases common to population served recognizes importance of early diagnosis of serious life-threatening illnesses 2. Fam.lly medicine is a community-based diadpline provides information and access to community services responds/adapts to changing needs and circumstances of the community 3. The family physician is a resource to a defined practice population serves as a health resource advocates for public policy to promote health 4. The patient-physician relationship ia central to the role of the family physician committed to the person, not just the disease promotes continuity of patient care

common ground

,, 'Apndu in hmily MedicmHistory, physical, invatigation, diagnosis, planDoettl(s Aalllda

Patillnt'o Agenda FIFE fillings ldExpectmions

Periodic Health Examination (PHE) Canadian Task Force on Preventive Health Care established in 1976, first published in 1979, last updated in 2005 mandate: to develop and disseminate clinical practice guidelines for primary and preventive care recommendations are based on systemic analysis of scientific evidence most notable recommendation is the abolition ofthe annual physical exam; replaced by the

PHE

Purpose of the PHE

', '

,,}-----------------,

Adult Pwriodic HHIIh Exam Mala and f1mala evidanc&-buld prevenllltive care checklist fonns are evailliH onlino It www.cfpc.ca.

primary prevention: identify risk factors for common diseases; counsel patients to promote healthy behaviour secondary prevention: presymptomatic detection of disease to allow early treatment and to prevent disease progression update clinical data enhance patient-physician relationshipTable 1. Pariadic Health ExamGnral PapulltianDISCUSSION Dental hygi111e (conrnunity fluoridation, brusling. flossq) (A) Noise cortrol In! hearing pmteclion (A) Smokln: colll51ll on smoking cessation, pruvide Nicotine replacement therapy (A) Referral to 5flloking csssation 1J11Qillll (B) Diebry advi:e on leafy green vegelables In! fruits (B) Seat bd use (B) l"ll'f prewntion (licycle helmets, smoke detecloli) (B) Modnte plrjsicalaclivity (B) Awid sun expos118 and well" protective cladling (B) Problem screering and counselling (B) Counselling to protect 81J11inst Slls (B) Nu1ritio1111l coun&elling and dielll"y advice on fat artd

','Clauilicmion of _ _.....no A GDINI avidii!Ca to racommand Ills clinical prwontativ. action. B fllr avidanca to recommend tha clinical prwontativ. action. C Existing evidence is c:onllic:liq 1111d d011 not allow to mab arecommendlltion for or agailst use of tha clinicol prevantativliiiCtion; however, other factors may inlluence dacision-fllllking. D fllr avidanco to r.command qoi..t Ills clinicol prevantativa action.

s,ecilll Papuhdian

E Good avidii!Ce to racommend opinot Ills clinical prevantative IICtion. I lullici..t llvidance (in quantity or qualityIto mab a recommendation; howvver, othar factors may inlluence dacision-fllllking.

l'lditria: Home viii!& lor ri&k t.rnii (AJ lnqLiry into developmental milestooes (B) AdaiiiCIIII: Counsel on sexualaclivity and conlnlceptive methods(B) Counsel to prevent smoking irili!lion (B) Pari_...UIII wom; Counsel on osteoporo&is Counsel on risks/benefits of hormone repl111:ement therapy (B) Adulll >&5: Follow-up on cngiver concern of in..,airment (A) poRfallaSS86111111nt (A) l'ldltria: Repeated mmilations of hips. and hearing (especially in fim ye11 of life) (AI Serial heights, weij11s and head citurmrence (B) Visualaailytesling rfterage 2(B) Adulll >&5: Visualaaily (Snellefl sight ct.rtj (B) H11rilg impairment (inquiy, whispellld voice test. (B) Fill dag111 ralatiwl with mallnoma: Full body &kin ex1m (B)

cholesleltll (B)PHYSICAL Clinical biiiiiSI tiXIITl (women age 51J.69) (A) Blood pressw meastJrement (B) BMI measuranent in obese ldiJis (B)

Toronto Notes 2011

Periodic Health Examination/Health Promotion and CounseJlins

Family Medidne FM3

Tabla 1. Pariodic Health Exam (continued) ..... MiJ!iphllse screening witl1 the llemoctiJI test (lldiJ!s age >511 q1-2yrs) (A) Sigmoidoscopy (dills >50] esllblished] (B) Bane minenl density: if 111 risk [1 major cr 2minor critaria] Fasting l..dprufile [C): VJomen 11118 >50 cr if Ill risk Men 11118 >40; if 111 risk (optimal frequency unknown, at least q5yrs) Fasting blood age >40 q3yrs (orsoaner and mo111 frequently if risk factors present] Syptilis screen if Ill risk (OJ Men: PSA testing screening glid&linas nat aslabilsh&d (1) Women: Mammog111phy (\Dillen age q1-2yrs (A] Pap smeanrully (women age 1B-69l ever sexually IICtNe, start alter sexllll debut]; q3yrs after 2norma119SiJ!s (more frequently if conc&ms) Folic acid SlWemeotatian to women of child-bearing 11118 (A) Varicela wccine fur children age 1-12and susceptible adclascanWIMUtB (A) vaccine for all noiJiRgnant women of chikHieariiV,l

,,

l'ldillrics: Raulile hillno;obin for high risk iTfanlll [B) Blood lead screening of high risk infants (B) Diabltics: Urine (A) Fundoscopy (B) Tltigh riilk fWps: Mantoux skin testing (A) mh9l risk f'OUpl: Voluntary Htv antibody screening (A) Gonorrhea screening (A] Chlamydia SCIVIIring in women (B) FAP: Sigmoidclcopy end genetic lestiJ,j (B) HNPCC: CaloiiDICDpy (B)

VVIum Ordllring Futing Blaodwalk Results 11111 Vllid only if atained wilh tlaurs of fasting. Remember, "ffssing" mel/IS no toad, no drinb (except smlll quantities of water). no gum, no limaking. Prescription medications ant okay

unless Dlherwin specified.

