FAMILY MEDICINE

CLERKSHIP HANDBOOK
2015-2016
Department of Family Medicine
Undergraduate Medical Education
University of Ottawa
Authors:
Kimberly Reiter and Sarina Scaffidi Argentina, third year medical students at the University
of Ottawa with a passion for family medicine, updated the handbook for the 2015-2016
academic year to reflect the most recent guidelines. Several medical students at the
University of Ottawa have contributed to updating this handbook in previous years including
Kelly Frydrych and Bonnie Tang. The handbook was originally crafted in 2011 by Stephanie
Ahken, a second year University of Ottawa medical student, as part of the Faculty of
Medicine Undergraduate Summer Studentship program. The handbook has since served as a
valuable resource for all clerkship students rotating through their core family medicine
rotation!

Please Note:
We have made every effort to ensure that the information and references in this handbook are correct at
the time of printing. However errors may be present and web based references may change. Please refer
to the original references whenever possible in making decisions relating to patient care.

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CLERKSHIP HANDBOOK.PDF (1.99MB)

For a comprehensive list of links to resources pertaining to all learning

objectives, please visit the University of Ottawa Department of Family Medicine
Website (Undergraduate Medical Education).
http://www.familymedicine.uottawa.ca/eng/ug_Clerkship-3-year.html
 This handbook is intended as a reference
document to 3rd year medical students
during their family medicine clerkship
rotation. It outlines specific objectives
and includes references to various
resources such as best current practice
guidelines as well as diagnostic and
management algorithms on selected
topics. Content of the handbook is based
on (but not exclusive to) the University of
Ottawa Family Medicine clerkship
learning objectives.

1
Common Problems
Abdominal Pain
Differential Diagnosis by Quadrant 5
Alopecia 6
Asthma
Management of Asthma 7
Asthma Control Criteria 8
BPH
Diagnosis and Management 9
COPD
Pharmacological Treatment 10
Examples of Drugs Used in Asthma and COPD 10
Diabetes
Diagnosis of Diabetes/Dysglycemia 11
Diabetes monitoring and Targets 11
Gestational Diabetes 13
Dizziness/Vertigo
Approach to Dizziness 14
Dyslipidemia
Target Lipid Levels 15
Treatments to Achieve Targets 16
Monitoring Safety Recommendations 16
Dyspepsia/GERD
Investigations of Dyspepsia/GERD 17
Eczema
Atopic Dermatitis Presentation and Management 17
Gout
Treatment of Acute Gout 18
Headaches
Red Flags 19
Hypertension
Non-pharmacological Treatment of Hypertension 20
Hypertension Diagnosis 20
Initial Treatment and Monotherapy 21
Health Behaviour Modifications for Prevention and Treatment 22

2
 Lower Back Pain (Acute)
Red Flags and Assessment 23
Indications for Diagnostic Imaging 24
Otitis Media
Diagnosis and Management Recommendations 24
Osteoarthritis
Indications for Surgical Referral 25
Osteoporosis
Clinical Assessment 25
Pharmacoptherapy 26
Pain
Nociceptive Pain 26
Neuropathic Pain 27
Psychiatry
Depression 27
Anxiety 27
Skin Issues
Antibiotic Management of Common Skin Infections 29
Acne Treatments 30
Red Eye 31

Problems in the Elderly

Elder Abuse
Elder Abuse Suspicion Index (EASI) 32
Falls
Assessment and Management of Falls 33

Health Promotion and Screening

Breast Cancer Screening
Indications for Breast Cancer Screening 34
Cervical Cancer Screening
Recommendations for Cervical Cancer Screening 34

3
Colorectal Cancer Screening
Indications for Colorectal Cancer Screening 35
Periodic Health Examination 36
Skin Cancer Screening
Recommendations for Skin Cancer Screening 38
Smoking Cessation
Smoking Cessation Medications 39
Smoking Cessation Flow Sheet 41

Family Planning
Contraceptive Options 42

Quick Reference Guide

Commonly Used Antibiotics for Primary Care 44
Commonly Used Antivirals for Primary Care 45
Immunization Schedule 46
Developmental Milestones 47
Dermatology Glossary 48
Antenatal Care Timeline 49

