Np Famiy Medicine Sarah Basma. Karen Dobkin, Vanessa Rambihar and Ashley Zaretsky, chapter editors Kenneth Lee and Raheem Peerani associate editors David Katz, EBM editor Dr. Ruby Alviand Dr. Azadeh Moaveni, staff editors pics Four Principles of Family Medicine Periodic Health Exar Purpose of the PHE n (PHE) Health Promotion and Counselling Motivational Strategies for Behavioural Change Nutrition Obesity Dyslipidemia Exercise ‘Smoking Cessation Alcohol Common Presenting Problems ‘Abdominal Pain Allergic Rhinitis ‘Amenorrhea Anxiety « ‘Asthma/COPD. Benign Prostatic Hyperpiasia (BPH). Bronchitis (Acute). Chest Pain. Common Cold (Acute Rhinitis) Contraception. Cough.» Dementia Depression Diabetes Mellitus om Diarrhea Dizziness Domestic Violence/Elder Abuse Sept ei rage Spmecacma come Source Same Spec hie ‘ec sss ‘Toronto Notes 2012 ce a Sete ar i fomene rao ey Mewar ont ate = 2 Dyspepsia... Dyspnea 2 Dysuria Epistaxis Erectile Dysfunction (ED) Eye Complaints. Falls in the Elderty Fatigue Fover Joint Pain Headache Hypertension Low Back Pain, Menopause/HAT. Osteoarthritis 11 Osteoporosis 11 Rash 12° Rhinorrhea 13. Sexually Transmitted infections (STIs) 14 Sinusitis, 15 Sleep Disorders 16 Sore Throat (Pharyngitis) ” Hearing Impairment 18 Complementary and 19 Alternative Medicine (CAM)... 20 20 Primary Care Models. 20 21 References .. 2 25 a tome ‘sin ieee ce ena Sremcey i oe ==. a. Eee Zao ime = 60 51 53 Pers Swat ‘pew ‘Sere peer medi Sedona oe macro aes Sela me Family Medicine FMIFM2 Family Medicine Four Principles of Family Medicine/Periodic Health Examination "Toronto Notes 2012 @ Four Principles of Family Medicine Penton lia Mato "Bolo po plas nt Sede anager ner + Comoran en, eye rae toes te ‘hone yt seu wot ‘Seren Ina oston ofthcaues {wh yuh go) ‘ert tas rt nf {tense steregyen wot et) Gents these ‘reat pcg s—— Nitateniecmpete ‘aires nome So Geo of Racommendtins incl porta acin Incl pera cin Essig ones Se oeentaoy mate ‘Senter pense iene prev sen Seong ast incl pete ical eee reer {aly ons areccrrendatn — When Orden Fasting ssnark ‘sats oy eae it) + Ronen in’ mas o ‘at eum oa, + Fergani 57 tos owe acid ‘ovine PSk seeing aro 1 Fast sedi cnig Ervin nape fren ‘howre cn College of Family Phy: 1. The family physician isa skilled clinician jans of Canada Guidelines + in diagnosing and managing diseases common to population served + recognizes importance of early diagnose of serious life-threatening ilnesee 2, Family medicine isa community-based discipline + provide information and aces to community services + responds/adapts to changing needs and circumstances ofthe community ‘3. The family physician isa resource toa defined practice population + serves asa health esource + advocates for publi poly to promote health 4. The patient-physician relationship is central tothe role of the family physican + committed tothe person, not just the disease + promotes coatinuty of patient are Periodic Health Examination (PHE) + Canadian Task Force on Preventive Health Care established in 1976 fist published in 1979, last ‘updated in 2005 + mands: to develop and disseminate clinical practice guidelines fr primary and preventive care 1 recommendations ae based on systemic analysis of scenic evidence * most notable recommendatio DHE Purpose of the PHE «+ primary prevento healthy behaviour isthe abolition ofthe annual physical exam: eplaced by the lentfy rik factors for common dscases; counsel patients to promote «+ secondary prevention: presymptomatic detection of disease to allow early treatment and to prevent disease progression + update clinical data + enhance patent-physician relationship Table Periodic Heath Exam ene Pion Sarl yes ry ison tig Neel am pee 1 Sti el ng mn, oe: eat ey A ‘Rabson este pa Deny tcc ses i + sects + sy pete nares soe det + Nepal * isn essa apt iati ) + Poaenang cence + Ganado pec oT * ten mele ol tay rata tle + Dao en rn eens (sence tne) PIAL + Cid nam en 8) + Bhs earner) + Bresette 8) ‘Sc on Peds ness ih iti ey regan ites Anti nen ty nde ‘tl Chi pet sina Peinaapid woe ts ae od tae ane noo Ceo neo omer rena Ienmcroen t itn) Ais >t: Fugen cere cmcan df cpiie ine itera pos asset A apn marines es eg (epson to Sordi isd erie) Vite 2 (8) Vana ase sta Hexen min, speedo sts Fit opel ln: ot inca as >‘Toronto Notes 2012 Table 1. Periodic Health Exam (continued) Periodic Health Examination/Health Promotion and Counseling Family Medicine FMB Cone Pepa Wise cing act faatese ta 0 Spay a > guns ted) * Bam ay a ma 2 na en ero en ‘erst! + Fatale * it erp rt tk ‘Nera seta * tte ey eo ht rs * angen hn eh eee eum) Hato + Space fete 1 lec sce les ied) TE ced ct ep ele + Wnt a ae Pps ay ort 188 Sec ae st er so et the tow nasi et fame, Ste Dont rma 0 yp Steet 61 ced any dns Fbdatreshemenctcerry ome vir + Flea prt sare tg A ‘Vea ee ciel a sts leet + te i along wen cf cleeg : + Rt often th Ptmaiso 18 esau A + enum ets pa a 1 Scare edu se Stepan pot Spel oton Podcasts eno ws Brot segs tie ates une ny Tih ek upto ei Sigh ik gest HV xe ras soy Chana soeag non Col cme hi gre Coy Ae Sips get sg) wee: ers Sy to VRL A Petiice, Ran mia Npate rman) Oso bo ee oe tCathipge 328A losis one Du ees ‘act isin Gheowrcemeesetrd Tih ou: orb ct alse ones) ess gh es Iomega 6SCPD Pram ei) Fame 126 ‘Geta dndsnisan ro Gat Fe sa ah CE CCC mL ULL | + health promotion isthe most effective preventative strategy 140-7046 of productive life lost annuals preventable 1 there ate several fective ways to promote healthy be appropriate toa patients present sage of change avioural change, such as discussion Motivational Strategies for Behavioural Change Pcs Fon Tas sina rane Dr etinps anata ecg ot ilomaten te nosrace rap tet noe posi ange ses eis change nowt s res of hepa ais ss Cotemisim —Undeirdtieseties fear gO qty aa pod Sitetieerguconennets e cond corey Poparin ——_Screoraancurnaerstapepse ae Ul rate Za Excyigpidcnaaessdlowiaaropeen feet seas me a Seale SSietosmato arteeensormine eto ‘opis nm aoe Oe ptveecenr ote Soup smape ee ee secon woo Scpoteeeeesnnstrtatinotem hoe Ex snp ‘ere Ames Hpi nn Osos ges west fondest sao estos igs ‘Scr ames ote ise sig weiner tnt asin at tromeres uraning bps fon onroper nhs eases pn edness were Fite spt aprons pact ol of dies ost gs ag ea Oa RT SLI “arses oe ea coy [n3 rams ks bon 3 won Som ogni ates tare Cae (it eves Bove Some Pests See SOUS HEVONA sig nen (Sean you HPV erg oa Sat pet ytdogy 6 ont + ASEM HL, AUS, sqm at ‘bes + Sere. 16 Shines Abs Common (Gc acommendeons or rset, {noe Sronng Foro oes 059 Owes ‘sien amend ee (teting teat a aman (Bybee tom ‘et BSE and gn oes an Pat “8 ‘Setar ee peer ‘Sinan pe ‘ae wp ee cn Pare sent ge FE, Sei wee aot nce rests ‘haga eine eS ASL Bremen ‘com scocedorerceminth issn Ponte er sce ‘Mibitedeen bene ‘ha oe yo Bec — Foti Sepanenatonn Progeey Uae SCM MSpennnrt he dso ‘ror oan canna retFMA Family Medicine ‘Health Promotion and Counselling "Toronto Notes 2012 Nutrition General Population + Canadas Food Guide is appropriate for individuals >2 ys old + counsel on variety, portion size, and plate layout (se Figure 1) Tole 3. Canad Food Guid 2007 Recommendations for Adults Food Gop Sev ‘Cheese More tee Bangs 8 ‘Wis gan ered yah roe Vogieard tat 70 Dorgan ns eng eater it ik rats 23 Lower yp Chto 28-2 Yuh 1834 Figure 1 Plato Layout Poon: 34 estnd terete 23 @ any Sen Si Campari Sere fh ny pan a {ap oryiacroget ss tat 5 fests dha Cardiovascular Disease Prevention “Table Dietary Guidelines for Raducing Rsk of Cardiovascular Disease in Foot om aconmendtons | tots et Fatale 102 0) (ha hss Women 18 on 5 Usenihe 185 Normal ms2s Ore ons reset vy esi snosts ' Ho ey Hoh soa3 1 ey toe ey Hoh evone hesiy 400+ 1 ery oh Bere gh “ro Cen Owego On BM Va Caer aan a er ad rag nls ruse | Epidemiology 6% (4 milion) of people 218 yes old are obese, 32% (8 millon) are overweight in Canada, according to StatsCan (2007) «+ obesity rte in people of aboriginal origin ie 1.6 times higher than the national ave 1 proportion of deen aged 11 rhe we erright ea mere than dele i Gh lt 25 ye, percentage of everveight adolescents ha tripled «+ overweight and obesity atesin children ae directly proportional to screen ime (see Exercise, FM) + only 10-158 of population consume <30% ft daly + obese persons generally consume more energ)-dense food which tends to be highly processed, ‘micronutrient poor, and high in fats, sugars or starch Phrmactaray fe hese aac eam ese Ins eon at bp by Sevoy manor of prepa «Sethu roman ane rere eae en ‘es year ste « Sihedeaton ae nt ‘tty sel sen et at {porate args ban ine * faididoeae aera Seen cre eae, daa Settbemeteinpes eatery ren er‘Health Promotion and Counselling "Toronto Notes 2012 non eee 2 decursanemsipidgos tenon eA) | Cone eo sa) ‘eoetinares| wii oer a ‘roar ese ites Aaio wget eteht i h (BME >25 and <3 ka me conieed a nator gets y Tans ige ava eae pas oa tenes pom coc ene 4. “eet eccciesScee + Prater teers) ‘Conduct lea and brary " “ Invstnons oases cameos. ¥ ods ett ig ne ‘ahaa ‘easel coer vai an pon telstra dl eto HO Sls) + + utestyle moditication program ‘agnor ator ote gina = Physical acbuty: evil 30 mnutas of madorat + meyer oom > Sa aaa “Ringe etter sabre eg roe + Cepia bey Tamara Sg ino ela wate Seiden paw ge? Fon onan seata magt ase as ty tg nd scala sc ‘Wap ns Teme oie wy pomsndenpewpn || omatignrat ies || su:tiiget Sth roe % FA fsa ay ior saith Copitebeioestney || aguante || cami tan agit os Aaiwseterit tcp || “oeietpataceat || Sangster tung egte Silva || “oStig 2) pea Ta eden Ceara || seme Saree — fase ray eats Gina Dotson ot nase porary Gal es menos ae + Pusey WO eg on Fate Sma ey) gt 2H Oa) tama seo) Aint stead Clinical Practice Guidelines onthe Management and Prevention of Obesity in Dyslipidemia + see Endocrinology, E2 1 defined as abnormal elevation of plasma cholesterol or triglyceride levels *inereased risk associated with obesity, DM, alcohol use Assossment ‘mest fasting serum TC LDL-C HDI-C,and 76 ¢ Sren with lating ip profile in mals oer ge 40, feral ver age Do who ae ‘enopasl or ny ads with atonal CAD ra actors Sen + tne fr presence of ther CAD rk factors, 1 Sten frsncondary canes hypotyoiim, chronic key dss, DM, nephrotic syndrome, iver diese «tk category "ena sng the model or 10-y¢ CAD ri deeaped rom the Framingham dats + primary target of teapy LDL-C level the alee primary ret Apo (not wed vide) + Optional stconday tres once LDL-ClapoB isa agetncade TCHHDI-C ratio spotapoaT aia CRP (oed more for riksetfeton of CAD), nm: HDL-Cand ‘rum 8 her‘Toronto Notes 2012 “Health Promotion and Counselling «emerging risk factors (from Framingham group) * lipoprotein a + metahaiesyndeome * genetic rik * hormone replacement therapy * infectious agents Tale 8. Target Lipid Values fr Primary Prevention of CAD isk ator, iat Testa ue i Ctersemmornalpaiows —_—38 nett <2mmator ayo tw 1oLe 250 mol 2 desi OLE (Moyers 108) ee ea ind ebro nt 2 eet Goel A ‘Management «+ intenaty and type of treatment is guided by risk category” assigned {health Behaviours (can decrease LDL-C by up to 10%) * smoking cessation: probably the most important for preventing CAD * dietary modification: reduce saturated fas, refined sugars, alcohol increase Fruits, vegetables and fibres, + physical activity: 20-60 min of moderste to vigorous activity on most days * employ consistent lifestyle modifications fo atleast 3 months before considering drug ‘therapy igh risk patient should start treatment immediately with concurrent health ‘bchaviou interventions 2 pharmacologic therapy (can decrease LDL-C by up to 40%) foe comparison of dyslipidemia medications, see Endocrinology, ES * stains (HMG-CoA reductase inhibitors) * currently recommended as "ine monotherapy following unsuccessful exe ‘modifications + sks: myopathy and hepatotoxicity - mut fllow LFTs q6-L2months * other agents bile aid sequestrants, nicotinic acd brates, plum, cholesterol absorption inhibitors (eg eetiibe) + afer niating drug therapy * monitor ALT, AST, CKat baseline then 6 whs ater for signs of transaminii or myositis tolerate risen CK up t010 times upper imitof normal (2-3 times upper limit of normal f ‘rmptomatic). or serum creatinine of =25%: repeat ALT. AST and CK with lipid bloodwork + fasting lipids shouldbe measured st 3 months * ifadequate response is achieved, evaluate fasting lipids q6-12months isolated hypertilyceridemia (does not increase your cardiovascular risk) * normal HDI-Cand TC, elevated TG * mild 222 mmal/L (2200 mg/dL) marked 25.6 mmol. (2800 mg/dL.) * principal therapy islifestyle modifications * weight loss, exercise, avoidance of smoking and alcohol, effective blood glucose control in Aiabetis, increased omega-3 ft acid intake * drug therapy * nicotinic acd + fbrates Enidemiotooy 123% af the pops exercises ely, 0% ocasionaly, 25% ate sedentary 1 sree ime me spent stching I V/movis, plying veo gues ong the compet has ben increasing en inthe as severly, wile ime spent being yea ste has been decreas + Suen reeommendation fom internatonl peda soceess tht chien (2 ys ld) should mith ceen ine toes than 2d Sieegocemanea 2oaeem Eesnars cern ss