.....

,,

Guldlltin AdviHry CDIJimilD (QACJcammllldatieMior Brwut Clllt:llrScre.mng Far warn., ag1d 40-69 ytlllr'l, t1Mir11 is fllir evidence 1D recommend that routine

Fldillrics: Routine imm111izltions (A) ll&patitis Bimmunizlllian (A) tnllem high risk fWpl: Outr811ch strllegias far vaccilation (A] ennual immunization (B), now recommended lor 1111 INH pruphytaxis for household contacts cr skin test . INH prophylaxis fur hiQh nsk (B) Pnauii10CDccal vaccile [A)

teaclling of br8llll salf-IIXIIminatian

(BSE) be excluded from 1he PHE. ReHin;h shows fair evidence of no b.mit 1D BSE lnd goad IIVidlnCI of

harm.

of hypertension will1 dBP >90 mmlig (adiJ!s age 21-&4, specific (A) 1B high TetaiiiS vaccine: routine boaster q10yrs if hed 1 series (A) Pertussis vaccine: routine boaster of acellular vaccine cnce during dllthood (cen b& giwo as d'Tap)Clllssfficllicm ahammmandlllian illnc:kstl. Sell sidllbllr on IN2. llftence: Car1lllln Task Fon:e on I'IMnlllive Heailll Cn, 2005.

Health Promotion and Counselling health promotion is the most effective preventative strategy 40-70% ofproductive life lost annually is preventable

there are several effective ways to promote healthy behavioural change, such as discussionsappropriate to a patient's present stage of change

Motivational Strategies for Behavioural ChangeTabla 2. Motivational Strlltagias for Behavioural ChangePatient's Stage af Changa Physician's AinPre-contlmplation EncoLnge patient to consider the passibiity of Assess readiness for change 1nC1'811Se patient's awaneness of the problem nJ its risks UnclersbnJ patient's IITibivalence and encourage change Build confidence and gain commitment to change Expllll\l optians and choose cou11e mast appropriate to patient Identify higiHisk situations and develop strategies to prevent relapse ContiiJJe to strengthen canfidence and Help patients design 18W11rds for success Deielop strategies to prevent relapse Support and reinforce convictions towards lang-temn change Help patient maintain motivation Rsview identifying highii&k situations and &trlrtllgies lor preventing relapse Help patient view relapse as a Ieeming experience Provide support appropriate to present level of readiness post-relapseCt.nga. Mmlg SIMdtnl2001; 1612):45-52, 54-55.

Physici's PillaRaise issue in asensitive mamer Offer (not iq!ase] a neutral exchange of information to avoid resistance Offer opportunity to discuss pros nJ cans of change, using reflective listening

Conlllmplltian

Offer rlllllistic options for chqe andoppcrtunityto discuss inevitable difficLJties

Al:tian

MlintlnlnceRe11p1e

Offer positive reinforcement and ways of coping with obstacles Encourage self-rewards to reinforce change Discuss progress and signs of irllJBnding relap&e Offer a nan-judgmental discussion about cirt:umstances sWTDunding relapse end how to avaid relapse in the future Reassess patient's readiness to change

Adllptlld from lbt P.

FM4 Family Medicine

Health Promotion and Counselling

Toronto Notes 2011

NutritionGeneral Population Canada's Food Guide is appropriate for individuals >2 years old counsel on variety, portion size, and plate layout (see Figure 1)

Tabla 3. Canada's Food Guida 2007 Recommendations for Adults Food Group Grain products Vegetables and Milkpndn:b Figura 1. Plate Layout Meat and alternatives 6-8 7-10 2-3 Children 2-B years: 2 Youth S.1 Byears: 3-4 Pregnant,.breastfeeding: 3-4 2-3ChaDH Mara Oflln IJ\Ihale grain and enriched grain pnllilcts Dark green vegetables, arange vegetables and fruit Lowur-fat dairy producl8

Lean meat. poulby, fish, peas, beans, lentils

Cardiovascular Disease Preventionltl

lllndy Serving liD Com111rilona 3 oz msat, fish, -+ plllm of hand 1 dairy {rnilr/vovLrl) -+ sim of fill: BreaQ/grains -+ one slice, pam of hand cup rice/pasta -+ one hand cupped 1 of fruit/VIpbbl -+ two cupped hands 1 oz ch8818 -+ fullength of thumb 1 tsp ollbutter -+ tip of thumb Nul.tchiprlsnacb -+ plllm covered

Tabla 4. Dietary Guidalinas for Reducing Risk of Cardiovascular Disaau in Ganaral Population Food him ht Rllcamm.ndlllions Saturated fat 25 kGfm' or waist circumference is lbcve cutoff point