4
 Differential Diagnosis by Quadrant
Abdominal Pain

Right Hypochondrium Epigastric Left Hypochondrium

- Gallbladder - Pancreatitis - Spleen
- Liver - Peptic Ulcer Disease - LLL Pneumonia
- RLL Pneumonia - Cardiac (i.e. MI)
Right Lumbar Umbilical Left Lumbar
- Kidney Stone - Abdominal Aortic Aneurysm - Kidney stone
- Renal - Early Appendicitis - Renal

Right Iliac Hypogastric/suprapubic Left Iliac

- Appendicitis - Urinary (UTI) - Diverticulitis
- Gynecological (PID, ovarian) - Gynecological (PID, ovarian) - Gynecological (PID, ovarian)

Irritable Bowel Syndrome

Red Flags • Rome III Criteria
• Acute onset • Recurrent abdominal pain or discomfort for =/> 3 days/
• Fever month over the last 3 months. Symptoms most be
• Nausea/vomiting present for 6 months with at least 2 of the following:
• Hematochezia • Improvement with defecation
• Melena • Change in stool frequency
• Anemia • Change in stool consistency
• Weight loss >10lbs (unintentional) • Investigations
• Change in bowel habits • Celiac antibiodies +/- CBC
• Chest pain • If no red flags, further investigation unnecessary
• No improvement with current management • Treatment
• Family history of colon cancer or IBD • Education and strong therapeutic alliance
• Wakes from sleep • Dietary changes: stool bulking (psyllium, polycarbophils),
increase fluid intake, decrease caffeine and alcohol intake
• Probiotics: bifidobacteria for minimum 4 weeks

Sources:
Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-Hill
Education; 2013.
Kolodziejak L, Schuster B, Reiger L, Jensen B. Irritable bowel syndrome (IBS). RxFiles Drug Comparison
Charts. 8th ed. Saskatoon, SK: Saskatoon Heath Region; 2010; 43.
Wald, A. Clinical manifestations and diagnosis of irritable bowel syndrome. Uptodate. Retrieved from
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-irritable-bowel-
syndrome-in-adults?source=search_result&search=irritable+bowel+syndrome&selectedTitle=2%
7E150. Accessed June 10, 2014.
Wald, A. Treatment of irritable bowel syndrome. Uptodate. Retrieved from
http://www.uptodate.com/contents/treatment-of-irritable-bowel-syndrome-in-
adults?source=search_result&search=irritable+bowel+syndrome&selectedTitle=1%7E150. Accessed
June 10, 2014.

5 COMMON PROBLEMS
 Alopecia

Alopecia
Male-pattern hair loss
• Slow frontotemporal hair loss advancing to vertex and possibly entire
scalp
• Treatment: Minoxidil (Rogaine), finasteride (Propecia), hair transplant
Female pattern hair loss
• Hair thinning in frontal and vertex scalp with sparing of the occipital
region
• Treatment: Minoxidil (Rogaine), Spirinolactone, Cyproterone acetate
(Diane-35), hair transplant
Trichotillomania
• Individuals compulsively pull hair from the scalp or other regions
• Irregular shapes of hair loss with hair at different lengths
Alopecia Areata
• Autoimmune disorder resulting in total hair loss of the scalp but can
also include any body hair
• Spontaneous regrowth can occur but frequent recurrence precipitated
by emotional stress
• Treatment:
• Intra-lesional or topical corticosteroids (Triamcinolone 2.5-5 mg/mL
q4-6 weeks for 6 months)
• Topical immunotherapy
• For extensive scalp involvement
• Most effective
• Performed by Dermatologists
Cicatricial (scarring) Alopecia
• Irreversible hair loss
• Physical: radiation, burns
• Infections: fungal (tinea capitis), bacterial (cellulitis), viral (HSV), TB,
leprosy
• Inflammatory: lichen planus, discoid lupus erythematosus
• Treatment:
• Treat underlying infection
• Intra-lesional or topical steroids