Carn iy ECA ‘one Igy am 2 Sia Sn eosin ‘Stern Say td ‘ay ane osteo ‘pune pt ee ‘Sony tedamirmanea ee ‘oud gee ns ‘Srna! SeoPites wosan sre Sen aan ste ‘homed ‘Soe Ora ogg es ‘Ger true Ti et atone pen ‘nines sn ra eos ‘shy econ carbinesFMS Family Medicine Aas Pat in erp it Pon Seautate Tey ste te pe) recess hepa wos Avo bce naps eg SSeayeliees) The As for aes Wing it Bei pti anes ave tet ses ress tot asst net anon reper ‘Health Promotion and Counselling "Toronto Notes 2012 ‘Management + asses current level offitness, motivation and acces to exercise {emconrage warm up and ca down period toalow transition between ret and activity and to avoid inares «+ exercise with caution for patients with CAD, diabetes (rik of hypoglycemia), exercise-induced ‘asthma + balanced exercise program incorporating all types of exercise aerobic (endurance) exercise fr 30-60 min, 47 times!wk * improves cardiac function, lowers B, increases HDL, increases insulin sensitivity ‘target FIR: 60-80% of maximum HI ‘maximum HR=220-age 2. weight-bearing (sometric) exercise 10-20 min, 2-4 tmes/ek * builds muscle strength, improves bone density, improves posture 3. stretching routine 10-12 min, 7 tmeske * prevents cramps, sities, injuries, back problems + other Benefits of exercise * ieprovesfelog of well-being, ido, quality of sep, sol-eteens 1 decreases depression and ansiety * weight contol Smoking Cessation Epidemiology «smoking is the single most preventable cause of premature illness and desth + 70% of smokers see a physician each year + 2008 Canadian data fom the Canadian Tobacco Use Monitoring Survey (CTUMS) on ‘population age 15 o older 118% are current smokers (lowest since 1965) * highest prevalence in age group 20-24 (28%) 115% of youll aged 15-19 ste (Uevteased fons 254 jn 2000) sno males suo thas, females; numberof cigarettes consumed per day also decreasing, ‘Management + general approach * identity tobacco users elit smoking habits, previous quit attempts and results| * every smoker shouldbe offered treatment *+ make patient aware of withraval symptoms “Tow mood, insomnia irritability, anxiety, dfculty concentrating, restlessness, decreased Iheart rat, increased appetite 2-4 counslling sessions >10 min each with 6-12 month fllow-up ye better results 114% abstinent with counselling vs. 10% without counselling (AR 1-55) * approach depends on patients stage of change (se Motivational Strategies for Behavioural Change, FMS) + willing yu * fallow the 5 As se sidebar) + provision of social support, community resources * pregnant patents advise o quit st without pharmacotherapy. NRT should be made alll to pregnant women who are unable to quit using non-pharmacologic methods, nicotine patches are strongly encouraged. Use buproprion (no evidence of fetal or ‘reproductive harm) only i benefits > risks; consult Motheisk. Varenilin has not been studied in pregnancy and should not be used in pregrant women + Nicotine Replacement Therapy (NRT) 19.7% abstinent at 12 months with NRT vs. 11.5% for placebo (AR 1.66) ¢ no difference in achieving abstinence for diferent forms of NRT + reduces cravings and withdrawal symptoms without other harmful substances that are ‘contained in cigarettes + us with caution: immediate post-MI, serious/worsening angina, serious archythmia + Boproplm SR Zyban") 121% abstinent at 12 months vs. 8% for placebo (AR 2.73) + Varencline (Champis*) * partial nicotinic ceptor agonist (to reduce cravings) and partial competitive nicotinic Feceptor antagonist (to reduce the response to smoked nicotine) + more effective than bupropion (23% abstinence from 9 wks to 52 wks with varenicline vs. 16% for bupropion vs 98 with placebo)‘Toronto Notes 2012 “Health Promotion and Counselling Family Medicine FM Tobe 9. Types of Nicotine Replacement Therapy im ne comme Santos Hien Gan(OT] 2m 90 ys ap aah ee oF pain Ul anconne Ath te pumton ‘somatic pain sharp, localized pain rrormmerem clea etests, * visceral pun ~ dull generalized pain + location of pain * epigastric (foregut) - distal esophagus, stomach, proximal duodenum, biliary tre, pancreas, ie + punt (gu - tl demo procina 2 of ncn Ss 1 pet Ong) iS often oo tocol gn OO Investigations Sg «guided by findings on history and physical + possible bloodwork: CBC, electrolytes, BUN, Cx amylase lipase, AST, ALT, ALR bilirubin, ico, INR/PTT, ox sreen, hCG. ieee oe ++ other tests arly 1H pyr! esting (urea breath test, erl0gy, DOpsy) Allergic Rhinitis + see Otolaryngology, O723 Definition inflammation ofthe nasal macoss thats trggered by an allexgic reaction 1 classification: * seasonal * symptoms during a specific time ofthe year + common allergens tees, gras and weed pollens, airborne moulds * perennial ‘symptoms throughout the year with vanation sn seventy + common allergens dust mites animal dander, moulds Etiology increased Ig level to certain allergens ~ excessive degranulation of mas cells > release of inlammatory mediators (eq, histamine) and eytokines “local inflammatoryFMI2 Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Epidemiology $B Fe apprrinaely 408 of chien and 20-30% of aduls Orn Spas {prevalence ha tncreed in developed conte, pail nthe at two decades otSrvaalatesa 1 associated wth asthma, sinusitis and tls media itt ce foe ‘Assossment Shooto {sete te = eniyalge a 1 btn 1 take an environmentaloccuptinal history res 5 ek bout elated conditions (eg atop dermatitis, asta, sinus, and fay history) Management ‘conservative * minimize exposure to allergens * most important aspect of management, often sulficent (may take months) + maintain hygiene, saline nasal rinses, + pharmacologic agents oral enthstrsnes ~ Et line therapy for mid siphons * eg cetirizine (Reactne", fexofenadine (Allegra) loratadine (Clrtin") * intranasal corticosteroids for moderae/severe or persistent symptoms (1 month of consistent use to see results) + intranasal decongestants (ase must be limited to 10puck ys eas nee Reveriy of Aw bso ere dpa Ai absense a yee wih ‘iow Oecion ey roe ‘Slow pagesve weer peiode Sul, pad, kas thn SR wl acess stay of Alyy bt pains Precip Entomortintars ait), Evert intr tpn ry rial ot, ‘te sting spscn rcoy, _snacn Ui cgay ASA Walfecton expat oe {oigton cay ea) Shmpton'Sges Chere couph spend dprea Whee talnak symptom spa est hes, up wnihre oad eng ed eat AM Frngat eran DisonCapcty Deets nresonpueenysena| Nmap ate) Apoxenia rin arn stages eal preset psd wen seers Somer Mey inpoenent wih ondositrs Mate nreveen wi chose seis ‘oc vey wen CeeXeay tuna hen oma oro hpi ‘renosec bec anings (reser dg ost atock ‘won| aeehone pews {empisena tance ot Masaginet Mid Cin of sve maa (SAAS alan onpn ‘Sap $884 star tess endmantne mean an nate ‘Sop2:6ABApm.' UC a teopum) tase asi cou oir cympene| + DBA eg seo} Noronuea meer Moire Sep Lae ‘Supt SABApn + LANG +lowdese _Sip2: Mami ero des ES site ‘oid SAABA ender ks. ool ABA UT ode err ang hye seve ‘ep Masi oss Spl ete LABA, CT ‘Sovre rod erg acg pyle ‘Sept = tuoi ‘Sup Asabme pls munstewp = oo) Aeon Mtn Pero” | aaa igri UE = yg N= an Pap = ene =i al Benign Prostatic Hyperplasia (BPH) + sce Urology, U7 Definition «+ hyperplasia ofthe stroma and epithelium inthe periurethrl transition zone History and Physical + include curent/past health, surgeries, trauma, current and OTC meds 1 specific urinary symptoms (se Table 13) + physical eam must include DRE for size, symmetry, nodulariy and texture of prostate (prostates eymmetricaly enlarged, smooth and rubbery in BPH) Investigations «+ urinalysis for microscopic hematuria (common sgn) + serum PSA: protein produced by prostate tissue iinsewsed PSA younger nan este ole de camer Una er nen * an abnormality on DRE or PSA should trigger further assesment * discuss test with men at increased risk of prostate cancer (FHx,Aftian ancestry) or who are ‘concerned about development of prostate cancer * considered normal when <4.0 ng/ml; but must take Into account patient’ age and rate of PSA increase (PSA velocity) + ifbetween 4-10 nim: consider measuring fe/toal PSA * if >10 ng/ml, can diagnose prostate pathology * PSA testing inappropriate in men with life expectancy less than 10 ys * PSA should not be measured inpatients with prostatitis, UTI When rag Vn ach {ate ops thei try, tty porters als, ‘tas, pace ro soins S—— ‘Sip oP Cone Astne SFrepmsine st + Atm eed bea a wo + Sie nnd etna * Mate sane uk B—— Wnt Cburi Yor ible? Nine oe Bice Fv Pi” Bef ap al hiro tego vitae cexgeych ‘ete pole ces cleus Stooge ttre —— ‘rl, M+ Se) Mb loves ih acest hese te ‘poe aout ales "inane eye 210 pont le es ae dl ey ‘Se dpa as i atl con bo acer ge mae sre stemmed frie ConesrenMIG Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 + other "Ce, BUN 1 port-vod residual volume by ultrasound * rodymamic stadies + patient voiding diary + tests NOT recommended as part of routine initial evaluation include: * cystoscopy * cytology * prostate ultrasound or biopsy sve Table 13.5) plications of BPH Obstet Syptons ‘eta Stns ne Compton iene iy staring ube fo) gy Hons Drain sen tea iy soe Fewery Lassen sty Ste argon ote ig Nec Symi Unum etter carttayenpy) —Uemesinence alte Posto tig Dyas owners ‘Management + referral to urologist if moderate to severe symptoms + conservative: for patients wth mild symptoms or moderate/severe symptoms considered by the patient tobe non-bothersome * fuid restriction (veld alcohol and eafeine) * avoidance/monitoring of certain medication (eg antihistamines, diuretics, antidepressants, decongestants) + pelvic oor exercises + bladder retraining ~ scheduled voiding + pharmacological for moderatesevere symptoms receptor sans [ey erazusin (Hy sin), saan (Cardura), tani (Flomax), alfuzosin (Katrl")] ‘relaxation of smooth muscle around the prostate and bladder neck + Screductase inhibitor (eg. finasteride (Prosar) * only for patents with demonstrated prostatic enlargement due to BPH ‘inhibits enzyme responsible for conversion of testosterone into DHT thus reducing growth of prostate + phytotherapy (eg saw palmetto berry extract, Pygeum africanum) ‘+ more staies required before this can be recommenced as standard therapy * considered safe + surgical * TURP((cansurethral resection ofthe prostate), TUIP (transurethral incision ofthe prostate, for prostates <30 8) '* absolute indications: fled medical therapy, intractable urinary retention, benign rental tein leing eval aliceney + complications include: impotence, incontinence ejaculatory dificult (retrograde ‘jaculation), decreased libido Bronchitis (Acute) Definition + acute infection ofthe tracheobronchial tree causing inflammation leading to bronchial ‘edema and mucus formation Epidemiology «Sth most common dagnosisin family medicine most common is URTT Etiology + 80% viral rhinovirus, coronavirus adenovirus influenza, parainfluenza, RSV + 208 bacterial: Mz pneumoniae, C.preuononie, 8, pneumoniae Investigations «acute bronchitis is typically clinical diagnosis 1 sputum cultureGram stain is not very informative + CXR ifsuspect pneumonia (cough >3 wks, abnormal vital signs localized chest findings) or CHE + pulmonary function tests with methacholine challenge if suspect asthma‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMI7 ‘Management + primary prevention: frequent hand washing, smoking cessation, avoid ivtant exposure 1 Eymptomatie relist rest, id (3411 when file), humidity analgesics and antoeives required «+ bronchodilators may offer improvement of symptoms (eg. albuterol) 1 current literature doesnot support routine antibiotic treatment for the management of ace bronchitis because it is most likely tobe caused by «vel infection * antibiotics may be useful if elderly, comorbidities, pneumonia is suspected or ifthe patient is toxic (reer to Antimicrobial Quick Reference, FMS1) * antibiotics in children show no benefit Chest Pai + See Cardiology and Cardiovascular Surgery, C4 and Emergency Medicine, ER22 Differential Diagnosis Bc scans ato gre Ni fe xsi overt Fie sto ad ay oat th cos CPO, teepaotap artery Toble 14. iret Diagnosis of Chast Pan Cone 1 @ we Peli eget Pri ceo Cosochndis Arty we framstera’ PID Iesclsren Pre. Prt e Foto vas" ris Deon Nees Finca Nagel Bac os—— Jone scie? Ling Glee Hagan fk oct Crary Ary fers Hes mn “met Ms be Investigations eee «ECG, CXR, and others if indicate (crdac enzymes, D-dimers LFS et.) sree 1 flor io BRI onpect crows etlogy (og aortic direction, Ml) 5 ant Management of Common Causes of Chest Pain a + anginaischemic heart disease Me "nitroglycerin (NTC) wait min etwoen sprays andifno ect after 3 prays, sendto ER | POE + myocardial nfartion ike * cher ASA (TD mg) STAT, to ER for “MONAT (Morphine, Oxygen, NTG, ASA) + epertason therapy with tPA or teptolunae (SK) within (Noe can onl use SK ‘nce eine) or percutancos intervention (cath ab) + Sart locker (cg mtoprlal starting dose 12.5mg PO OD and radually increase dose, titrate ta the HR ste goa of 60 bp) wo. + endocarditis: IV pencil G20 millon uits OD or IV ampiilin 12g OD 1 GERD: antacids blockers, PPs ‘igh Spams nS 1 costochondnitis NSAIDs et Panle ‘Sele chon Hear Disease pee ¥ eae nai 60 