ICidlri:ll'llldic:al Cfii1W il Bostun. MA; , llO pirticipltds- rllldomilld tD Aikins (cllbGIIydrlll rwh:lila),l.n blllncld 111d 1owglojamic lold), W.ightWR:hlll l1ow cdlrie/PIIIion lile), or Onish lilt reslriclila)

illl

Conduct dinicel and llbonrtory investigations 1D a111111 comortlidities {Blood pressure, hellt rate, fasting glucose, lipid profile [!Dill cholesterol, triglycerides, LDL and Hill choiiSIIrol. and ratio of tolll cholesterol to HilL cholesterol )I Anen and screen for deprenion, eating and mood disorders

Important m11uge A modest weight loss of 5-1 0'1. of body waigllt is benrrficill Weiglrt maintenance and prevention of weight regain should be considered as long-tenm goals Devise goals and lifestyle modification program for weight loss and reduction of risk factors Weight loss goal: 5-1 0'11. of body weight. or 0.5-1 kQ (1-2 lb) par weak for 6 months

Heelth 111m to advise lifestyle modification programmodmc.ti.. program Nutrition: Reduce energy intake by 5001 000 kcaVday Phytical activity: initially 30 minutes of modarall inllnsity 3-5 limer/Wk; eventually >60 minutes on most days. Add endurance exercise lnlining. {Medical evakllltion is advised before sllrting activity progrem) Cognitive behaviour thrnpy

Pri:ipl* Adulls 221D 72 v-l'litll known KIN. dfllipidernil. or l?jpergljcemiL Asanrilg lhlll puqw wllo discanliurd 111&1t!Jdy lll1l'lllilad It blllllirw, lila m Wlight ball 1 111111111 .. IIIICIId dielllyadlleranca ra111 per tafraportj ware 2.1 kg far AlldDS (53\alpirticipns P=0.0091, 3.2 kg lar the Z.(65% of !*lic\llnls CDU"j1llllld. P=O.OOZ), 3.0 kgfarw.ijaWelchlll 1Mcompleted, P5.0

2 years old) should limit their screen time to less than 2 hours/dayl'lllnll 11111111 dlifiil-,_.. JAAM 2004; 212(21 ):2585-25110

--.arl..,............,.ilil

l'lllnll: 2524Sl pDa ll'lltld with ipid-

Sludr:llelrolpectMI cohort n..d.

lllil Dllanle: Rllbdomyuft!is bolpilllimliarL 11116: 11252460 patianD. 24 Cllll al halpilalimliln acCIIIIII. Incidence Illes per 10000 95\ ClAllmllldii 0.5410.221.1Z)

kr.wrirG lglllll.

Ceriva111in PrMs111in 0 IG-1.11) Sii!NIIIItin 0.49 (0.06-1.76)

Ftnofibrat&O IG-14.51)

lncidanca clltilbdomyolylis inc181sad 10 5.111 (95\Cl, 0.72-216.0) plVIIII1il Of sinMIIII!in- US8d with a1htt, and up ID 1035

Gal11fimlljJ.70(0.76-111.82)

witlallillle.

(M Cl, 389-2117) i carivulatii was CGI!Dilld

FM8 Family Medicine


Toronto Notes 2011

Use with caution when prescribilg combined stalin and fibnltelhenpy IS tfun hill bun 111C8nt CDnCIII!II regarding 1he llfBty Ill certain combination&.

Management assess current level of fitness, motivation and access to exercise encourage warm up and cool down periods to allow transition between rest and activity and to avoid injuries exercise with caution for patients with CAD, diabetes (risk ofhypoglycemia), exercise-induced asthma balanced exercise program incorporating all types of exercise 1. aerobic (endurance) exercise for 15-60 min, 4-7 times/wk improves cardiac function, lowers BP, increases HDL, increases insulin sensitivity target HR: 60-80% of maximum HR maximum HR=220-age 2. weight-bearing (isometric) exercise 10-20 min, 2-4 times/wk builds muscle strength, improves bone density, improves posture 3. stretching routine 10-12 min, 4-7 times/wk prevents cramps, stiffness, injuries, back problems other benefits of exercise improves feeling ofwell-being, libido, quality of sleep, self-esteem decreases depression and anxiety weight control

Smoking Cessation--------------------------------------

.... .......e..n. Crisks; consult Motherisk Nicotine Replacement Therapy (NRT) 19.7% abstinent at 12 months with NRT vs. 11.5% for placebo {OR 1.66) no difference in achieving abstinence for different forms ofNRT reduces cravings and withdrawal symptoms without other harmful substances that are contained in cigarettes use with caution: immediate post-Ml, serious/worsening angina, serious arrhythmia Bupropion SR (Zyban) 21% abstinent at 12 months vs. 8% for placebo {OR 2.73) Varenicline {Champa-) partial nicotinic receptor agonist (to reduce cravings) and partial competitive nicotinic receptor antagonist (to reduce the response to smoked nicotine) more effective than bupropion

111 S AI for Plltianls Wl&q to Quitpatient smobs

Advise patient to quit Assess wiDingness ID quit Asllist in quit lllt8mpt Arnnge follow-lip

Aui.t Patilnl in Developmg Duit l'llln

STAR

Set quit date TID family and frilllds {for support) Anticipate challenges {e.g. willldlliWIII) lamoveiDblcco products {e.g.