Sources:
Messenger, AG, McKillop, J, Farrant, P, McDonagh, AJ, Sladden M. British Association of
Dermatologists’ guidelines for the management of alopecia areata. British Journal of Dermatology.
2012; 166:916
Price VH. Treatment of Hair Loss. New England Journal of Medicine. 1999;341:964-73
Shapiro, J., Otberg, N., Hordinsky, M. Evaluation and Diagnosis of Hair Loss.(http://www.uptodate.
com/contents/evaluation anddiagnosis-of-hairloss?source=search_result&search=alopecia&selected
Title=1%7E150
Woodford, C, Yau C. Toronto Notes – Comprehensive Medical Reference & Review for MCCQE I and
USMLE II. Toronto, Canada: Toronto notes for Medical Students Inc; 2013.

COMMON PROBLEMS 6
Asthma

Very mild, intermittent asthma may be treated with fast-acting beta2-agonists taken as needed.
Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for
asthma, even in individuals who report asthma symptoms less than three times a week. Leukotriene
receptor antagonists (LTRAs) are second-line monotherapy for mild asthma. If asthma is not adequately
controlled by low doses of ICS, additional therapy should be considered. In children six to 11 years of age,
the ICS should be increased to a moderate dose before an additional agent such as a long-acting beta2-
agonist (LABA) or LTRA is added. In children 12 years of age and over, and adults, a LABA should be
considered first as add-on therapy only in combination with an ICS. Increasing to a moderate dose of ICS or
addition of a LTRA are third-line therapeutic options. Theophylline may be considered as a fourth-line agent
in adults. Severely uncontrolled asthma may require additional treatment with prednisone. Omalizumab
may be considered in individuals 12 years of age and over with poorly controlled atopic asthma despite high
doses of ICS and appropriate add-on therapy, with or without prednisone. Asthma symptom control and
lung function tests, inhaler technique, adherence to asthma treatment, exposure to asthma triggers in the
environment and the presence of comorbidities should be reassessed at each visit and before altering the
maintenance therapy. After achieving proper asthma control for at least a few weeks to months, the
medication should be reduced to the minimum necessary to achieve adequate asthma control. HFA
Hydrofluoroalkane; IgE Immunoglobulin E; mcg Micrograms; PEF Peak expiratory flow; yrs Years

Source: Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in
preschoolers, children and adults (http://www.respiratoryguidelines.ca/sites/all/files/2012_cts_asthma_
guideline.pdf). This information was originally published in Can Respir J 2012;19(2):127-164.

Note: For a list of examples of drugs used in Asthma, see Examples of drugs used in Asthma and COPD on
p.10

COMMON PROBLEMS
7
 Asthma Control Criteria

Asthma
Alopecia
Characteristic Frequency or value

Daytime symptoms <4 days/week

Nighttime symptoms <1 night/week
Physical activity Normal
Exacerbations Mild, infrequent
Absence from work or school due to asthma None
Need for a fast-acting beta2-agonist <4 doses/week
FEV1 or PEF ≥90% personal best
PEF diurnal variation* <10% to 15%
Sputum eosinophils† <2%–3%

*Diurnal variation is calculated as the highest peak expiratory flow (PEF) minus the lowest
divided by the highest peak flow multiplied by 100 for morning and night (determined over
a two-week period). †Consider in adults with uncontrolled moderate to severe asthma
who are assessed in specialist centres. FEV1 Forced expiratory volume in 1s.

Source: Canadian Thoracic Society 2012 guideline update: Diagnosis and management of
asthma in preschoolers, children and adults
(http://www.respiratoryguidelines.ca/sites/all/files/2012_cts_asthma_ guideline.pdf). This
information was originally published in Can Respir J 2012;19(2):127-164.