ull wg nae) Mong conaner ues Naren eet peta.) supose eer ng ede 1 le parses whet ny ‘Acct pes yor wy canst con ‘Sonor ey se Tatar dre ch woe ar ‘ingatreni pans yond es ‘ings le stra we ‘Sent ose ie sa ay cy anos Figure 6. Treatment Algorithm for Stale Ischemic Heart Disease es heya a at eo De Pap Oe Tes oe {tse 10 sonnet sa rp eset Fern oir AMIS Family Medicine Srp eyes Pont na Cora ‘Common Presenting Probleme "Toronto Notes 2012 Common Cold (Acute Rhi Definition + viral URTI with inflammation Epidemiology + most common diagnosis in family medicine; peaks in winter months + incidence: adults = 2-4/ye, children = 6-10/yr ¢ organisms * mainly thinoviruses (30-35% ofall olds) + others coronavirus, adenovirus, RS, influenza, paainfvenza, coxsackievirus + incubation: 5.4 + teansmision person-person contact via secretions on skin/abjects and by aerosol droplets Risk Factors + psychological stres, excessive fatigue llegic nasopharyngeal disorders, smoking, sick contacts Clinical Features + symptoms * Hoc nasal congestion, clear to mucopurulnt secretions, sneezing sove throat, conjunctivitis, cough 1 general - malaise, headache, myalgias, mild fever «signs * boggy and erythematous nasl/roparygel cosy enargedymph nodes + complications * secondary bacterial infection: otts med, sinusitis, bronchitis, preumonia * asthma/COPD exacerbation Differential Disanosi + allege rhinitis, pharyngitis, influenza, laryngitis, croup, sinusitis, bacterial infections ‘Management «patient education symptoms peak at 3 dand usually subside within L wk * cough may persist for days to weeks after other symptoms disappear * no antbiotis indicated because of viral etiology + secondary bacterial infection ean present within 3-10 d after onset of cold symptoms + prevention * frequent hand washing avoidance of hand to mucous membrane contact, use of surface disinfctant «+ symptomatic relief "rest, byation, galing warm salt wate, steam. * analgesics and antipyretics: acetaminophen, ASA (not in children because rsk of Reyes syndrome) + cough suppresion: dextromethorphan or codeine ifnecessary ‘decongestants, antihistamines * inc gluconate lozenge use is controversial + patients with reactive airway disease will require increased use of bronchoxiators and inhaled Steroids‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMI9 Contraception + see Gynecology. G¥I9 Thble 15. Methods of Convacepon bes Binge ‘aie O3? then wa ce STA hal, er ong sti wa i lic noon ain med {ject prion meta ow in oes open, sey manda weer rtrd Toone oak, ene virsasn (ELM sk, ome ay bh pg Pra ya in ir nto Haman ie tes canis 07 (eaitewn ‘eran ne ‘ret VIE Mrs, sae rest rq lc rT pec cna entity isi plat ‘Heeame te ah tin 3, ot fe Tanfoma Puch Sunes O08 yo se, anged ea, SPhefecine wth Sarwas OO sini (oe) comctue Nuraing? Sane OC eyo ne hs uf es sytnic Sane OD ahs, some amen may be eae wih seen (eowtey pea) hemor Sc ees, Os efecvewih comes ua {9.7% fein pint roan eq sg Insp tong ie ect ety mT ptt, ti heal [Mpopeseone neal ew araneenhe atl exealcacxe spelt conon shee) weg an bo me oat ijt 2s leek ata | (ea Depew") Male Conlon —_sT%efocne post orery a STs when ud pony Lt aly tat, oy esr beth ey, rust aed ‘en ed pope HTH seis ae coset 995% pope en any bese ce tte reas Diprapn «296% ivi prot, anton mee cmled Math et fr sarinucousa rst bo sd wih pois eat eto tea, fee canes Spotting, ms bed hehe wr, of ik sft sek some Spon Ores ir matid dwsrot mute iby ME, ‘asin nei, ry £0 eve npr wren onl ‘abn pamai, 80s ect wits eda osc atte ect yee ate cdon IntrinDovin 9% fee poet esr ect Sys a repnen opto, sive kof Dina ant must eis by MO ik oy ‘und nia ond inp snmnn Seatac nappa ef uma #051 sp epusen ae UD Venton ks syseichomond seas thn 00? Hema side eet oe cain 007 gers ($40) Capper tU0, sk oendonatia cress ens tan Mees?(-S170] arb ora on, 20% women orton us nf 5 ys (eter) ‘emer pane) Hosg| Fecty aries) tev: 65-4 wi praca 76805 wth ue, Hh bey ire mate ost cones oS prsaton Neural Family sce ees of yee th, era cols Paiog| ‘nrwinm nuns pany weld ea (eo sretthoral cttoes Vey riven brated ware fess aetaned Uy fs ina ess yd uaa aig Anonoriea__ ea ly stony tby says ortho Mostra ay ove ro we i test Emergeney Contraception (EC) + hormonal EC CYuzpe" or Plan BY, usually 2 doses taken 12 h apart) or post-oital IUD insertion + hormonal EC iseffectve taken within 72h of unprotected intercourse (reduces chance of pregnancy by 755%), most effective if taken within 24h doesnot affect an established pregnancy + post-coital IUDs inserted within 5 dof unprotected intercourse are significantly more effective ‘han hoemonal BC (reduces chance of pregnancy by ~99%) + pregnancy tet shouldbe performed ino menstrual bleeding within 21d of ether treatment + Advance provision of hormonal emergency contraception increases the use of emergency Contraception without decreasing the use of regular contraception + pharmacists across Canad can dispense Plan f* OTC.M20 Family Medicine Tenet, es en ‘Latter ape milesne Septet hy + Seen nine 73 ed noma = ete 23 wor anlage me Iromal= > 12mane ma) 2) Dingo ‘Set pas aa Soe bere crane ingens INTERPRETTON 3 3 ts atin ‘aoa ns ete eee ete tne monet hae wn ‘seni papa + iaenon ae ect (da, teen + acts (eens ‘Common Presenting Probleme "Toronto Notes 2012 Cough History and Physical + duration (chronic >3 months), onset, frequency quality (dry vs. 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 seats + Fisk factors smoking, occupation, exposure, family history oflung CA or other CA, TB status, recent travel + medications (ACE inhibitors) allergles + PME: lung (asthma, COPD, CP), heart (CHE Ml, arrhythmias) chronic illness + vitals inclading O, saturation, respiratory exam, HEENT and precordial exam Investigations + guided by findings on history and physical * consider throat swab, CXR, PFTS, upper GI series, sputum culture test for acid-fast baclt GETBis suspected) Dementia + se Bayhiatry PSIS Epidemiology + 108 in patients over the age of 5, 25% in patients over the age of 85, 50% inpatients over the age of 0 + prevalence increases with age, Down syndrome and head trauma 1 differential diagnosis Alzheimer's dementia, vascular dementia, Lewy-Body dementia frontotemporal dementia. Investigations + history, physica, MMSE, MOCA (best sreening test), dementia quick screen (see sidebar) + investigations are completed to exclude reversible causes of dementia and shouldbe selected ‘based onthe clinical circumstances + CBG, liver enzymes, TSH, renal function tess, serum electrolytes, serum calcium, serum slucos, vitamin By, folate, VDRL, HIV, SPECT, head CT, BEG Management + teat ond prevent reversible causes { provide orientation cues eq calendars clocks) and optimize vison and hearing {Tamil edscation, counseling snd support (epte programs, gop homes) + pharmacologic therapy: NMDA receptor antagonists and cholinesterase inhibitors ow rat of ogntve decline low-dose neuroleptics and at-depressans canbe used o tet behavioral Sn emotional symptoms + 20% optients develop clinical depression, most commonly seen in vascular dementia Depression «+ see Psphiatry. P57 Etiology + often presents as non-speciic complaints (eg, chronic fatigue, pan) {depression i clinical diagnosis and tests are done in order to Tle out other causes of symptoms 120 of depressed persons may not receive sppropristetestment for their depression 1 identification and early treatment improve outcomes Sereoning Questions «Are you depressed? (high specify and sensitivity) + Have you los intrest or pleasure i the things you usually keto do? (anhedonia) + Do you have problems sleeping? + For geriatric population, use the Geriatric Depression Scale (GDS) short form for screening‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FM21 Geriatric Depression Scale (GDS) Instructions Score | point foreach bolded answer. A score of Sor more suggests depression, Are yu basally satisfied with your fez ye 80 2. Have you dropped many of your activites and interests? ar) 3. Do you fee that your life is empty? a) 4.Do youotten get bored?” yes no 5. Are you in good spits mos of the time? yee ne 6. Are you aad that something bad is going to happen to you? ye to 7. Dov you feel happy most of the time? yes no Do soutien fel helpless? ar) 9. Do you prefer to stay at home rather than going ot and doing things? Yes 0 10,Do you feel that you have more problems with memory than most? a) 11:Do you think tis wonderful to Be alive now? ye no 12: Do you fee worthless the way you are now? re) 13, Do you feel fll ofenergy? yes 0 14, Do you feel that your stuation s hopeless? aa) 15: Do you think that most people are beter off han you? je to Assessment ‘isk factors sce Psychiatry, PSB + personal or family history of depression 1 medications and potential substance abuse problems + sucidalty/homicidality * fill out Form | (in Ontario) application by physician to hospitalize a patient against his/her trlforpyhirc assent (op 07219 eee Ar et en + fatto inpirment eg wre rec) = a ‘atleast out ef ertria including anhedonia or depressed mood 22 wks for actual diagnosis to | ———__— tw Be met (oe sidcba) =a, me some « tllsted depen rating cals Bek’depeson inventory, Zang’ slang depresion | epee HR, BOR tele Chile depres tmenony. Gerasic Deposion Sal Pera Hebh Scien! Bete Sot Garstonnate Depression ele (G3) SEch Sua ee «+ routine medial wer (physical examination, CBC, TSH, clectroytes, urinalysis glucose, et.) | Mareeba) saa" Ene Baas Treatment fan Gate aoe 1 goa fill reisio of symptoms and return to baseline pychosoil function (erent een tdeeed apnea ce eee Somer ooo stro * acute phase (8-12 wha): relieve symptoms and improve quality of life Som, Ee Soe + maintenance phase (6-12 mons afer symptom eohaton): prevent elapse/ecrrence, | Se=eiune SSE SES, ‘mus stress inportanceof ortinaing mediation estent for fll urston to paints «eaten can cont of pharmacotherapy aloe or peychatherspy alone aaa = { combination ofantidepresant rug therapy and paychotherapy res n synergistic efits | Pelee ede Assnyny I Table 16. Common Maiatons Serban nose ‘Se Ganges Aen Settee ms | Fit korg ai SSR pron FE) Skekaroeoh Soc snc rosie, Fiesty aroma | Matter a {wre rom, tepals foneenibn geteoaiten, ot tne act | Senne Seat a Sipmuthetss ten” comeactreee | ROT atcha ‘lan ea), odio tem mene emo So ‘rane te) nent |SNRL venlafaxine (Efexor*) Black serotenin Insomnia, Pemars, tachycardia, rt CTO ee snblérople Seng Scat stews ORL bepeponMetbtn®)Beckésanine — Hadoc soma rights uns, ree catemgss bese oyiecin sss it TA abhi") aksowtn Seatac weit pin Nowtempscinin, | sti ‘einen wow ec stn isthe 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) oy + see Endocrinology. E Epidemiology + major health concer, affecting up to 10% of Canadians + Type 1 Diabetes (DMi): 10-15% of DM, peak incidence age 10-15 1 Type2 Diabetes (DM2): 85.90% of DM, peak incidence age 50-55, up to 60,00 new cases in Canada per yr + gestational dabetes mellitus (GDM): 2-4% ofall pregnanciesM2 Family Medicine Dr Rote Stone tperdcome: 2st. sen ern gt he Bay on {ow cers Dia aes (OK ty, ‘rea town aoa, ‘Geert det ee eel intr, seating ‘ott con ees HA cn ano yin, ‘medcnsnnorcogionee ‘Common Presenting Probleme "Toronto Notes 2012 + incidence of Type 2 DM is sing dramatically a result of an aging population, ising rates of ‘obesity and sedentary lfesyles «Heading cause of ew onset hindness and renal dysfunction {Canadian adalis with diabetes ate twice s likly to die prematurely compared to persons without daberes Rsk Factors = TypelDM. 