Toronto Notes 2011Table 9. Types of Nicotine Replacement Therapy

Health Promotion and CoUDBe11ing

Family Medicine FM9

TypeNiclllina Gum IOTC)

Daslge 2mg if 25 cigfd 1piece q1-2h for 1-3 mos (max. 24 piecetld)Use for 8weeks 21 mgldx4weeks 14 mg/d x 2 weeks 7mg/d x 2weeks

Camment Chew until taste then "park" between gum and cheek to facilitate absorption Continue to chew-park inll!rmittently for30 milStllrt

Side EflectsMouth stra1ess

Hiccups Dyspepsia Jaw ache Most SFs are1ransient Skin irritation nomnia Palpitations

Codnnellllflbllsed_.RMws 2008; IIU1 This s,stlmltic fiViM rl132lltldani!ld 1rilll MIT111 piiCIIbo or n 1Jullmart or o dillarantlfiT d-.

e-n.

lillalill ........ lBiprfar Sniali"

Nicutina Patch [OTC)

lower dose if < 10 cigfd Change patch q24h and albmate sides

llllilwln' Cllllibml: AI c:o11111111dlti Millbll fum rllfiT (gum. trndlnnll pn:ll, 1'DIIIJIIIIY, im*rllllsubqulllllbi!Q'krzangBIII118 aflwctMt 1111 pill ci111r11BQy bl promote smoking ceslllion. Theyiacaue1he llbl cl quilling lrf 50 111 raQIIdlew oheUing IIIII indlplndlnt 111 tt.IMI allddilioniiiUppart pravided 111 hlrnolrlir. C..lllll 11111ingll bm al NRT, combining I nicolila IIIIth witli I liPid delwly loan of NRT lillY be mm effective.

AnxiBtyNicllline inhaled through mouth, absorbed in mouth and throat but not in lungs Not Milable in Canada

Niclllina lnhiiIOTC)

6-16 cartridgSIOI'day

for up to 12 weeks

Local irritation Coughing

Nicutine Naill Sp11y !Rxl

Tabla 1D. Bupropion as Treatment for Smoking Casution Clllllnlindicatian Inhibits re-uptake of 1. 150 mg qAM x 3 days 1. Decide on a quit date dopamile ancllor 2. Then 150 mg bidx 7-12 wks 2. Continue to smoke for first 1-2 wks Ill norepinephrine 3. For maintenance consider treabnent and then completely stop **Side alhlcts: insomnia, 150 mg bid lor up to (therapeutic lewis 11111ched in 1wk) dry mouth 6 months Seizure disorder Eating disorder MAOI use in past 14 days Simulllrleous use ol bupropion !Wallbutrin41 ) for depression'lOO'l; IIU1 This systandc review rl&& 11ndolriled 1rilll llllidrlpre-' mediclliln1o pllcebo llf lbmltiw ph11111ICOII!apy lol11110king Cllllli111 IIIII wll11111 fvlaw-up -111m &ll1llllhl.Ad....... far Smali" Cllluliln

llllilwln' Cllllibml:

-mn1111 biVIalimimllliclcybl f.IIT.

Tabla 1I. Varaniclina 11 Treatment for Smoking Cessation

Colnpl!1d 111 Yftllicline 1huwed higher 11181. SilactMI-ain . . . inhibm

Mechanilm

Daslge

Prescribing

Clllllnlindicatian

(e.g. illllllinel GrveDIIildne lid not hM I lignificlnt 8ll1ct

Partial nicotinic receptor 1. 0.5mg qAMx3 days agonist, llld partial 2. Then 0.5 mg bid x 4 days competitive antagonist 3. Continue 1mg BID x 12 nicotinic receptor weeks plus additional **Side effects: nausea, 12 weeks as maintenance vomiting, constipation, headache, dream disorder, insomnia. increased risk Ill psychosisMry be used in cariinlltion with nicotine replarnenttlunpy

Begin 1reatment 1week before quit date, Caution with pr&-existing then stop smokilg as planned psychiabic

....

;

1IHI 2-3 httwlrn !If SmDidng CNIIon Onset of withdnrwal is 2-3 hours after last cigarette twk withdnrwal is at 2-3 days Expect improvement of ayrnplllms at 2-3 waekl Resolution of withd111W1IIt 2-3 months Highest rellpte 111111 willli'1 2-3 months

unwilling to quit motivational intervention (5 Rs) (see sidebar): 1. Risks of smoking short-term: SOB, asthma exacerbation, impotence, infertility, pregnancy complications, heartburn, URTI long-term: MI, stroke, COPD,lung CA, other cancers environmental: higher risk in spouse/children for lung CA, SIDS, asthma, respiratory infections 2. Rewards: benefits improved health, save money, food tastes better, good example to children 3. Road blocks: obstacles fear of withdrawal, weight gain, failure, lack of support 4. Repetition reassure unsuccessful patients that most people try many times before successfully quitting (average number of attempts before success is 7} recent quitter highest relapse rate within 3 months of quitting minimal practice: congratulate on success, encourage ongoing abstinence, review benefits,problems

1111 5 Rs for l'ltients Unwilling tD Quit Relewnce to patient {tlelllth concerns,family/locialsitullli0111)

RisksRewatds of quitting

ROidblocks to quitting Rapstilion of motivlllional inlllrvanlionat IIICh

prescriptive interventions: address problems ofweight gain, negative mood, withdrawal. lack of support

FM10 Family MedicineAllltinence


Toronto Notes 2011

Law Riek Drinking 2D min New -81 pain at 1811 Seven SOB

l..olll of comsci01151111H

Hypotension Tachycardia

llnldycanlia Cyanosis

Ml in Eldllly Wamen Bd811y women can oftan preaent will1 dizziness, lightlleadedness or weakness, in 1he absence of chast pain.