COMMON PROBLEMS 8
 Benign Prostatic Hyperplasia (BPH)
BPH

Diagnostic Algorithm
History Symptom severity and level of bother
Formal symptom inventory (ie. International Prostate Symptom Score)
PMHx, prior surgery, trauma, medications (including OTC)
Physical examination DRE
Investigations Urinalysis (to rule out diagnoses other than BPH that may cause LUTS)
PSA level (in patients with at least 10-year life expectancy and when knowledge of prostate
cancer would change management)
Therapeutic Algorithm

Lifestyle Modifications
Periodic physician-monitored visits
Fluid restriction prior to bedtime
Avoidance of caffeinated beverages and spicy foods
Timed or organized voiding (bladder retraining)
Pelvic floor exercises
Prevention/treatment of constipation
Pharmacotherapy
Drug Mechanism of Action
Alpha blockers -Relax smooth muscle in/around prostate and bladder neck without
Alfuzosin (UroXatral) 10 mg PO daily affecting the detrusor muscle.
Doxazosin (Cardura XR) 4-8mg PO daily -Do not alter natural progression of the disease.
Tamsulosin (Flomax) 0.4mg PO daily
(may increase to 0.8mg PO daily after 2-4
weeks if inadequate response)
Terazosin (Hytrin) 1 mg PO QHS
(may increase to 5 mg PO QHS)
5 alpha-reductase inhibitors -Inhibit conversion of T to DHT resulting in decreased prostate size and
Dutasteride (Avodart) 0.5 mg PO daily increased peak urinary flow rates.
Finasteride (Proscar) 5 mg PO daily -Reduce the risk of acute urinary retention (AUR) and need for surgical
intervention
Combination therapy
Dutasteride/tamsulosin (Jalyn) 0.5mg/0.4mg

* TURP remains the gold standard treatment for patients with bothersome moderate or severe LUTS who request
active treatment or who either fail or do not want medical therapy
Source: Canadian Urological Association 2010 Update: Guidelines for the management of benign prostatic hyperplasia

9 COMMON PROBLEMS
 COPD
Pharmacological Treatment

COPD
Source: CTS recommendations for management of COPD 2008 – highlights for primary care
(http://www. respiratoryguidelines.ca/sites/all/files/CTS_COPD_Highlights_2008.pdf). This
information was originally published in Can Respir J 2008; 15 (Suppl A): 1A-8A.

Examples of Drugs Used in Asthma and COPD

Drug class Common names Side Effects

SABA (Short-acting Beta-agonist) Salbutamol (Ventolin) Fast heartbeat, irregular
Terbutaline (Bricanyl) heartbeat, irritability (feeling
LABA (Long-acting Beta-agonist) Formoterol (Oxeze) cranky), difficulty sleeping,
Salmeterol (Serevent) muscle cramps, shaky hands

ICS/LABA (Combination inhaled Advair (Flovent + Serevent) Shaky hands, fast heartbeat,
corticosteroid and long-acting Symbicort (Pulmicort + Oxeze) thrush, sore throat, hoarse
Beta-agonist) voice
Theophylline (Uniphyll, TheoDur, Phyllocontin, Nausea, heartburn,
TheoLair) restlessness, fast heartbeat
ICS (Inhaled corticosteroid) Budenoside (Pulmicort) Hoarseness, sore throat, thrush
Fluticasone (Flovent) or yeast infection
LTRA (Leukotriene receptor Zafirlukast (Accolate) Headache, dizziness, heart-
antagonist) Montelukast (Singulair) burn, upset stomach, tiredness
Anticholinergics Ipratropium bromide (Atrovent) Dry mouth, urinary retention
Tiotropium (Spiriva)
Sources: 1. Canadian Lung Association (2010). Medications for COPD. (http://www.lung.ca/diseases-
maladies/copd-mpoc/treatment-traitement/medications-medicaments_e.php. athme/treatment-
traitement/medications-medicaments_e.php)

COMMON PROBLEMS 10
 Diagnosis of Diabetes/Dysglycemia
Diabetes

Test Result (mmol/L) Diagnosis

Fasting Plasma Glucose (fasting 6.1-6.9 Impaired Fasting Glucose
for 8 hours) >/= 7.0 Diabetes