1 personal or Family history of autoimmune disease + Type2 DM. ‘first degre relative with DM * age 240 ys + obey (sei aomina, hypertension, hypeipdemis coronary artery dase, * prior GDM, macrosomic baby (>4kg) + Poos ° doy a eine genus tlernen or inmine fasting goer * presence of complication associated with diabetes + both * member of igh rik population (Aboriginal, Hispanic, Asian of Afecan descent) Diagnosis, + pesistent hyperglycemia isthe hallmark of ll forms of diabetes “Table 17. Diagnosis of Insulin AssocitodDisordrs Canon Dios Gita Dats ate he othe loving or case: dom B21. nit 9 ng wth spins of iti pou, to, led wet OR Fang 6627. a (5 ae) 8 ‘SG 2hpext 75 0G = mnt (200mg) 0N faaresesh Inpaed Fosting Oa (FO) FsingBE ~ 6.168 mal 110-124 Inpsed Gucae Trance JOT] 86 2pst 7S gOGT = 78110 1-18 gi) Screening = Type2DM. ERG in everyone 240 g3yrs + more frequent and/or earl testing if presence of 21 risk factor (see above) + GDM (see Obsetrics OB15) * all pregnant women between 24-28 wks gestation * non-fasting 'h 30 g OGCT 210.3 mmol/l. (186 mg/d.) is agnostic between 78-102 mmol/L (141-184 mg/dl) do confirmatory fasting 275 g OGTT + if develop GDM. have a 5% chance of developing Type 2 DM over 20 78 Goals of Therapy ‘Table 18. Goals of Therapy in Diabetes Melts ner ‘hoi cnpiaios (ag istics paar won) Pree rom conplatns (cms and macros Mrz ree eg etd wth emp hyp wat i) FasingorPrepanal Gucose Woo: 7 roll (72128 mi) ‘Stspea7 10 mel 18180 rg acon may bo oid deat 100 el 10 mg ancl vate 07 #0085 sane ype 20M pets a epopaty Sta 00 84 smote 0054 anroopachcoe $0: 000m Ec taene bom 4 At Blot Pre 100 ns (OM tH ies) {01 <2o nmi 6 mt) te Wontar ct St ‘etd ehdegeoltate erm (T2m9 i)‘Toronto Notes 2012 Assessment and Monitoring a ‘stent nas Tole 8. Assacsmen and Moitiog ‘Strvaetny mer Pr Tesi —y fy iy + Sytem Dba acnhay —-Dabdrciy | Sita ocosaiyajene’ — SSmnivemeaced —Seearirenmeeced | Stemi booed et «ites ny tay dpaprns—femncyatiprpana | EMER os + fanesealinqiry and A sd A {pot ec ppb nye + Gee + Sen ting Grondeh ulcer fattane Umdnednedttopes ‘Uaiainertelapcs | Seatances hones Shes + So ee ee larhcorsperinen i peantaeet + te caretng Qeonraneemes ie + yoo enat mitsewaatin den ee a + caegtemaonantr — | Seualaaterme {Nene cy tas“ Rta ain es,” poe mse mn cite «inne pr + Gator ea: ons P anal poles bits ‘io nae iia ean en tx ommenes) etn de oe 2 hedonic i 2 Neg orn oy ect Sineitincg tn neee ae resins + Fig i + atte + Feat Stereos on piste ge he RE san feamywenetntcoeage | eomnmeomet carota? o °s ea agerdetn igen + Darya ee pre ri a Somnnrs omg ‘asm mene ‘sotrie? au tp ysptten Wee tr Comes ire coer ‘Bonners 2s Mangia + Neoe ed iil ein Arps toting = ode hne nmr 2 Ciel ates ‘emeonesrs + age ey owe Séiotonpogenfeatbe Attest nt nosy aay pe oc + Nang 8 on ean ‘pee fency + Meteo cueing od yom nro sanbstazn, Sse sens + Opin cont pet wos Te zataopes ‘Common Presenting Problems Family Medicine FM23 + ra enn ay ‘Nonpharmacologic Management edict * all diabetics should see a registered dietician * strive to atain healthy body weight * decrease combined saturate fats and trans-faty acids to <10% of alors * avoid simple sugars, encourage complex carbohydrates, choose aw glycemlc-Index foods «+ physical activity and exercise * encourage 30-45 min of moderate exercise 47 dk * promote cardiovascular fitness increases insulin sensitivity, lowers BP and improves lipid profile * if inslin treated, may require alterations of dit, insulin regimen, injection sts and self-monitoring Self-monitoring of Blood Glucose 1 Type 1 DM: 3 or more self testa/d is associated with a 1% reduction in HAC + Type2 DM. optimum frequency of elf tess remains unclear + iLFBG 214 mmolL, perform ketone testing to rule out DKA. + ifbedkime levels <7 mmol/L, have bedtime snack to reduce risk of nocturnal hypoglycemiaM24 Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 ts arr te Hours Ar nection Figute 7 Types of Insulin Preparation Tie owen ern ta ep NT ne <0 neomie ‘at nage est si oe ini sel igo nrg bao oe ‘Ne Wma Obed ‘te ee epee ae smectite teats ake gene Teasnspee aS oe Teed pale Nowa rea wegen aoe pt it ‘ae we ea en Ne lees Tal see Magis nS te eeopecpaces! Sitti Stier VS Ye ‘erafemelsci, Ten Sonam ™ wie aie Sits lemaal a ‘een om Mf ee ree Weider me ‘Se oe mead a rb hast ago aie + hein ta ei re Se tegeenctioe fo fami Sy Sana topes ana sat an add era ined Crp Rev ade [Camino Snes nor no ey Figure 8, Management of Hyperglycemia in Type 2 Diabetes (et et onl rr oie Spt rein vii ii pep erin pet St Cts ol pr‘Toronto Notes 2012 ‘Common Presenting Problems Oral Hypoglycemies (M2) + available ages bigianide: metformin (Glacophage?) hiazolidnedione:trogiazone (Rezuln®, rosiglitazone (Avandla*) ‘glucosidase inhibitor: acarbose (Precos") nonsulfonylareasnateglinde (Starlix) epaginid (Gluconorm*) * sulfonylureas glyburide (DiaBet'), glimepiride (AmaryP),giclaide (Diamicron*) * DPP-f inhibitor: stagliptn Januvis") Other Medications Used in DM. «ACE inhibitors for: * all hypertensive DM patients * elevated microalbuminuria (30-300 mg albumin in 24h) * overt nephropathy (2300 mg albumin in urine in 24h) * ARBs are second line for these conditions + ASA for all diaries, less contraindicated + statins ‘ah roquted to attain target + se Gastoentrology, G15 Definition + passage of 3 or more loos o iid stools in a day or more frequently of what i normal forthe Individual (WHO definition) + canbe acute (<4 d duration) or chronic (14d duration) Etiology and Clinical Features ‘acute dares * majority of cases are sel limiting + most commonly caused by viral infection (eg. otavicus) * fever and bloody stols increase probability of bacterial infection * consider C. dif infection ifrecent hospitalization, recent antibiotic use age 65, Jmmunosuppression «+ chronic diaehes * most commonly of noninfectious etiology * common causes include drugs (laxatives, antibiotics), infection (bacteria, parasites), inflammation (IBD, diverticulitis), neoplasia colon cancer), malabsorption, maldigestion, TS, and idiopathic Treatment + acute d infecton) «+ chronic diarehes: nonspecific treatment often required before workup i complete * antidiarrheal opiates (e loperamide) - mos eflective nonspecific treatment, * shouldbe used on a scheduled bass before meals rather than PRN * fre (eg, plum) ~ commonly used as adjunctive treatment * oral rehydration solution ~ offet electrolyte imbalances * lfestple and det changes hea: ensure adequate hydration, teat underlying cause (eg, antibiotics for bacterial 1+ 7085 se general practitioners iniily 49% refered to specialists 1 frequency proportional o age commonest complaint of ambulatory patients age 275 Family Medicine FM25 Rete wen Type 2 Dabs ‘heme nosed es heat Sie} + Sesfuc: woah gn at >M26 Family Medicine Diet Tat he seta thes + Py tet sre aston taku sen ore ‘Common Presenting Probleme "Toronto Notes 2012 Differential Diagnosi erin baci ann men ke nd ‘aco saci eda oraves sec) aortas ronesrsn Foxe este oy et” “eal cot rar Paehegne | [Weer ear loupets tate | | ve ‘Diem el nian ‘zat History + clarify typeof dizziness: vertigo, pre-syncope,dsequilrium, lightheadedness + onset, precipitating/lleviating factors, preceding infections and activites, associated symptoms, previous experiences of dizziness + Saati (econ mints hours days, weeks or essen) * worse with head movement or eye closure (vestibular) * no change with bead moverent and eye closure (nonvesibuar) + worse with exerise (cardiac) pulmonary causes) + associated symptoms * neurologic (central) "transient diplopia, dysphagia dysarthria, ataxia (TTA, VBI migraine) ‘+ persistent sensory and/or motor deficits (CNS) + audilogic (peripheral) * hearing os, init, aia, aural fllness + others ‘ nauses, vomiting (peripheral vestibular disorders) + 503, palpitations (hyperventilation, cardiae problem) + general medical history ' HTN, diabetes, heart disease, fainting spells, seizures, cerebrovascular disease, * ototoxic drugs: aminoglycosides (gentamicin, streptomycin, tobramycin), erythromycin, ASA, antimalarials + hypotension (secondary to diuresis): furosemide cafeine, alcohol Physical Exam/Investigations «+ syncopal * cardiac, peripheral vascular, and neurologic exams * bloodwork, ECG, 24h Holter, treadmill stress tes, loop BCG, tilt table testing, carotid and vertebral doppler, BEG + vertiginous * ENT and neurologic exams + Dix-Hallike(se sidebar), consider audiometry and MRI if indicated + non-syncopal, non vertginovs dia and neurologic exams + Sminate hyperventilation tril (patient i coached to hyperventilate until patient becomes ‘izzy to identify ifsymptoms ae reproducible and confirm that hyperventilation isthe etiology ofthe symptoms), ECG, EEG Treatment «guided by history, physical and investigations ‘Include education, lifestyle modification, physical maneuvers (eg, Epley for BPPV), ‘symptomatic management (eg. antiemetics), pharmacotherapy and surgery + refer when significant central disease suspected, vertigo of peripheral origi is persistent {sting >24 wks) or ifatypical presentation‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FM27 Domestic Violence/Elder Abuse INTIMATE PARTNER VIOLENCE ee Definition Srmia nrmntDamete * inches physica, sexta emotional psychological and financial abuse pepe (ee Emergency Medicine, ER28) : a a iecrentton wa Epidemiology S2iieyareaeny + time previence of intimate parizer violence against women s between 25% 30% Steen {women who experience suse have incenied ter of tury death and hen coneequcces i Sean including 507% Increase In gyecologial central nervous sytem stress-related problens «occ inal socioeconomic education and clara! groups with increased incidence in 2. Dayan yar amen at progancy Gib women and 18-24 ae group ke « S-fow chance of hil abuse or neglect i files where partner abuse occurs er! { phyaleunrecopnton rates as ow 25% Chea Presentation Ateea oer? Chet * inp vite wit vague l-dfined complaint such ac headaches, gastrolnestinal symptoms, | Heys ina pate Insonnl; hone pals, hyperventilation vues eguss at «ay ao present wih inj Inconsistent wit history pate Management Shen tat screen ALL patients Phat © eas have high nde of suspicion roe ant {pein ies int psont get dlosare {aocineenetyr + fetth cae vitae an lnportntpporty for physcanstaddesinimateparnervilece_| xan oS and + sting about abuse the strongest predictor of dclosure ciespomesemanneon? welts tes + Several screening tools Se sidebar) exit to identify victims of partner violence eee te *+ make sure to determine the victims level of immediate and long term danger and askif there {te weapons in the house + ensre patent sey * vist most tk for homicide when tempting toleavehome or fllowing separation [€———— On == ‘other emergency tems prepared should the patient need o leave quickly a er 1 Sagem tems peel de the pte aed oe Soiree ee ee en celeron ererccn cae on eee pane rl or te cin eo eo > goals to convey the message that “As your doctor, lam concerned for your safety” and ee meee ae Seetat naa tamrceirmeoneese aspen | -Reitgbeanmts DOSER nag as barren rie me aac ce einen aeuse ee Definition trtemet of ery by toe in potion ts, power o responsi fr ts ce raf be aptnogal(ethesenig, ning ning deme wing information Slinepbempsie thet gary + Saal og tng petro oslo share home, missing pover of atorney) 1 pte C$ hting ening ling in soe prope we apse res Taltoldng or ntsing etic Sal et Epidemiology += 3% of adults In Canada age >65 reported experiences of emotional or financial abuse + ler adits who live with someone are more likely tobe abused than those who live alone + 21 of teported abuse cases involved family members, most often adult children followed by spouses «older females ate more likely tobe abused than older males {men ae more likely than women tobe victimized by an adult child (45% vs. 35%) i ‘+ women are more likely than men to experience violence atthe hands ofa spouse (30% vs. 19%) | 1 eululnanar funy’? (Statistics Canada, 2008) «+ reasons for underreporting: fea, shame, cogoitive impalement, language/cultural barriers and social and geographic isolationM28 Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Screening + insuficient evidence to include or exclude as part of the periodic health examination, but recommended that physicians be alert for indicator of abuee and inte menses to prevent further abuse «general questions such as “Do you feel safe at home?" and move into more specific questions bout diferent kinds of ebuse Presentation + signs that an older adult i being abused may include * depression, feat ansiety, passivity, unexplained injuries, dehydration, malmatrition, poor hygiene, ashes, pressure sores, and over-sedation/inappropriate mediation use ‘Management + gather information from all sources (eg, family members, heath care providers, neighbours) {perform a thorough physical examination + ensure immediate safety and devise a plan for fllow-up 1 Editi stops depend on whether Une pion ccnpt intervention und whether they at ‘apahle of making decisions about thei are + interventions may include use of protective and legal services, senior resource nurses elder abuse intervention teams and senior suppor groups Dyspep: + see Gastoentrlog. 