FM18 Family Medicine

Common Presenting Problems

Toronto Notes 2011

SIBbie IICbamic Heart DisaaLif&.style modifiCIJiion (addi"IJS$ diet, smoking. 8XBrcise) Menaga concomilllnt disortln (a.g. hypartllnsion, diablllls, hyperthyroidism, anamia) Arm-plllllluttharapy fur all patian!J (upirin 81 mg PO 00 unlau conlniindica!Bd orfBilad) fl-blocbr for all post-MI patients or 1hosa with haart fliluna ACE inhllitor for patients >55 years or with any coincident indiCIJiion Stati11harapy for pllliants with coronary diseasa

+

Start a p-bloclalr not already using it){swi1ch ID p-1 selective blocker Sublingual nitrata for prophylaxis end acute symptnm relief

Add long-acting (onll or1ransdarmal) nilrall calcium channal blocksr

Ass111

suilllbility for coronary artllry nMISCLHrization

Figure 5. Treatment Algorithm for Stable Ischemic Heart Disease

llalanmcas: Onllrio 1NJ Thllllpy Gi.idalinls lschmlic lllan Di- in l'limuy C.. {2000).0n!Mo Propn frr Op/inl/ 111etrpeuta. Toroii1D: ban's l'rillllr of0n11rio, pp. 10. Gi.idalines an '6ia1111111Q81T1111 ofsllbll paclllris..Recommelldl!io of file 1i.!kForce offile EIIO/Iflll Sociefyof ClnfiDiologr. 2006. p63.

Common Cold (Acute Rhinitis)c - Cold EtiDiogyPRIMAlhinoviruses lnfiU811lll virus Myxoviruus Adanoviruses

Definition viral upper respiratory tract infection (URTI) with inflammation

Epidemiology most common diagnosis in family medicine; peaks in winter months incidence: adults= 2-4/year, children= 6-10/year organisms mainly rhinoviru.ses (30-35% of all colds) others: coronavirus, adenovirus, RSV, influenza, parainfluenza, echovirus, coxsackie virus incubation: 1-5 days transmission: person-person contact via secretions on skin/objects and by aerosol droplets

..... ,

......Fevtr

lnlhlllllz vs. Colds: A Gllide Ill

SympiDms

Onsetr/Hnea

... Sudden

e.ldSlow None

Risk Factors psychological stress, excessive fatigue, allergic nasopharyngeal disorders, smoking, sick contacts

Higii!Mr

Exhaustion IMI Smra Dry IIMII CCIIIIIb orhlckilg File Tlloll Dry 11d cleu Nose Achy lle1d Appel ita D8CIIIS8d Musclll Achy

Mid

Clinical Features symptoms local- nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough general- malaise, headache, myalgias, mild fever signs boggy and erythematous nasal/oropharyngeal mucosa, enlarged lymph nodes normal chest exam complications secondary bacterial infection: otitis media, sinusitis, bronchitis, pneumonia asthm.a/COPD c:xacerbation

Sore RllmY

Cb.

Y81

lleedec:ht-free Normal Fine No

laiw:llfor ........ lllll ,..... dillCIJdnll Dllllllst II Sjtmmlfi: lllMilws 2tlD&; luull This i'/lflmlltic nMIIW Df 16 triali11181111d thl rl Echiul il IIIII trellillll c:ompll8d c:orDililg Echinlc with pilclllo. no 11111mlllll. 111 11brnatiw camnan cold lr8IIJna. vntin il p1pmtims and IJIIIty rl Edlinlcel mtda matlJut in reds suggeslld 11111"1 J11F1111ians rl Echillcae nwy Ill blllll thin pllcebll. c..:.- Echil8CBI plllpllllioni VI!YwidllrSome prepations l'lidl nwy be . . ueilconsinnt.

Differential Diagnosis allergic rhinitis, pharyngitis, influenza, laryngitis, croup, sinusitis, bacterial infections

Management patient education symptoms peak at 1-3 days and usually subside within 1 week cough may persist for days to weeks after other symptoms disappear no antibiotics indicated because of viral etiology secondary bacterial infection can present within 3-10 days after onset of cold symptoms prevention frequent hand washing, avoidance of hand to mucous membrane contact, use of surface disinfectant

E."""""

Toronto Notes 2011


Fam.lly Medicine FMHI

symptomatic relief rest, hydration, gargling wann salt water, steam analgesics and antipyretics: acetaminophen, ASA {not in children because risk of Rc:yc:'s syndrome) cough suppression: dc:xtromethorphan or codeine if necessary decongestants, antihistamines zinc gluconatc: lozenge use is controversial patients with reactive airway disease will require increased use ofbronchodilators and inhaledsteroids

"' .... eo....... Cold lllviiM CJnne llllllllse flfSyl/rlmllicINuu 3; t.t IIITIIIIdmant: 19119

1M!

eftecls al lin!; lolenges far cold (laD UIJPII rnpitlbJiy tJ1c1 irllclimj TiMI trills the lallloges Wlll1l ullactiw in rming -aymttlntila al

TJ-.I'/SIIIIlltit miuw ol71111111onUad C8111181

Contraception seeGY18

111e lllliages lid not IPPIII1D be eft\Jr:M. .........._lhlll'idlnclfarzinc 1rlllillllhe t:QIII111111 coil ii inc:ancllliw,llld 1hanJ ill potantiellor lidelllflcts.