2h Plasma Glucose in a 75g Oral 7.8-11.0 Impaired Glucose Tolerance

Glucose Tolerance Test >/= 11.1 Diabetes
6.0-6.4 Pre-diabetes
HbA1C
>/= 6.5 Diabetes
Random Plasma glucose >/= 11.1 Diabetes
Symptomatic plus one of the above = diagnosis
• If asymptomatic a repeat confirmatory test (fasting, 2h OGTT, HbA1C) in
addition to one of the above = diagnosis
• Screen in individuals >40 q3years or earlier and more frequently if at high risk
Diabetes Monitoring and Targets
Factor Monitor Target
Proper glucose meter use, ability to Pre-meal (mmol/L) = 4.0-7.0
Self Monitoring
understand results and adjust 2hr Post-meal (mmol/L) = 5.0-10.0 or 5.0-
of Glucose
treatment 8.0 if not achieving A1C target

A1C testing q 3 months

Blood Glucose • consider q 6 months when lifestyle
A1C ≤7.0% for most adults
Control and glycemic targets have been
consistently met

Ask about hypoglycemic episodes every

appointment.
Hypoglycemia Avoidance of hypoglycemia
Educate on signs, symptoms, and
treatment hypoglycemia

Hypertension Measure BP at diagnosis and every visit <130/80

Baseline ECG Vascular protection is the first priority in prevention of

ECG q 2 years if : diabetes
• >40 years complications
A – A1C: </= 7%
• >30 years and DM >15 years
• In elderly, hypoglycemia unawareness:
• end organ damage </= 8.5
• cardiac risk factors B – Blood pressure: </= 130/80
C – Cholesterol: LDL-C < /= 2 (if treating)
CAD risk assessment: D – Drugs for cardiovascular protection
• ACE-I or ARB
Coronary Artery • CV history
• age ≥55 years
Disease • Lifestyle • macrovascular disease
• Duration of DM • microvascular disease
• Sexual function • Statin
• Abdominal obesity • age ≥40 years
• macrovascular disease
• Lipid profile
• microvascular disease
• BP • DM >15 years and age >30
• Glycemic control • ASA if indicated
• Retinopathy E – Exercise
• Kidney function S – Smoking cessation

11 COMMON PROBLEMS

Baseline fasting lipid profile (TC, HDL, TG, LDL)
Dyslipidemia then yearly
If treating, more frequent monitoring required
Diabetes
Lipid targets for those being treated:
• LDL ≤2.0 mmol/L or ≥50% reduction
• apo B ≤0.8 g/L or non-HDL-C ≤2.6
mmol/L

Screen for:
• proteinuria with random urine ACR
(2 out of 3 samples over 3 months)
AND
Chronic Kidney • renal function with serum Normal ACR <2.0 mg/mmol
Disease creatinine/eGFR. Normal eGFR >60 mL/min
Type 1 diabetes
• at 5 years duration then yearly
Type 2 diabetes
• at diagnosis then yearly

Screening by an eye care professional

Type 1 diabetes
• 5 years after diagnosis then yearly
Retinopathy Type 2 diabetes Early detection and treatment
• At diagnosis then repeat 1-2 years
later
• Follow-up interval will depend on
degree of retinopathy

Screen with 10-g monofilament or 128

Hz tuning fork at great toe dorsum
Early detection and treatment.
Type 1 diabetes
• 5 years after diagnosis then yearly
If neuropathy present: foot care education, proper
Neuropathy footwear, smoking cessation
Type 2 diabetes
• At diagnosis then yearly
If ulcer present: multidisciplinary team required
(wound care, infectious disease)
Foot physical exam: structural abnormalities,
neuropathy, vascular disease, ulceration,
infection
Central obesity:
Waist
Indicator of abdominal fat WC: ≥102cm in males, ≥88cm in females
Circumference
(North America)
Body Mass Index Calculate BMI kg/(ht2) 18.5-24.9