65 Definition and Clinical Features + defined as epigastric pain or dacomfor 1 canbe anole with fulles, belching blasting hestbur, food itleranc, nase or vomiting Epidemiology + annual incidence 1-2%, prevalence 20-40% Etiology + common: functional, peptic ulcer disease, gastroesophageal reflux disease, gates + others cholelithiasis irritable Bowel disease, esophageal or gastric cancer, pancreatitis, [pancreatic cancer, Zellinger-Blison syndrome, and abdominal angina History «symptoms may not be useful in finding cause + association with food, anorexia, nausea, vomiting, NSAID use + symptoms suggestive of underlying pathology weight los, dysphagia, persistent vomiting ‘gastrointestinal bleeding (hematemess, hematocheza) Investigations and Management + empice therapy H receptor blockers, proton pump inhibitors {ating for pyiord serology area reste 4 upper endoscopy (prefered), upper Gt series Dyspnea + ee espimlogy Rnd Eryn Maing E27 History and Physical history cough, sptum, hemoptysis, wheezing, ches pain, palpation, dzsnes, edema 2 Sth allergy. eres, ASAVNSAID sensty, ned polyps + Constttional symptoms + Smoking ecrestional drugs medications + cecopetbend exporn artnet erpeware Gig pty allegon, oke) 1 tevel and beh place 1 Hk of topy + previous CXR or PETS «exam: tal respiratory, precoril, HEENT, sgn of anemiafiverfaiure/hear faire Investigations “CXR ECG 1 PPTs, ABG acutely if indicated ‘Management + ABCE send to Emergency Department iin severe respiratory distress 1 depends on cause‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FM29 Dysuria + ee elogy. US Definition S—_ + the sensation of pin, bring or discomfort on urination Sey ‘ct noton Epidemiology ieee + in adulthood: more common in women than men Rega 1 approximately 25% of women report one episode of acute dysuria per yr Se eter ‘+ most common in women 25-54 yrs of age and in those who are sexually active ees ae 1 inmen, dysura becomes more prevalent with increasing age Fovinmaae 1 hore eee ‘nmarosyesten inectious pei ate "most common cause 1 presente ar ati retrits, pyelonephritis, vaginitis or promaii + nominfctoae "hormonal ondons(hypoestogenam cbtracon (BPH, urethral sce) neoplasms, - > slengicreacionschemicl foreign bodes, trauma Pn i Tob 20. Ellon, ins ad Symptoms of Dyin “Tee ah eer ico Eloy Signs and Symptoms of Dysui ger ein Eley nd epone _Aigrustefen fetes ‘netomat “ Rrotrins ere spay on pe Uveptis Eat sanophyrs Pou ai feracac Keele Possrns, confer wat fea) on + Eel omy dee etite Craton omni, omens, tl i, ure sche ST ae Ca es Vane Coke ala Tso Cream ama sini sage et nen, sop ees en ss ‘epee obama ea eg Protas Ea Cachan Pus Dye cis. uc. ogy dr psa rails Eta Mets Pars Plena S spor Poms mini, neal ui ve his, flak panting gn, actor Kesler CRs rsa erg Investigation: ‘+ no investigations necessary when history and physical consistent with uncomplicated UTI ~ treat empirically (urinalysis can be performed when indicated by dipstick or microscopy) trinlyse/dipticle positive for nitrites and lekocytes urine R&M: pyuria, bacteriuria, hematuria urine C&S if vaginalurethral discharge present: wet mount, Gram stan, KOH test, vaginal pH, culture for yea sind trihiomonas, endocervical or urethral awa for.nochese and C. trachonas radiologic studies and other diagnostic tests if atypical presentation renal US + voiding cystourethrogram (VCUG) in children wth recurrent UTI + see Beatie, P55 for UTT in chilzen ‘Management 1 see FMS2 for antimicrobial treatment 2 UTticysite * pregnant women with bacteriuria (2-75) must be treated even if asymptomatic, de to rsk $f preterm labour; need to fllow with monthly rine cultures and retreat ifstl infected + patients with eeurrent UTIs (>), shouldbe considered for prophylactic antibiotics * if complicated UTI, patients require longer courses of broader spectrum antibiotics + urethets * when swab is postive fr chlamydia or gonorrhea must report to Public Heath 1 pasents should return s-7 d after compleson of therapy for nial evasionM30. Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Epistaxis + see Otolaryngology, OT26 Tile 2, Carats of Anti Past ‘Aatr ) esti (1) neato Ogi weaKessobis os Wot pasphpae tay nae 21000 Us 80 Cannen Case Tuna toc ovina col Stemi ae ee, pra erny clr os UAT aa ayes eric facd Deed are, meats ASA, SAD, ‘Ss cosine, tne von HT howseoss Tenet Caner: Emagen EXTER cot ptr acting ‘Poston et eng ow witht ital wth na aon ett ess er stparf et >On tan Fin wp cata) + Heer ata sl se srs bacticn orate patos Ls es + Sherrie Gaon Nas kg wih sc? gaz, eto sme + Coon rtd sorter onal 0.) ‘este nee se apd ns tslcatywih de ess r>0 in ‘ines 8A oss pe Tey awe) Tsp Hepes Propecs Us stps wih >10minet pseu se Cepia yan vanes Meade hposlons sho ned amply Erectile Dysfunction (ED) + see Uinlogy U30 Definition + consistent or recurrent inability to attain and/or maintain penile erection sucent for sexual performance of 23 months duration Epidemiology + "209% of men aged 40-50% of men aged 70 Etiology + organic: vascular (90%) (arterial insufficiency, atherosclerosis), endocrine (low testosterone, ‘liabetes),anatomie (structural abnormality eg, Peyronie’), neurologic (post-op diabetes), medications (clonsine, antihypertensive, psychotropics) + payehogene (10%) Neenah ta Pectin Saany Loy Peowpalen Sunny Meat i ns TaN History + comprehensive sera medical nd peychoscil history + ime couse Tas satisfactory erection * gradual or sudden onset + attempts at sexual activity + quantify (se Table 22) * presence of morning or night ime erections * Sulfiness (sale of I-10) * ability to initateand maintain an erection with sexual stimulation * erection stiffness during ex (seal of 1-10)‘Toronto Notes 2012 ‘Common Presenting Problems + qualify partner or situation specific * Toss f erection before penetration or climax. 4 degree of concentration required to maintain an erection * percentage of sexual attempts satisfactory to patient and/or hs partner * Significant bends in pens or pain with erection * difcuty with specie positions * Impact an quality of ie and relationship Investigations + hypothalamic pituitary-gonadal axis evaluation: testosterone (tee + total, prolactin, LH + risk factor evaluation: fasting glucose, HbA, lip profile 1 others: TSH, CBC, urinalysis 1 specialized testing * psychological and/or psychiatric consultation * inedepth paychosexual and relationship evaluation * nocturnal penile tumescence and rigidity (NPTR) assessment + vascular dlognostes (eg, doppler studies, angiography) ‘Management Table 23. Management of Erectile Dysfunction Nonphamselpc Pharmacol Sage sa chose Claes as (es, sein ees), ay Aaiontipsouutcowsdig —QAISE mae wah suprstoylor ecto) ay aoe deies Injections «+ pharmacologic treatment * phosphodiesterae type 5 inhibitors (see Table 24) + teadrenerglc blockers (eg, yohimbine) * serotonin antagonist and reuptake inhibitor (eg. trazodone) * testosterone ~currenly only indicated in patients presenting with hypogonadism and testosterone deficiency (note: breast prostate cancer ate absautecontrindications) Table 24 Phosphodiesterase Type §intibitors “Bamps Dig ete) Species “Sie es Conitions er ee Mayloath ingesting ‘eal (Ce*)—520mpine esa 95 toton ssn enti) 2520mpHo% Te hptaiwenuse Asada Asa Eye Complaints «+ See Ophthalmology, OP3 for Vision Loss and Red Eye Falls in the Elderly + see Geriatric Medicine, GM Fatigue Epidemiology + 25% of fie visits to family physicians > peaks in ages 20-10 * omen 34> men + 5085 have associated psychological complaint problems, especially if <6 month dation Family Medicine FM31 ‘ate news ‘ro te verano ‘anes ‘Sitter {Tesi ye a tobe Pater adM32 Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Differential Diagnosi Taha 25, Dilaratinl Diagn of Fatigue: PS VINDICATE er ss nha ete vale Sila 1 lecious log mneucss ts ner og TB yal past NMopasie —— Arymaigazey een Fe enc, 8 een) Naroic Meni rani, tie sees Pinan de D ngs blocs attains, nicole, towed optics 1 Hopatie © Choices CH kg disesso CPD sds alae cori dase (A Adsense SIE RA, nbd tert diese, pm tart Tin ‘Subst abe eg sao hoy ett E_twosine _ ypu, det, Cts setens, ao ni Concur ol Investigations + psychosocial causes are common, so usually minimal investigation is warranted 1 physical eauses of fatigue usualy have associated symptomsigns that canbe elicited from a cused history and physical examination «+ investigations shouldbe guided by history and physical and may includ: * CBC + differential electrolytes, BUN, Cr, ESR, glucose, TSH, ferritin, vit B,» total protein, albumin, AST, ALT, ALR biliubln, calcium, phosphate, ANA, BshCG 1 inal, CXR, ECG + editor esses (Lyme esse hepts Band Cece, HIV, ANA) and PPD ‘Treatment + treat underlying cause + ifetoiogy cannot be identified (1/3 of patients) * reassurance and follow-up, especialy with fatigue of psychogenic etiology + supportive counseling, behavioural, or group therapy * encourage patient to stay physically active to maximize function 1 review all medications, OTC, and herbal remedies for drug drug interaction and side effects * prognosis afte I yr, 40% are no longer fatigued CHRONIC FATIGUE SYNDROME (CFS) Definition (CDC 2006) - must met both criteria |.new or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not relieved by res which results in occupational, educational, socal, or personal dysfunction 2.concurtent presence of at east 4 ofthe following symptoms for «minimum of & months. * impairment of short-term memory or concentation, severe enough o cause signiieant decline in function + sore throat * tender cervical or axillary lymph nodes * muscle pain + mult-join pain with no swelling or redness ‘ew headache * nrefesing sleep + postexertion malaise lasting >24h + exclusion entra medical conditions that may explain the fetiguc, certain paychitricdiorders (Geprssion with psyehotic or melancholic features, schizophrenia, eating disorders), substance abuse, severe obesity (BM >45), Epidemiology + Fo>M, Caucsians> other groups mort in hee 30s 1 ound in cS of pects peoentig wa gue Etiology + unknove, likely multifactorial + may ince infectious agents, immunological factors, neurohormonal factors, and/or ional deficiency‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FM33 Investigations + no specifi agnostic laboratory tests Treatment «promote sleep hygiene 1 provide support and reassurance that most patients improve overtime 1 hon-pharmacological * regular physical activity * optimal dit * psychotherapy (eg, CBT), family therapy, support groups + pharmacological to relieve symptoms: eg antidepressants, ansolytics, NSAIDs, antimicrobial, antilergy therapy: anthypotensiv therapy Fever Differential Diagnosis Table 26. Dtferema Diagnosis of Fever ew 7 ae f= oa ‘pied gts a geet an a Weis Slee Be on saan — > Hi Definition + mean orl temperatr ‘sual 04°C higher + diurnal variation: usually 0.5°C higher at 4PM vs. 6AM * fever = oral temperature >37.2°C (AM), 37.7°C (PM) + fever in children under 2 must bea rectal temperature for accuracy 468°C, unadjusted TM temperature is 0.4°C lower, etal temperature History + fever "peak temperature, thermometer, route ‘time of day * response to antipyretics + systemic symptoms * weight los fatigue ras, arthralgia + symptoms of possible source ‘Uriipyelonephriis dysuria, foul-smeling urine, incontinence frequency, hematuria flank + pneumonia: cough, pleut chest pain + URI cough, corya, ear pain * meningitis headache, confusion stiff neck, rash * osteomyelits: bone pain sie purlentdlcharge + PID: discharge, dyspareunia * gastroenteritis abdominal pain, darthea, blood per rectum, vomit * medications * DVT: swollen legs, pain in al, shortnes of breath, pleurtc ches pain * history of eancer/fmilyhisory of cancer infectious contacts ‘travel history, camping, daycare contact with 8, foodborne, animals Investigations “CBC & differential, blood culture, urine culture, urinate + stool O42 Gram sian, culture 5 CXR, TB skin tet, sputum culture op Management + general sponge bath, ight clothing + acetaminophew ibuprofen as needed + treat underlying causeM34 Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Joint Pain + see Rheumatology RES Differential Diagnosis ‘Table 27. Differential Diognosis of Joint Pain or Arce ‘sear Locaind —__Gewralind Inet Dagens esis From ‘Seopa Pinay Tindote ——Puyryaarhuman + Rhum ais oni bee de Cops { Sytemichnisertemtoss + Osuprtits 1 Seater ‘Rogol tre + Rivest * Spas syntone Seoneptive Seedy ‘kas ris Wenbate {lay ol ese + Henphiiae ‘anes ‘nsec ‘cc ee “rae or sing Pasteont Miva s,s ects History + numberof Joins involved - monoarticulr, oligoaricular, polyarticular + pattern af joints involved ~ symmetrical vs asymmetrical, large vs. smal joints axial skeleton 1 felation to setivty (inflammatory better with activity, degenerative worse) + relation to rest (inflammatory worse with rest, degenerative better) {+ morning stifiness>30 min (inflammatory) + soft tissue selling, erythema (inflammatory) + onset ~ acute vs. chronic (26 wks) 1 trauma, infection, medications (serolds, duet {FH of arthritis + co-morbiites:dabetes mellitus (carpal tunnel syndrome), renal insuficiency (gout), psoriasis (psoriatic arthritis), myeloma (low back pain), osteoporosis (racture), obesity (OA) + constitutional symptoms (neoplasm) + systemic features * fever (SLE, infection) * rash (SLE, prorat arthritis) * pall abnormalities (psoriatic, reactive arthritis) + inylgias(ibromyalgia, myopathy) + weakness (polymyositis, neuropathy) + Gl symptoms (scleroderma, IBD) + GU symptoms (reactive arthritis, gonococcemia) Physical Exam vals 1 speci joint exams + systemic features skin, nal eyes, hands) Investigations + CBC + diferent, PSR, CRP, RE, ANA, HLA-B27, serum uri acid, calcium + urinalysis 1 tise cures Sry + Join aspirate for cell count + differential, culture, Gram stain, mleroscopy‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FM35 Headache + see Neurology N42 Primary Headaches Table 28. Primary Headaches Hageee 7 i Taine FS iii Pts “Bolas nla 2001140 * develops in about 1% of hypertensive patents + hypertensive urgency "SBP >210 or ABP >120 with minimal or no target-ongan damage + hypertensive emergency "high BP + acute target-organ damage‘Toronto Notes 2012 ‘Common Presenting Problems Etiology + essential (primary) hypertension (290%) undetermined caee + secondary hypertension (10%), see Table 29 1 watch for lable, “white cot” hypertension (ffie-induced elevated BP) Predisposing Factors + family history 1 obesity (especialy abdominal) 1 alcohol consumption + stress sedentary lifestyle prey comps be + dyslipidemia. Table 29, Causes of Secondary Hypertension Conan ae al owas HT Feral precy ec, oor pont, paestickiy die Piyponsism Prechonecrnns Cag saan mtn jean of oy case Vasa Comets ct heen Rol sss Drapindced Eiopes Sti sane wae thin Dacometans Coane ___Angetunies Noah Investigations + forall patients with hypertension (D) * CBC, electrolytes, Cr, fasting glucose and lipd profil, 12ead ECG, urinalysis «+ for specific patient subgroups (D) * DM OR renal disease: urinary protein excretion * increasing Cr OR history of real disease OR proteinuria OR HTN resistant to 3 meds OR pretence of abdominal brit: renal ltrasound, captopril renal scan, MRAICTA (B) + ifsuspected endocrine cause: plasma aldosterone, plasma renin (D) * if suspected pheochromocytoma: 24h urine for metanephrines and catecholamines (C) * echocardiogram fr left ventricular dysfunction assessment i indicated (C) Family Medicine FM37 .