Tabla 15. Methods of Contraception CombmlldOCPEfhlctiveness: 99.!1% with perfect use, 97-9!1% with typical use, 111'811ulilr bleeding, systarnic hormonal side eff8cts (breast tendarness, lliiUSiil, mood cycle co1111'DI, II; dysmenorrhea, II; menstrual flow, II; ovarian cancar, changes), no Sll protection, slightly increased risk of venous 111'ambaerdlolism II; endometrial cancer, II; risk af fibroids, II; acne, II; hirsutism (VTE), Ml, and stroke, decreased quantity af breast milk pos1partwn

Progestin Only Pill

(e.g. Pllb:h(e.g.

At least 95% effective with pelfect use, II; mensl!ual flow, >If cramping, no 1' risk af VTE, Ml or &troke, 5Uitable for postp.tumSame as OCP, easy to use, changed weekly, 99% elfactive with correct use Same as OCP, easy to use (in for 3weeks. out far 1). less systemic hormonal side affects, 99% ellactive with correct use 99.7% effective agai1st pregnancy, infrequent closing,II; mensbual flaw or amenarmea, .J; risk of endometrial cancer

Irregular bleeding, no STI protection, contraceptive reliability requires taking pill at the 5arne time each day (within 3 haul$), no pill free intarval Same as OCP, skin irritation Same as OCP, vaginitis, some women may be uncomfortable with IITl!llular bleeding, delayed return of fertiity, no STI protection, systemic hormonal side effects (most common is headache), weight gain .J; bone mineral density (check ahl!r 5yean)

NuvaRig (inserted by patient)

DMPAIM prog11518rone injection q12 wlcs (e.g. DepoProvere")

MllaCDOdom

97% effec1ive against preiJlancy and STis when used properly. 'IJhen used properly WITH spermicide 1heyIll! close to 99.9% elfactive, no Rx rvquired 92-96% effective with perfect use, non-hormonal, female-controlled method !i contraception, decreased risk af cervical cancer

Latex allergy, irritation, only effec1ive before the expiry date, must be applied properly, can only be used onceMust be left in for 6h after intercourse, must be used with spermicide, incomplete STI protection, latex allergy, must be fitted by health care worker, increased risk of UTI, risk of toxic shack syndrome

Sponga

One-size-fi!HII barrier method, does nat rvquire fitting by MD, available in pharmacies, 90% effective without a condom, 98% effec1ive with a condom 99% effec1ive against preiJlancy, effective for 5yrs, no daily regimen required, can be easily removed, ideal in post-partum womenII; mensbual flaw, less systemic hormonal side effects than OCP

Relatively expensive, only -60% eff8ctive in parous women, incomplete S1l protection, risk of toxic shock syndromeNo STI protection, increased relative risk af PID in first month, must be inserted by MD, risk of post-insertion vaso-vagal response, risk of uterine rupture is 0.6-1.6 per 1DDD, 2-10% expulsion rate Hormonal side effects (see combined OCP), expensive (-$400) 111'811ular bleeding or 1' menstrual flaw, 6-211% women discontinue use in first 5yrs because af pail or '1' bleedi"cl Hilt! probability of flliiWll nat used consistently and corractly, no STI protection

lntl'llllllri1111 Dnic:e (IUD} Llvonorgtiiii'IIIUD

(e.g.Copper IUD (e.g. Nave

>If risk of endometrial cancar,less expensive (-$170)

typical use, Fartility A'NIImiW/ Efhlctiveness: 95-98% with perfect use, Natural Family ilcr811S8d awaraness of gynecological health, 11111Sanable for couples Plannilg for wham an unplanned pregnancy would be acceplable

(e.g. symptothennal method)Llc:talilllllIR11101rhll

Very effective in breastfeeding women nat returned, fully or nearly fully breastfeeding baby and baby is under 6months old

Nat infant receives any food supplementary to breastfeeding Must treastfeed regularly, even through the night (at least q6h)

Emergency Contraception (EC) hormonal EC {Yuzpe or Plan B, usually 2 doses taken 12 hrs apart) or post-coital run insertion hormonal EC is effective if taken within 72 hrs of unprotected intercourse {reduces chance of pregnancy by 75-85%), most effective if taken within 24 hrs, does not affect an established pregnancy post-coital IUDs inserted within 5 days of unprotected intercourse are significantly more effective than hormonal EC {reduces chance of pregnancy by -99%) pregnancy test should be performed if no menstrual bleeding within 21 days of either treatment advance provision ofhormonal emergency contraception increases the use of emergency contraception without dc:crc:asing the use of regular contraception pharmacists across Canada can now dispense Plan B without a doctor's prescription (as of April2005)

AhohQ Contraindicmons tu Combi1111d0CP

IAldiagnosad abnormal V1Qi111 bleeding Thromboembolic disorda11 Carabi'OVIICLJir or coronary ertaydiseue Es!rogln dlp1ndlnt llmOUill (brlllll. Ullrus) lmpllirld livlrfunction with III:W livlr diAII88 Congenital hyper1riglyceridemia