Follow Eating Well with Canada’s Food

Nutrition Nutritional therapy by registered dietician
Guide

Encourage and determine amount of aerobic Aerobic: ≥150 minutes /week

Exercise
and resistance exercise Resistance: 3 sessions/week
Diabetes

COMMON PROBLEMS 12
 s
Diabete
Diabetes

Gestational Diabetes

• Screen all pregnant women at 24-28 weeks gestation with 50g glucose
challenge
• Screen at any stage of pregnancy if high risk
• previous diagnosis of GDM, prediabetes, >35 years,
BMI>30, PCOS,
acanthosis nigricans, corticosteroid use, hx of macrosomic infant,
current
fetal macrosomia or polyhydramnios, high risk
population including
aboriginal, Hispanic, south Asian, Asian, and African
• 50g glucose challenge and measure plasma glucose (mmol/L) 1 hour
later
• <7.8 → Normal → reassess at 24-28 weeks gestation if measured
earlier
• 7.8-11.0 → 75 g oral glucose tolerance test
• Fasting plasma glucose >/= 5.3
• 1hour plasma glucose >/= 10.6
• 2 hour plasma glucose >/= 9.0
• any of the above → Gestational Diabetes
• >11.1 → Gestational Diabetes

Sources:
Canadian Journal of Diabetes. 2013 Clinical Practice Guideline – Diabetes and Pregnancy.
Retrieved from http://guidelines.diabetes.ca/executivesummary/ch36
Canadian Journal of Diabetes. 2013 Clinical Practice Guidelines - Quick Reference Guide. Retrieved
from http://guidelines.diabetes.ca/CDACPG_resources/CPG_Quick_Reference_Guide_WEB.pdf
Canadian Journal of Diabetes. 2013 Clinical Practice Guideline – Sample Diabetes Care Flow Sheet
for Adults. Retrieved from http://guidelines.diabetes.ca/CDACPG_resources/Diabetes_Care_Flow_
Sheet_for_Adults_Fillable_Saveable.pdf
Cheng, AYY., et al. Clinical Practice Guidelines 2013. Canadian Journal of Diabetes, 2013; 37.
Retrieved from http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_
en.pdf

13 COMMON PROBLEMS
 Dizziness/Vertigo
Approach to Dizziness

Source: Post, R.E., & Dickerson, L.M. (2010) Dizziness: A Diagnostic Approach. Am Fam Physician, 82(4),
361-368. (http://www.aafp.org/afp/2010/0815/p361.html)

COMMON PROBLEMS 14
 Target Lipid Levels
Dyslipidemia

Primary targets
Risk Level Initiate treatment if:
LDL-C Alternate
HIGH
CAD, PVD, atherosclerosis apoB ≤ 0.80g/L
<2 mmol/L or
Most patients with diabetes Consider treatment in all patients Non-HDL-C ≤ 2.6
≥ 50% ↓ LDL-C
FRS ≥ 20% mmol/L
RRS ≥ 20%

LDL-C > 3.5 mmol/L

apoB ≤ 0.80g/L
MODERATE For LDL-C < 3.5 consider if: <2 mmol/L or
Non-HDL-C ≤ 2.6
FRS 10-19% Apo B ≥ 1.2 g/L or Non-HDL-C ≥ 4.3 ≥ 50% ↓ LDL-C
mmol/L
mmol/L

LOW LDL-C ≥ 5.0 mmol/L

≥ 50% ↓ LDL-C
FRS < 10% Familial hypercholesterolemia
FRS = Framingham Risk Score
RRS = Reynolds Risk Score

Source: 2012 Update of the Canadian Cardiovascular Society guidelines for the diagnosis and
treatment of dyslipidemia for prevention of cardiovascular disease in the adult –
http://www.onlinecjc.ca/action/showFullTextImages?pii=S0828-282X%2812%2901510-3)
This article was published in Can J Cardiol, Volume 29 (2), TJ Anderson, J Gregoire, RA Hegele, et al.,
Update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia
for prevention of cardiovascular disease in the adult, p. 151-167, Copyright Elsevier
(2012)

15 COMMON PROBLEMS
Dyslipidemi

Treatments to Achieve Targets

Dyslipidemia
Targe First-Line Medication
t
LDL-C Lifestyle + Statin
a

Consider adding second line-medication :