—— et gomonionses Ft err clan te ‘See pearson ning on 6. Erni eeiing ‘totes Freres Torco tee 9 ‘tne wih Symeetonimete sap ele tocar Fund ater cesta types ose cone! 5 Elenyie oy Gate Recemmendaons ‘av bpencasn Dngecoe enue A Wahe ctinenal 120 Loner titan y sd suted penn 2 tperopiinM38 Family Medicine ethene i sommauente tain ‘ho ey ite dg ‘Spon ‘Common Presenting Probleme "Toronto Notes 2012 Diagnosis yee neyierney —Y— igs of 8140 nye 230 ty 2 reg ig some Sarco ret on daage iow Ms Race and Coal Caesar ik ak amine ‘TivStole + Nesogcal eae Se Nation That feriedmasege Sate [eeiuesion + Fano o {Fan ete steraomee "ets Toe Feepevesoke Ub framipdos it NW) Sud Bad E08 * ‘ogee cant date oe pagan TH han ay ese or 10D 8° 1017890109 mnlg om oF Ansty os Sto lat Presie esting Presare Moning Now hese’ Spats meyer Prisha aPiabenty “FTA omy st Man 28 P00 abt oman ro 10. Approach t Hyperton Aegon tc sey ETS, Treatment + target BP is<140/90 mmblg,<130/80 DM or chronic kidney disease 1 lifestyle modification (In all HTN patients) * may be suficient inpatients with tage 1 HTN (140-159/90-99) diet * follow Canadas Guide to Healthy Eating see Nutrition, FM) and DASH (reduced cholesterol and saturated fats) (B) 4 Tmit daly sodium intake to 65-100 mmol (15-23 g) (8) + potassium/magnesium/caleium supplementations are NOT recommended fr HTN (B) + moderate intensity dynamic exerese: 0-60 min, 4-7 xlwk (D) higher intensity exerelse Is ‘no more effective (D) + smoking cessation * low-risk alcohol consumption (se Aloo, FM10) (8) * achieve and maintain a healthy BMI and waist circumference (C); BP wil decrease by ‘10/28 mm foreach 44g of weight loss; use multidiscplinary approach to weight oss (B) + individualized cognitive behavioural interventions fr stess management (B) «+ pharmacological * indications regardless of age be cautious with fal elderly patients “* dBP 250 mmig with arget organ damage or independent cardiovascular risk factors (A) * ABP 2100 mmiigor «BP 2160 mmllg without target organ damage or cardiovascular risk factors (A) + SHD 2140 with target organ damage * fest in atihypertensives diuretic, ACEI, B-blockr, CCB‘Toronto Notes 2012 ‘Common Presenting Problems * i pata response to standard dose monotherapy, add another first-line drug (©) * caution with combination of non: DHP CCB and blocker (D) * combination of ACEI and ARB ic not recommended (A) * if sil nt controlled or adverse eflets, can ad other classes of an-hypertensives(D) * choice of therapy in patients with unique conditions (se Table 30) «+ most patent will equi combination therapy for optimal contol Follow-Up + assess and encourage adherence to pharmacological and non-pharmacoogial therapy a every visit 1 lifeatye modification > q3-Smonths 1 pharmacological * ql-2monthe until BP under target for 2 consecutive visits * more often for symptomatic HTN, severe HTN, antihypertensive drug intolerance, target ‘organ damage + gismonthe once at target BP. + referral is indicate for cases of reffactory hypertension, suspected secondary cause or ‘worsening renal failure «+ hospitalization sindicatd for malignant hypertension Table 20. Pharmacologic Treatment of Hypertension in Patints with Unique Conditions Family Medicine FM39 —— lage Coe “ensore ‘ose en shysoorn 8s g ow Cambie Aner ACB [><] cB Diuretic intone at cr Teme Oogh Ar Daps Raton inti Desai Tas, ic, Omit ptr tea 509 amyspa apes a et ttc iogac tts Se CenmneAtcsanme | "ake arsed a am seit nc Shamemeasne ett peMT Tie is ABry Cainslitne Smee stinteenaiei Since te ge teu yn Coronary Artery Diseass ACEIcr ARBs (Hbochers for Longacting CCBs, when Shar-acting CUB reine) or (rbrsinerabronarard ates sabe angea—cansin thew ih ACE A se comme tps, ce OPCs Spa! ier lose + ACIARB teat Lonsstn CCB 08 + A coin at fete a) ‘eared et ener eesot fit intl remem Cambodian mio Mrperwoty rermerdaiow oon neces Ses, ‘acre Caras Oise ACL + dtc Conbiaiontedstond ACE + ARB anti sara (eee) saa sia at commande aut Fare C8 AS ACK] ARBn aon ACE. DHP CB nt eae tod oct Hidcrssoide Coy mir ste as Sproeitlasstens i) hea caribou Bary vista eynone Thal craop deo we ACE AE reared 88 erry Dp eesat fet intl emantCanaion cf tnd ‘creer | eons Dabs Metins ACEI AE as te utes, Haun >I80 yl. slay ‘ith Alii arose PBloders, duce euttecoaeees (ick >20.mg/anatin logs Cs Inston dose inte dc tren and>28 ma inane abt Moline ACL ARS, DHPC, or Conan rina dps ADL + ARB coin et witb Abana ai sires Sc tisogetsnt cemented. (erent abo) lated teste lca PCBs Nondbae Chane ACE/ARESACB okt, Conivansl ail ACL + ARB centininisnt Ginoy iene with utes aati Baapy es ‘eared Prin ror breton >800 retiree or > 18890 be, espe W>eardovasesa Rs Sin ASA Caution ita ot ASA pats ‘ross wheres hosel dese pita oie ar Gg Can moa rape ae (ia arses ao ea seagrass Low Back Pain + sce Orthopedics, R22 Definition + acute: <6 wks 1 subacute 6-12 wks 1 eheoni:>12 whe Epidemiology «sth most common reason for visting a physician 1 hfeume prevlence: 909% 1 peak prevalence age 45-60 1 Targest WSIB category + most common case of chronic disability for persons <45 ys old + 908 resolve in 6 wks, <5% become chronic Etiology + source of pain can be local, radicular referred or related toa psychiatric illness 196% mechanical ase * ligamentous/musele strain, act joint degeneration, disc injury, spondylosis, spondylolisthesis, compression fractute, spinal stenoss, pregnancy + orse with movement, improved with rest, + 28 non-mechanical cause * most concerning when pain is worse at rest and does not change with position + surgical emergenctes * auda equina syndrome: low back pai, arflesa, ower extremity weakness, fecal Incontinence, urinary retention, saddle anesthesia, decreased anal tone * neoplastic (primary, metastatic, multiple myeloma) * infetions (osteomyelitis, TB) + metabolic (osteoporosis, osteomalacia, Paget’ disease) + sheumatologic (ankylosing spondylitis, palymyalgia rheumatic) + referred pain (perforated weer, pane is, pyelonephritis, ectopic pregnancy, herpes zoster) Physical Exam + neurologic exam fr [4 15, SI helps determine level of pinl involvement (muscle strength, ‘sensation, reflexes) + peripheral pulses 1 special tests * straight log ase (postive if pin at <7 degrees, aggravated by dorsilxion of ankle), positive testis indicative of siticn + crossed straight leg rise (more specifi raising of uninvolved leg elicits pai in leg with Sciatica) * femoral stretch test (patient prone, knee flexed, examiner extends hip) to diagnose LA radiculopathy‘Toronto Notes 2012 ‘Common Presenting Problems Investigations «plain films not commended in inital evaluation 1 Indications for lamar spine x-ray * no improvement afer I month * fever 38°C * unexplained weightloss * prolonged corticosteroid use * Significant trauma progressive neromotor deficit + Suspicion of ankylosing spondylitis 1 history ofeancer (rue out metastases) * alcohol drug abuse (increased risk of osteomyel + CBC, ESR, urnasis (infection cancer) {bone scan (infection, tumou, occult fracture) TEMG indicated + consider CT or MRI (vorsening neurologic deficits, infection, tumour) trauma fracture) Treatment trance and education ifno underlying serious condition = 70% improve in 2 wks, 90% in 6 ws + recommend comfort measarelconservative treatment * limited bed est (>2-4d bedrest has potentially debilitating eects and no proven efficacy) * staying ative (within limits of pain) leads to more rapid recovery and less chronic disability * activity modification (temporarily avold activites that stress spine, eg. heavy iting, prolonged unsupported sting) + Rest orcold therapies notes for work or WSIB to endorse “modified, appropriate work" vs time of + epee Tut wrk rates * short course of massage may be beneficial + NO proven efficacy of spinal traction, TENS, boleedback, injection (rigger point facet joint or spinal manipulation; ome evidence that acupuncture may be ahepfl adjunct to bother theres + pharmacologial | NSAIDs * muscle relaxants sometimes helpful but may cause drowsiness and are no better than [NSAIDs short term muscle relaxant use <7 d may be help + NOT opioide + no improvement after one month of conservative therapy consider further investigations + rajsand appropriate abs in presence of any red lags «surgical evaluations "rsuspeced cada equina syndrome + worsening neurologic debt * intractable pain not responding to conservative therapy Table 21. Approach to Nonraumatc Low Back Pain Back omit {oa doit (Pon get shove ual et) [Pon geste boo eo) sey Pata Poca 2 Pete 3 ate ‘Wee wien Wrens Pantages witsck ies hac Canadien Neverwosewih —mevenertpston Ings wh nd Seon Carvey ——_pshrcange ‘Avapstemitat cant Ironton deta Physical am Nemaineoeam — Nemstasoean — Lapancaninpwvebit Noise edegs Exiagonke —ingonswithlin rte Somatelss gees th Pete sain e nn ramon Sian ssn ‘Tce sees wth eee were th back poston en Seana ft i pi age aly Patlgy Big om Post conper Seca Nope daeatin inanorsr dss asad pars ‘can iganens sndogder snes) si Studded onumsion Scediedtaion Pens exeson idol xcs Massgonent Lear Liiedecesion Sipe Ze Nigra Ngituntarnt —Notuniaret Lr Suen Neston ss eeatonseqited Nght nb aetna reid edema ete ‘ata ep a av a Pa ge eC Family Medicine EMAL Sj Tr wt i (we ter Gona oe Midd Spat ie Ce eet sng a Semaonbe nea rn Sedna ry nant ‘tenet ‘er a re tres staat aa rater fetus rnwert eevee Fewest reer eaten Pa i Be th ‘Nivedita ‘uta new etre Sparanprcacte ares eee ooh su cre pt ‘eopa tae sea wh (Seat ran See ee ‘Breapnav maar ee ‘press raptaesaaet ‘SebaFMA Family Medicine ‘rps Ppa tt ar Nera 33 Sere to oon ‘Sony rate yes yee ad ‘ese ee 8 Fe i omer yeaa Ire Caney oges [rod anmaoyaomc [neta Pace at pron ‘epost Ure tre th eerie Faeroe atthe ‘Serco aye 2 soto Chi eps pnt ‘arent tae edema {10 rg ey pom ‘nm ee yey ‘stern bet ct ‘pected fe omar anne om —— aT Reino Rese et 2 tl sug ‘coe este rs oe ‘meow | + Poguwere bate lanai (etal erepgsere cnet eee er Sot puch oman ry ees + ee 8 oH) we 1 Ligne 45,1581), $eopre Urner: we ses eo MR ete wrt ‘Common Presenting Probleme "Toronto Notes 2012 Menopause/HRT + see Gynecology, G38 Epidemiology + mean age of menoy yes +a woman will pend over 1/3 of her lifein menopause Clinical Features + urogenital teat ateophy, vaginal dryness, incontinence + blood vessels and heart vasomotor instability, hot lashes, increased risk ofheart disease { bones: bane los, fractures, os of height 1 bain: depression, mood swings, memory loss Management + encourage physical exercise, smoking cessation anda balanced diet with adequate intake! ‘supplementation of acim itamin D (1200 mg/800 1U OD upto 2000 per day) « Rormone replacement therapy (HRD) tne tse of FIRT no Tonge recommended + regimens: yi estrogen + progesterone, cotinuous estrogen + progesterone estrogen only (no werus, estrogen fing, estrogen gel + helps with symptomatic Flt of estogen deprivation * decreases risk of extcoporotc fracture, colorectal eancer * increases risk of breast cancer, coronary heat disease, stroke, and pulmonary embolism + inition of HRT requires a thorough discussion ofeach patient’ history, symptoms and isk factors and of the overall short and longterm benefits and risks 5 reap on treatment general «consider velafuxine, SSR, gabopentn to case vasomotor instability Osteoarthritis oy + sce Rheumatology RES Epidemiology + most common form of arthritis sen in primary care 1 prevalence: 10-12%, increases with 1 fesuts in long-term dssblityin 2-38 of patients with OA 1 almost everyone over the ag@ of 65 shows signs af OA on xray, but only 33% of these willbe symptomatic Clinical Features + pain with weight bearing improved with rst 1 morning stfincss or geling £30 min 1 deformity, bony enlargement, creptus, limitation of movement {usually affects distal ins of hands, spine, hips, and knees Investigations 1p laboratory test forthe dlagnsis of OA 1 radiographic features: joint space narrowing, subchondral sclerosis, subchondral cst, ‘osteophytes Management 1 goal lee pan, preserve joint motion and function, prevent farther injury + Eomservative * patent ection, weight los, exercise (OT/PT, assistive devices (cane, orthotics, ated Sete + pharmacologal "ep in ind co-morbid condos uch a HTN, pec ulcer disease, real disease + mediation do not aler natal course of OA + Ile: acetaminophen 325-1000 mg id en (OA is not an inflammatory disorder) + anne NSAIDs [COX-2 selective NSAIDs (Celebre Mobico) recommended i iong-teren therapy oi igh ik for serous GI problems + combination analgesics ( sestaminopben ani codeine) 4 ntearticular coecosterod injections (act more than 3/1) may be epi in acute fares (benefits lst 4-6 whe, ca be up to 6 190) + Inv ardcular yalarosc ai injections + topical NSAID (Penns?) 