KnowMuspected pregnancy

Smoker >35 yen old Migraines with focal neurologicalsyJ11)10ms

lklcontrollecl hypertension



Toronto Notes 2011

it' DiffertntialCommon eau Althml

CoughHistory and Physical duration (chronic >3 months), onset, frequency, quality (dryvs. productive), sputum characteristics, provoking/relieving factors, recent changes associated symptoms: fever, dyspnea, hemoptysis, wheezing, chest pain, orthopnea, PND, rhinitis constitutional symptoms: fever, chills, fatigue, night sweats risk factors: smoking, occupation, exposure, family history of lung CA or other CA, TB status, recent travel medications (ACE inhibitors), allergies PMH: lung (asthma, COPD, CF), heart (CHF, MI, arrhythmias), chronic illness vitals including 0 2 saturation, respiratory exam, HEENT and precordial exam Investigations guided by findings on history and physical consider throat swab, CXR, sputum culture, test for acid-fast bacilli refer to respirology for PFfs as appropriate

Upper airway cough syndrome

(postnasal drip)

GERD

Non-lllhmatic eosinophilicOlhlrC..p ACE inhibitnrs Aspiration Bronchietasis Cyllic fibrosis Pertussis

Chronic interstitial king disease Psychogenic Restrictive lq disease TB, atypical mycobacterium. and otl!lr chronic lung infiC!ions

Dementia see &)rchiatcy. PS18Epidemiology 10% in patients over the age of 65, 25% in patients over the age of 85, 50% in patients over the ageof90 prevalence increases with age, Down syndrome and head trauma differential diagnosis: Alzheimer's dementia, vascular dementia, Lewy-Body dementia, frontotemporal dementia Investigations history, physical. MMSE investigations are completed to exclude reversible causes of dementia and should be selected based on the clinical circumstances CBC, liver, thyroid, renal function tests, serum electrolytes, serum glucose, vitamin B12, folate, VDRL, IllY, SPECT, head CT, EEG Management treat and prevent reversible causes provide orientation cues (e.g. calendars, clocks) and optimize vision and hearing family education, counselling and support (respite programs, group homes) pharmacologic therapy: NMDA receptor antagonists and cholinesterase inhibitors slow rate of cognitive decline; low-dose neuroleptics and anti-depressants can be used to treat behavioral and emotional symptoms 20% of patients develop clinical depression, most commonly seen in vascular dementia

Depression------------------------------------------------

..._.

..

,

see Psychiatry. PS7Etiology often presents as non-specific complaints (e.g. chronic fatigue, pain) depression is a clinical diagnosis and tests are done in order to rule out other causes of symptoms 2/3 of depressed persons may not receive appropriate treatment for their depression identification and early treatment improve outcomes Screening Questions Are you depressed? (high specificity and sensitivity)

Differtntial Di11nosi1 Ottm- psychilltric disonlm (1.g. IIIXiety, personllity, bipollt', schizoallec:tiw, SAD, substllrn:e lbuselwilhdlliWII) Early damentil. Endocm {hyparJhypolhyroidilrn. OM) Liv8r failure, nmlll failure Chronic fatigue syndrome Villmin deficiency (pernicious 1U18111ill, pallllgra) Medication side elfecbbanms)

Have you lost interest or pleasure in the things you usually like to do? (anhedonia) Do you have problems sleeping? (for those not willing to admit depression)Assessment risk factors personal or family history of depression medications and potential substance abuse problems suicidality/homicidality fill out Form 1 (in Ontario): application by physician to hospitalize a patient against his/her will for psychiatric assessment (up to 72 hours)

Infections (mononucleosis) Menopause

Clncr

before the dilgnosis at cancer is rna)

of palilllts rumours, of brain, lung and pencraes, develop symptoms of dapnsuion

Toronto Notes 2011


Fam.lly Medicine FM21

functional impairment (e.g. work, relationships} at least 5 out of 9 criteria including anhedonia or depressed mood weeks for actual diagnosis to be met (see sidebar} validated depression rating scales: Beck's depression inventory, Zung's self-rating depression scale, Children's depression inventory routine medical workup (physical examination, CBC, TSH, electrolytes, urinalysis, glucose, etc.)

Crtt.illhr .,.,_.,.. M DIPIUud MoodS I G E C A Increased/decreased Sleep lntemt G uilt

Treatment goal: full remission of symptoms and return to baseline psychosocial function phases of treatment acute phase (8-12 weeks): relieve symptoms and improve quality of life maintenance phase (6-12 months after symptom resolution}: prevent relapse/recurrence, must stress importance of continuing medication treatment for full duration to patients treatment can consist of pharmacotherapy alone or psychotherapy alone combination of antidepressant drug therapy and psychotherapy results in synergistic effectsTabla , &. Common MadiclltionsClas

DecreaMd EnergyConcentnrtion lnc11111118d/dBCnlllsed Appetite

P Psychomotor agitationfretardation S Suicidal ideation

Must Ask Abold/Rule Ollt Bipol/ma'liclhypomanic episodes

Psychosis Anxiety

Exallplparoxstine (PaxiP), fluoxetine (Prozac8 ), sertraline (Zolaft), citalopram (Celexu"), fluvoxamine venlafaxine bupropion (Wellbutrin) amitriptyline (EiaviP)

Actian Block sl!l'lllanin reuptake

Side Effects Sexual dysfunction (impotl!nce, decreased libido, delayed ejaculation, anorgasmia), headache, Gl upset, weight loss, tremon, insormia. fatigue Insomnia, trlmors, lllchycardia, sweating Headache, insomnia, nijrtmares, seizures, less sexual dysflrlction 1han SSRis Sexual dysfin:tion, weight gain, 1remors, lllchycardia, sweating

NatalFirst line 1herapy for teens is

BIIIIIIMIII1ent

Sllbstance IISWabuse/Withdrllwal

SSRI

SllicidaVhomicidal ideation

ft.loxeti1e; paroxetine is notrecoll'ITI8nded for teens (conlnlVlnial)Common Dosing

llilrliltO. .....Block sBIIIIanin and NE reuptake Block dopamine and NE ll!llplllke Blocksl!l'lllonin and NE reuptake

SNRI SDRI TCA

....