1 Capesicin cea (Zoste) * Contider i persistent sgicant pain and functional impairment despite optimal Pharmacotherapy (eg, debridement, osteotomy total joint arthroplasty)‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMA3 Osteoporo: <3 «ve Endocrnlgs a2 ne ‘Hor current guidelines se: worwosteoporsinca 1 age-related disease characterized by decreased bone mass and increased sucepdblitytofractres | Qusemeeges#Y Asset Hist ind Canadian women and {a 8 Canadian men Roreesethren. ee Soe comers wir Tho nbn ea nna ns a fe gi mae canve || | oem brine ‘ian pone S69 ea ans BROT BOSE a ace maa oe : Soe casemate ‘ete rans be dese, —— Faia ‘endorses ieee || Remon aca otek are ‘seston case eee Tete dome | | «ect cen 1 eheocmniycoaea| | ie Pe pea td cy RRC rene a ereeyaae ace Sree Soria cee ae 3 Steeped ope Booctne Canada) ave been vlad i 8 cau Pre + snd a ct Seipmeuno semua ton testo at SSopracacae + + oy tac ik 108) Coyne 205 SB ¥ “eases aon dee? ‘Una to benefit ome > 1 ogy fracture) Gale a moves a acdsee atone en ec ‘me | | oop ==. ae) |. | ee Tedreassessist™ |) | "Aasnonl eta ac by vera Face teen 1950 1200m0 ‘esse oP sem - Fava acinar a Sat emt ab oa Fo << anor ck Peay + Menge nts derion ay o SB LI “eo? ~ ire amity on ot of amon ote pt ef ta oe {Sen 200 (heme tne oc ome SSB ERaw mt 2009 FeSeeT TE ep me Hageniedtoeat sm ‘ane ae aegis Figure 12.2010 Cisial Practice Guidlines forthe Diagnosis and Manayoment of Osteoporosis in (Canada (ntogratd Management Medal. thou 0 Ware ‘Management a + afl pee rogram fr ae tri opmie eet ee 1 Mess ‘Nite a co * wight bearing execs, smoking cesation, decease alcoal intake {totpe omen + det + ean * Toc women without documented osteoporosis cfm and vitamin D supplementation Saori yea, ‘lone prevents osteoporotic rates (grade i recommendation) ee * calcium (1200 mg/d) and vitamin D (400-800 IU/d if <50 yrs, 800-2000 1U/d if eae eee 530 ys) intake in dt or supplements Span sy + pharmacologic Moncratsows ey Isine terapies wth evidence or ate prevention in postmenopausal women tere, ort ‘Sette ote ~ vertebral hip and non-vertebral fractures: bisphosphonates (alendronate, sedronate, zoledronate), monoclocal Al (denosumab), estrogen (fst linen women with ‘menopausal sytptoms) = vertebral factures only: SERM (ralxifene) + bone formation therapy “vertebral and non-vertcbral fractures: PTH (teriparatide) * severe esophagitis the major side effect of bisphosphonate use «HRT, calcitonin: theres far evidence that combined esteogen-progesti therapy decreases the Incidence of total hip and non vertebral fractures; however, for most women the risks may ‘tweigh the benefits (grade D recommendation), see Gynecology, GY.FMA Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 Rash + see Dermatology, tory ome 1 ation oflesions 1 astocated symptoms thing fever, pin 5 iPr azn pene) + tvelistry {bene $ sak contacts ast medial history medications + Fexual history Physical Exam + vale 1 describe lesion (SCALD) Size * Colour (eg. hyperpigmented,hypopigmented, erythematous) * Arrangement (eg, solitary linear, retculate, grouped, herpetiform) * Lesion morphology * Distribution (eg. dermatomal,intertriginous,symmetrcal/asymmetrcal follicular Investigations + depends on history: may include swab of esion, biopsy ‘Management + depends on symptoms and cause of rash 1 refer to dermatologist as needed Rhinorrhea + sce Otolaryngology, 0723 Differential Diagnosis + common col, sinusitis, influenza strep pharyngitis, ear infections, vasomotor hints 4 allergies, contact with substances, Tearing + foreign body + opioid withdrawal {basilar sll fracture Investigations + CRC. throat sah, nasopharyngeal sw, xray injury allergy testing ‘Management «saline nasal rinse + consider medications antihistamines decongestants, corticosteroid nasal spray Sexually Transmitted Infections (STIs) + sce Gynecology. GY27 Definition «diverse group of infections caused by matte microbial pathogens 1 trsnamfed by either secretions or fui from micoalsrfaces Epidemiology Weiah eel + high incidence eats workdwide + Canadian prevalence rates in elinical practice * common: chlamydia, gonorrhea, PID. genital warts, genital herpes (increasing incidence) less common: hepatiisB, HIV and syphilis (both increasing in incidence), tichomoniasis * rare chancroi, lymphogranuloma venereum, granuloma inguiale + genital tact infections (NOT sexually transmitted): vlvovaginal candidiasis (VVC), bacterial ‘vaginosis (BV) + three most common infections associated with vaginal discharge in adult women are BV, VVC, and trichomoniasis, Wha i itt a pra rine‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMAS History + sexual history Teyelof sexual activity and type (oral anal and/or vaginal intercourse) * age of frst intercourse, sexual orientation, sexual activity during travel, * total numberof partnes inthe past yr/monthvk and duration of involvement with each + STIhiswory = STI awareness, previous Ss and testing, partners with previous ST. * contraception history, ast Pap test and results * Toca symptoms suc as genital burning, itching, discharge, sores, vesicles * associated symptoms such as fever, arthralgia, Imphadenopathy * partner communication with regards to STIs Investigations/Seree ‘individuals at increased risk, even those who are asym chlamydia, gonorrhea, HIY, hepatitis B, and syphilis «+ Pap tert ifnone performed inthe preceding [7 months matic should be screened for sone (boron BoC, We aepeuteprsat ‘Some ett ooo ery legen pin fer ore Geter ect aang mnuemarers Rstenseneonnpe sci Specie ‘Management + primary prevention is vastly more efective than treating STs and their sequelae + offer hepatitis B vaceineifnot immune offer Gardasil” to women under age 26 4 aliscuss STI risk ators (eg decreasing the numberof sexual partners), 1 dect advice to ALWAYS se condoms or to abstain from intercourse + condoms not 100% effective against HPY, herpes, genital warts + aSTI patient isnot considered treated until the management of hisfher pares) is ensured (contact tracing by Public Heath) + patients should abstain fom sexual activity uni treatment completion and for 1 month Aflerwards or unt test of cure competed + mandatory reporting chlamydia, gonorrhea, hepatitis B, HIV, syphilis Table 32 Diagnas Teatat Compton ‘Senco rts) Me un nt wlan Mrwie POR wthlowabs Celene 0g PO, age de> ‘tts reed ao Cats ‘yf, wb age forsonand care ongomezcodtestoveis Re? aeqteg nf anotig Vise pnarten) Emapauslendsanicl —— Feooriclousble FU RTuMslescared omens HY cag, dura apa, pal sda vged such wet pat Netra sires ing ean an sai ‘piety Mand ten ayretrat, on Pye ei ‘aoa sygcosincses pisrancy petal ‘epee nse Inc er pein Nonsonaciees! ———77 septate Same asatove tomy 9 Pig + Simos tov UrstiiivCeneis Foyt spay (pmace webvaseavets Rat (Usly amo 26s tar tn un Sir Same ow opasabor ona") Iwgorncel syns ee toe) Maman Pepilona Vins Most asymptotic Nncrendet sis Farce crate, M+ aml cee (gentlest Necatone eons onan cogs ‘eeu ey bokeh Foxveatgnse ‘unin enshivrucosepe) Poul ops fuscia Farcaveldpsas: cascaryandpssle carer alse lesen vison domrdotongadeaisce Mohn sxw M+ F Feniverens ANOOR Ge semen er cea whe ate a ‘eoneieclte ‘pase eau Secreta (eeosen eis rapm oh etry sews Geeta eres ‘eed pid vescncustia Saab el sider cetera ania poy wes, (eset and tla, = tee fara ypespece sevoge Aceon 00 mPO St fr7-104.0R sep menrgs criss, mga antewe, fet nd SV2 Fancsoe 20mg POUL S4OR noe i ing (porated cars vette Vase 100 PO a1 ‘neste uarem epsods kes ose Funai eso shterenuse ye spe mg Pid a gr 3,08, “wage elon 25 mg Dior, OF ‘eyo 20mg PS or 1307 Pt 260% Yoexsa aor gL ser Tamera gst nd hn ante 2g bah be memos nections Spi TS piss se Specimen clecie fon” Bouatin peri Mise depts on nese of scaing Mgorncepathin) — T-tshadtlesympons a ling scent sage) teat launPias asyrecrateindvalgwihseaepe Ney past 12m) rere alge 2 ‘Tenamlje edocs and sphitetng wl Cruse using ncaa oe tow conletas ‘Senegel paper woren pubes semepatie Foto ‘ia eacnisnosee easel ee denim ane sm oer snotFMI6 Family Medicine or Cer sane comecon id par Preity Sms By Sore Acca Ve! Site {hs ton ness rani eta mteveno ee TGerweroneg eyetone te dun paneer SL stegnererin sora ‘novolighorass ce or ‘Common Presenting Probleme "Toronto Notes 2012 + see Otolaryngology, OT24 Definition + inflammation ofthe mucous membranes ofthe nasal cavity and paranasal sinuses, uid within ‘those cavities, and/or the underiying bone Etiology + cssifications: acute: ch wks * ecurent4ormore episodes pe ech ting t ast 10 wth an absence of symptoms * chronic: 212 wks + common pathogens rhinovirus, influenza, parainluenza,S. pneumoniae, H.inuenzae, ‘Mcatarsalis Risk Factors + medical conditions respiratory infections allergic rhinitis cystic ross, immunodeficiency 1 anatomic: deviated septum, paps, adenoid hypertrophy, tumour + initants: environmental tobacco smoke, ait pollution, chiorine cocaine + iatrogenic: topical decongestant overuse, rauma Investigations + radiography s warranted only when the diagnosis of sinusitis isin doubt 1 CT scans are not costeffetve and should not be used routinely to diagnose sinusitis ‘Management 0% of patients wil resolve without antibiotics * oral analgescafatipyretic for painifever * nasal saline rinse ad humiifcation may be beneficial * short-term use of topical or systemic decongestants may be useful adjuncts * antihistamines are contraindicated * antibiotic limited to those diagnosed with acute bacterial sinusitis through history and physical 4 Ist ine: amoxicillin x 10 d (FMP.SMX or doxyeyeine if penicilin allergic) +» 2nd line: amoxil clavulanate clarithromycin azthromyein, cefuroxime + referral to ENT if “failure of second-line therapy ‘24 eplsodes per yr + development of complications (mucocele, orbital extension, meningitis, intracranial abscess, venous sinus thrombosis) Sleep Disorders + se Respumlagy, 2 Definition + most often characterized by one of three complaints: * difculty falling asleep ificulty maintaining sleep, early-morning wakening, rnon-refreshing ep * parasomnias * night terror, nightmares, reste leg syndrome, somnambulism (performing complex behaviour during seep with ees open but without memory of ever) + excessive daytime lepiness Epidemiology 11/3 of patients in primary cate setting have occasional lp problems 110% have chronic sleep problems {more common in women and with increasing age Etiology «primary sleep disorders primary insomnia, obstructive sleep apnea, restless eg syndrome, narcolepsy, periodic lind movements of deep‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMA7 si COPD, ths, CE ype, donk pin, PHL 4 drag alcool calle nesting ragnits andepeaani ee + pyar expecially mood and amet donde. “Heyer shit work Investigations «complet slep diary every morning for 1-2 wks * record beds sleep latency, total sleep time, awakenings, quality of ep + rule out specific medical problems (CBC + difeential, TSH) 1 Seep stay referral if suspect periodic leg movements of lep o sleep apnea + night time polysomnogram or daytime multiple sleep latency test, ‘Treatment «treat any suspected medical or psychiatric cause 1 paychologic treatment * sleep hygiene neni caffeine, nicntine,aenhol: comfortable sleep enironment regular see Schedule; no napping exercise regularly + relaxation therapy: deep breathing, meditation, biofeedback + stimulus coatea therapy re-assocation of bedjbedroom with lep; re-establishment of Consistent lep-wake schedule; reduce activities that cue staying awake + Sep restriction therapy total time in bed should closely match the total sleep time ofthe patient (improves sleep efcacy) + pharmacologic treatment * short-acting benzodiazepines eg lorazepam, oxazepam, temazepam, should be used £7 consecutive nights to break cycle of chronic insomnia Specific robloms + primary insomnia acy ones + peron reo insomnia wih far or anxiety around bode or wih a changin seep Fen can progres tos chron order (pychophysclogalnomni) + rents fom softs vibration atthe back of th nose and throat dus to turbulent ilow through narrowed a pases + rfactor: male gener obesity alcohol consimption, ws of tangzrs or mse ‘east and smoking + physi exam: est as pop, etl deviation hypertrophy of the nasal tbat, Sra enlarged vel and tons + Imesigations ony severe symptomatic nocturnal plsomnogrphy and airway sessment (CUM ee on ie (postion therapy) weight oss {Rul atas (ronnie ed itor made wil asic adhexv backing applied Over nasi, tongue retaining devies, mandibular advancement devices + ari of developing cbtrctie sep snes + obstrctve sleep apes (OSA). apne ning om upper sirway obstruction de to cllape ofthe bse fhe tong, sot alte waited pits ek Feces or Otetrativ Snp os "het wren en + Fespratry efforts present aune + leads toa stint noting choking, awakening ype pattern as body rouses itself to open | * Seefeninpcay airway ~ reauctatvebeah aes aes + Spc episodes can lt fo 20sec to3 man have 100-00 epsoes/ight «aa ym or, + diagnosis based on nocturnal psomography>1s apne epades per our of seep wth | me Sousa recorded + aah coe tment + consequences * daytime vmnolencs, non-reoratve sep 1 palruocta ane porormance, {hood hanges ane rt, depression $ fen dysfcton: por iio, poten { moming headache eo hyperepe) {HTN Gnas is) CAD (x ncesed is) stoke (x nce isk), cytes + Pulmonary hypertension, RY dysfunction cor pulmonale (et chronic hypoxemia) + emory ls decreased concentration, contin + investigations blood pe not hep TH inl indicted 5 eas BP nsec nose, oropharye (for elarged adeno or tol { Socturnalpopomnogephy cep ab) ‘tow hss ae uscelans Fon hrMIS Family Medicine ‘Common Presenting Probleme "Toronto Notes 2012 ‘ modifying factors avoid sleeping supine; weight lss avoid alcohol, sedatives, opioids, ‘nhaled steride i asl eweling present + primary treatment of OSA Is CPAP: maintains patent airway in 959% of OSA cases + dental appliances to modify manelibular position + surgery: somnoplasty, tonsillectomy and adenoidectomy (in children), ‘urulpalatopharyngopasty (UPP?) + report patient to Ministry of Transportation if OSA isnot controlled by CPAP + central sleep apnea * definition. * brain fails wo send appropriate signals tothe breathing muscles to inate respirations ‘dining featre is absent respiratory effort ‘often secondary to CNS diseases: brainstem infarction, infection, neuromuscular disease * investigations: PFs, nocturmal polysomnogeaphy, MRL * treatment: CPAP or mechanical ventilation (if brainstem origin) + prognosis poor ®-z Sore Throat (Pharyngitis) Definition + inflammation of the oropharynx 1 may because by a wide ange of infectious organisms, most of which produce asl imited {infection with no significant sequelae Etiology fet Ragen Paes withSoe | viral Tea ccectymponseogevan |" adenovirus, rhinovirus, infuenza virus, RSV, EBY coxsackievirus, herpes simplex virus, are CMV. HIV + bacterial group A Bchemalytic Steptoe (GARHS) * group Cand G Prhemalyc Streptococcus, Neserla gonorrhea, Chlamydia pnownonla, ‘Mycoplasma pneumoniae, Corynebacterium diphtheriae + most common cause, ocurs year round + bacterial * Group A B-hemolytie Steptococeus “most common bacterial cause + 5-159 of adult cases and up to 50% ofall pediatric cases of acute pharyngitis ‘most prevalent between 5-17 yr ld ‘+ occurs most often in winter months Clinical Features viral * pharyngitis, conjunctivitis, rhinorrhea, hoarseness, cough * nonspecific fu-like symptoms such as fever, malas, and myalgia * often mimics bacterial infection * coxsackievirus (hand, foot and mouth disease) ‘ primarily late summer, carly fal « Sudden onset of fever, pharyngitis, headache, abdominal pan and vomiting + appearance of small vesicles that rupture and ulerteon soft palate, tonsils, pharynx + leer are pale gray, several mm in diameter, have surrounding erythema, may appear on hands and fet * herpes simplex virus ‘like coxsackle virus but ulers are fewer and larger * EBV Infectious mononucleosis) «+ pharyngits tonellar exudate, ever lymphadenopathy, fatigue rath + bacterial * symptoms: sore throat, fever, malaise, headache, abdominal pain, absence of cough + sign: fever, tonsilla or pharyngeal erythema/exudate,swolln/tender anterior cervical nodes + complications ‘rheumatic fever * glomerulonepitis ‘+ suppurative complications (abscess, sinusitis ots medi, pneumonia, cervical adentis) + meningtis + impetigo‘Toronto Notes 2012 ‘Common Presenting Problems Family Medicine FMA9 Investigations + suspected GABHS ee Tale 3 for approach to dagnotis and management of GABHS * god standard for diagnosis is throat culture * rapid test for streptococcal antigen: high specifiy (95%), low seniivity (50-90%) * ifrapd tet positive teat patient + if rapid test negative, take culture and call patient if culture positive to start antbiotis * suspected EBV (infectious mononucleosis) * peripheral blood smear, heterophile antibody test (Le. the latex agglutination assay or Fmonospot”) Table 33, Sore Throat Score: Approach to Diagnosis and Management of GABHS PONTE Tanase? T ey offer 300? 1 “tren? 1 Swot oats a 1 doe3.yst 1 ee ye 0 deu>t6y? 4 ‘ncamunes wit mbes stp acto 10 rhs Seo ° 1 2 7 7 Chacopaiettoscr 238 STRESS N ste Sit tn Nocatuor abit aurea tet Cut al. vs th tio on cafe isos cll yous “Guna irae neste pi oooh lope Deane Uh oe Slated eae cel sept fon i eee axe say no Nd tao UU ‘Management + GABHS (see Table 33) * no increased incidence of rheumatic fever with 48-h delay in treatment * incidence of glomerulonephrits is not decreased with antibiti treatment * antibiotic treatment see Atimicrobial Quick Reference, MSL * routine follow-up and/or posttreatment threat cultures are not required for most patients * follow-up throat culture recommended only for: patients with history of cheumatc fever, patients whose family member has history of acue rheumatic fever, suspected step carrer + seal pharyngitis *anibotles NOT indicated * symptomatic therapy acetaminophen/NSAIDs for fever and muscle aches, decongestants + infectious mononucleosis (EBV) * antibiotics NOT indicated; administering ampicillin produces rash * sellimiting cours; rest during acute phases beneficial * if acute airway obstruction lve corticosteroids, consult ENT. * supportive cae, Le. acetaminophen or NSAIDS for fever, sore throat, malaise * avoid heavy physical activity and contact sports for atleast one month or uni splenomegaly reslves because of isk of splenic rupreMSO Family Medicine Strona SOU aes ‘rea 2 9418829 ‘ioe mere Upadestian paces ieee Foren ‘needa st Secon ‘Shosiyes a ma Uk exami or es ‘arcrarai Sroa tats Em erase ibe wie ee Seong ‘Complementary and Alternative Medicine (CAM) ‘Toronto Notes 2012 eta Cr term (er U Epidemiology + 50-75% of Canadians report some use of CAM oer their ifeime, and only haf wil disclose this use to thei physician + uses highest in Western provinces, lowest in Atlantic provinces + more likely tobe used by Younger patients, those with higher education and income + examples: chiropractic, acupuncture, massage, naturopathy, homeopathy traditional Chinese medicine, craniosacal therapy osteopathy + most commonly ued fr: back/nec problems, gynecological problems, anxiety headaches, digestive problems and chronic ftigue syndromes Herbal Products + ore 50% of Canadians use natural health products + most commonly ued include echinacea, ginseng, ginkgo, gale, St. John's Wo 1 relatively fer herbal products have been shown tobe effective in clinica rials ‘ many patents believe herbal products ae inherently safe and are unaware of potential side fects and interactions with conventional medicines + all natural health products (NHPs) must be regulated under The Natural Health Products Regulations as of January 1,200, including herbal remedies homeopathic medicines, vitamins, mineral, traditional medicines, probiotics, amino acids and estentlfaty aids (eg. omega-3) «always ask patients whether they ae aking any herbal product, herbal supplement or other natural remedy. Purther questions may include * ve you taking any prescription or non-prescription medications for the same purpose as the herbal product? * Are you allege to any plant products? * de you pregnant or breastfeeding? + ofan remureis National Centre fr CAM (wo sccanaiigon), Heals Canada website and soy Table 34, Common Herbal Products ee ES ee nckeokah Wexpasalyapions AUS Hoyts, era, ado Neve opted Ieutinten, ates {ideo horesin bs, vei tens omens Mid stv, anit, lactone caret, Aig, edabes Gamelan cxrmoncals ass Fetigeer Crome wns est, Hes tty Pte warn vito icon coear wipro se, se Innis voring pins Ossnenes acepasa, Hse atineess nase, Arbre sabes footie slrgesccema, dare ry ese sore wea teabat Femfow ——Manesreionherstod Amey seston io Aout, sets sees, efor ‘ad maine Footed Laut nonpusdssareoct Oars Dope wih ter masts tmepe ty t| ssbvecotet cn id as Ge Bewtalics Ipeeson, Gian amat amas, Annas pti Ipdyena, meri may eetsepsopbeedeg yess Giger ue, mots, pein Haun rt bed rN re ‘efor roving sess niyo hake rae pipe cin Al) Hench, camp Haig Aca ts ide ‘owe omit aces, mayest grams os Gru MAD hbo prensa tens vgn of itacmaltenorage Gey ——Enoay enact dese tus, Hyperion rnouses, Sit males, sina searches mnie benno, ayers Perea rece petits tenis hessanine —Ostzaris ‘lds hatch Caan shih ley (Chore) tress aio Sr oto BPH auntie acl éemee eas nae Sildhis Wet ldtonadeaedesion ——‘FRawsosiiynowsed er CNS ees, wih reyes devine ess, ina ren bates Volant Sede ane, mule Dashes each, hte CS dopssnsahistanins lsat PS pros prio so ‘aoa (Ooh hee wa Wn ace Aen Per SEIS Carr Nar sre weer‘Toronto Notes 2012 Primary Care Models/ Antimicrobial Quick Reference Family Medicine MSI et a eM rly Tale 35. Primary Cae Models 4 ‘ampere Model» Mfr FPPin ae pact with ied arbre ality Pet atorsaice Fay eat oom + Gps of athe professions og FP, GPs I Ns tans, socal tas) + Wienges bla, alive ca + Rosia poeld adn ae aa Pama yest: acy tattered epee ona ay Fay Hath Goup + Gop 2 Fs, with seme ars eat ells ncaa phe ath say sees + Pomat no eer snes perio Fay Hath Heoweck + Goin Fy can annus prions, wih phos eth sy esto (pode ube cock pena ca cogs Poy te sysed Fay Heath Orpstion + Sunes FT btu ger sins posal Antimicrobial Quick Reference 9 wth ese afer iy ain Microranisns aii AESPRATORVENT ‘eat ns Wo orig, dein, SY, Ne (conmonco Ia Planes owt) Vink Adrovins Finns Nae Sap Pharmie Grp A Herat Shop Pei ti pen V0 mgd diet ws 105 nae ‘erp (>21 igus aidos) sonnet ag PO 2h 108 ie etre eae rg hgPO ide x8 {eine ctor 1S mph PO id 106 ‘tonyen 2 mgigePO% Sa rac 500m as ‘ste pn V 300m Oe 0 mg bi Od Zales ovine 5 myP0 gd $line ernie 2 mg POM 43 Clatronyen 50mg POBI oe ‘ety rg oc, 250g Sly penn slog eytromysn Shes 5 pean ‘st anon S00 10d Henan Zale: area PO 108 Moses ‘fete 1000 0D x 105 Gu Srp ‘joyln 1g PO bt yen 10mg FOOD 104 Poe "PSNI OS a bi 10s desta apet Sara ‘nena genset erd frets {Hhins lta 0g? oe 1 maha 00m 04318 ‘ewe Oia Meda Vik ‘a wm oe 7 Spruronite 11624 eth wath wot appre pes con ‘hrenae cboeve clio 72h wth appa mea Meats {> 2vonts ovo f werner 92h Soup Srp Ohio Sonus ‘ste ano 20 ml ii ori air 3x Sete 2emaler ost at mal Zales aroxciincanin 089 gig Pi, cp lng care edroinn carom, aren, NSN. as {st most mg P7108 ‘en ave cera, erecta ‘tanyen wi chane ype mere peloton tpn ps bese pan slog cations. stare cramsM2 Family Medicine “Antimicrobial Quick Reference "Toronto Notes 2012 anion Microrarions ‘ei ESPRATORYENT Os tara Pknans ‘Dibatchnmuwconpamiat Sas fect 750 ng POU 4 ng ie oa, et Fm Voewie Neda: sine Bot 23 eps ‘alin Corso sin ops i ‘ymperc mera lc ode psi Boneh Vet Ribs Crean, Abe examnded we bers ‘doo ASV, en, Prachi Spree i etonee Meanie C.prounanoe Commu Aequred Opti wet omatisy Is ares | PO 7-10 rans nr Prous ‘oreuanie Show mezpsa fein ss Mpmarense tne 0 gO gs 7-08 eance tome 00 m0 a (OD mg x18 ‘ranye 50 Ps sn 280g POOD Ar Oupaicwticmeriany 500mg POODX3 = reaanie Mpmarenise Ling dee 209 0 ose the 100m Pid aance SH ts ane g PO .14 Sac sdante 10mg PO -108 eho AXS00mg P07. 108 a £00m PO 7108 Ace act apn sve hs ene a og Cheromysn S00 PO ODD ER OGD 08 ‘an S00 FO ay 50g 0D = exe 10 PO sy ta 100m 0 7.105 Monsters. Tease 10g F0.00x5 rexfoacn 00mPO 007108 Det iectns) Oro Po peta 00m PO gi 7108 Penpals Pardon Sn 20 m1 00 mbit hisses {GASTROENTEROLOGY Dinos rie Sala iit noes oe rte, <3 OTC ey Saino stands. Capac eo osteo oar rn i ed oe Ysa Cerin 5 singe dose 501g FOB 198 Lerten 0g POD 8 Danhva—postaix Cie A roiul0 mg Pix 10144 vercomein (conan win ‘a5s00rg PO galt soee) cinder PepicucerDissase Hp HPs ch crane 301i + (rontSA ad hntrenycnso0mPObd + aoucln 9 POST {nding PL meni S00 mand ornceing POT Oto Bsmt Subsystem etnias 250g earls Omg PO ge Pcl: ntl 0 ng PO + lotro 2mgPOE orapanle Dmg POUT ‘ToT oss Ait <20KE caret oT SA Ecol ‘RSI OS ae POtd 24 Ecbacor Say eal estos MPSA: Emre creo 25 mg PU roe 50 ay Prine Netreton Naot) 100m PO bax sf aly Scape Panu salen 2050 mg PO 7 ain Story Potids 4 anoxia 0 ry PO tx78 ight faceless ncn co. oy afr asap aod NS abou s sass a prrnc er 38 ws‘Toronto Notes 2012 ‘Antimicrobial Quick Reference/References Family Medicine FMS3 ain Microw ‘aio ‘seuTouRmaRY ial Cnet Cons “eat ny pits yt ‘ican 150 mF sige es tne 299 ean = Mensa: Ore apa en 78, cer Haadand Poe Feds human cants pasties 18 ono shat or (Cabs). Pps ‘mens. Reet wi Gemartentianysin grantee ceive 0 mg POsige cee + xtra gFO (ocho sg sor deer 10 mg PO apes pas seg is sey 401 mg FO 20g PO S704 a1 PO B18 anc 25 mgPO ‘ean: 200mg PO scl. ae Bing 8p erent em | Bec! 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