Nlm!W thel!lpeutic wildow, lethal in overdose

Prognosis up to 40% resolve spontaneously within 6-12 months risks of recurrence: 50% after 1 episode; 70% after 2 episodes; 90% after 3 episodes

Diabetes Mellitus (DM) see Endocrinolon. E6

... l'lrdlallliCII ,..._........:A,_.IIir:..,._

Epidemiology major health concern, affecting up to 10% of Canadians Type 1 Diabetes (DM1): 10-15% ofDM, peak incidence age 10-15 Type 2 Diabetes (DM2): 85-90% ofDM, peak incidence age 50-55, up to 60,000 new cases in Canada per year gestational diabetes mellitus (GDM): 2-4% of all pregnancies incidence of Type 2 DM is rising dramatically as a result of an aging population, rising rates of obesity, and sedentary lifestyles leading cause of new-onset blindness and renal dysfunction Canadian adults with diabetes are twice as likely to die prematurely, compared to persons without diabetes

1rillls.

lludr. $yllalllllie miew rmbrimd clinicll

..._: 1142plllienls. llllmdaft: Antidlplamtll'llli!Wit alone VI. c:omlimlln al intmwntion lf1CI llllidapmanttllmpy. Mlil llllall: Elicacy a! IIIII adherence ID

lllerlpy.

11116: IMrlll c:ombined tlmpysigniic:antly 1111111 &tiw ttu llllidupl8111rt 1llerlpy alone (OR 1.86; M a I.38-2.52L '-er u.n-110 Item. al drgpoul$and 11011-mpondn illilhlr llll1mlnt arm. .. lbJdill > IZ weeks, corrlliled 111nPV iiiiiWid 1 IICllclion in dJII)OUIS ClllfiiiiiCI to 1111nofiii)Onden (OR 0.59; M Cl D.39D.881

Risk Factors Type 1 DM personal or family history of autoimmune disease Type2DM first degree relative with DM age years obesity (especially abdominal}, hypertension, hyperlipidemia, coronary artery disease, vascular disease prior GDM, macrosomic baby (>4 kg) PCOS history of IGT or IFG presence of complications associated with diabetes both member of a high risk population (e.g. Aboriginal, Hispanic, Asian or African descent)



Toronto Notes 2011

Diagnosis persistent hyperglycemia is the hallmark of all forms of diabetesDM lltlm.d Symptoms

Hypeqtycemia: polyphagia, polydipsia, poi'(IN. weight change, blull'f vision, yeast infectionsD1abe11c IIIIIMcldosll (DICAI: fruity breath, anoruill, fatigue, llbdo pain, Kussmaul breathing. dehydration Hypoglrl:emia: IJinger, amdety,

Tabla17. Diagnosis of Insulin Allocillted Disorder&Canditi111Dilbca Milito

Dillgnosdc CriteriaOne of the folowing on 2occasions: Random BG 10.0 rrrncAA. {180 mgJdl); action is required :S0.07 or :S0.065 in some typa 2 OM patients at risk lor nephropathy Suboptimal: 0.070.084 Inadequate: >0.084 5-10 mmoVL (9G-180 mgJdl) HbA1ctargetmet 58 mmoVL (9G-144 mgJdL) HbA1ctargetnot met

HbA1c

Blood Pressure Lipids

< 13QIBD in adults (OM and HTN guidelines) LDL 50Syrlamic: hepatic disease, primary/secondary bleeding disorder, medications (ASA, NSAIDs, warfain), HTN, a1herosclerosis

Conservative: Emergerx:y: ENTlER consult for posterior packing o Position: upright leaning forward direct digital with an intranasal balloon/Foley ca1heter Embalimtiol\"surgery pressure over soft part of nostril for >10 min ("pinch" up to cartilage) o Humidiier in bedroom, nasal saline sprays, bacibiacin or Vaseline3 application to Utile's area Silver nitrate GelfoamiHemosllrt o Nasal packing with Vaselineat gauze, nasal catheter or sponge o Cotton soaked in vasoconstrictor (oxymetazoline 0.5%) and topical anesthetic (4% lidocaine) placed in anterior nasal cavity with direct pressure for >10 min Investigations: CBC, Hct, cross & type, INR, PTT (only if severe), CT/nasapharyngoscopy if suspected tumour Usually with > 10 min of pressure to nose Copious bleed, aflm swallowed and vomited May lead to hypovolemic shack if nat treated

Prognlllil



Toronto Notes 2011

Erectile Dysfunction (ED) see Urolo!D'" U30Definition

-------------------------------------

consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual performance of

10 - toronto notes 2011 - family medicine

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