- bile-acid sequesterant, or
- cholesterol absorption inhibitor, or
- Niacin (Niaspan or generic crystalline)
HDL-C Lifestyle: smoking cessation, weight loss (BMI<25), exercise (30-60 min/d),
moderate alcohol intake
Niacin or fibrate* (less effective) + Statin (for LDL-C)
Triglycerides Lifestyle: weight loss (BMI<25), exercise (30-60 min/d), restrict refined
carbohydrates, reduce alcohol intake, increase omega-3 fatty acids
if TG > 10 mmol/L: Fibrate* (to reduce pancreatitis risk)
if TG 5-10 mmol/L: Fibrate* or omega-3 fatty acid
if TG 2-5 mmol/L on statin, and high risk: add fibrate* or niacin
hs-CRP Statin

*Fenofibrate recommended in combination with statin therapy; less risk of myotoxicity

compared to gemfibrozil
Source: Saskatchewan Drug Information Services, College of Pharmacy and Nutrition, University of
Saskatchewan, Volume 27, Issue No.2
(http://www.druginfo.usask.ca/pdf/Dyslipidemia_Guidelines_FULL.pdf)

Monitoring Safety Recommendations

Baseline Fasting lipid panel
Glucose
TSH (as hypothyroidism contributes to hyperlipidemia)
Liver function
Creatinine
CK
apoB and apoA1 (if targeting as treatment goals)

Follow-up Repeat liver function tests and CK every 6-12 months, with any change in
measurements lipid therapy, and in the event of symptoms
Niacin ALT at baseline and 1 and 3 months after initiation
Fasting glucose and A1C every 6-12 months
Uric acid
Fibrates May increase serum creatinine
Start with lowest dose and increase after follow-up measurements of
creatinine and lipids
Source: Saskatchewan Drug Information Services, College of Pharmacy and Nutrition, University of
Saskatchewan, Volume 27, Issue No.2
(http://www.druginfo.usask.ca/pdf/Dyslipidemia_Guidelines_FULL.pdf)

COMMON PROBLEMS 16
Dyspepsia/GERD

Investigations of Dyspepsia/GERD
Recommendations for the Investigation of GERD
1. Recognize the archetypal symptoms of GERD: heartburn and acid regurgitation
2. Look for alarm features: vomiting, evidence of GI blood loss, anemia, involuntary weight loss,
dysphagia or chest pain
3. Do not endoscope routinely to diagnose GERD
4. Use endoscopy to:
- Investigate atypical or alarm features
- Detect Barrett’s esophagus
- Investigate dysphagia that has not resolved with 2-4 weeks of adequate PPI therapy
- Determine severity of erosive esophagitis (look for erosions or mucosal breaks)
5. You do not need to test for H. pylori before starting treatment for typical GERD symptoms
Source: Ontario Guidelines Advisory Committee (2007). Gastroesophageal Reflux Disease (GERD) in Adults.
Ref. #248 (http://www.gacguidelines.ca/site/GAC_Guidelines/assets/pdf/GERD05_Summary.pdf)
Eczema

Dermatitis (Eczema)
 Inflammation of the skin
 Various types: Atopic dermatitis, asteatotic dermatitis, contact dermatitis,
nummular dermatitis, seborrheic dermatitis, dyshidrotic dermatitis, stasis
dermatitis
 Clinical presentation:
- pruritus, pain
- acute: papules, vesicles
- subacute: scaling, crusting
- chronic: lichenification, xerosis, fissuring

Atopic Dermatitis: most common type of eczema

 Clinical presentation: subacute and chronic eczematous reaction associated with prolonged
severe pruritus distribution
 Distribution:
- Infant (2-6 mo): face, scalp, extensor surfaces
- Childhood (>18 mo): flexural surfaces (especially antecubital fossae, popliteal fossae and
neck)
- Adult: hands, feet, flexures, wrists, face, forehead, eyelids, neck
 Associated with personal or FHx of atopy
 Investigations: Clinical diagnosis
 Management:
- Enhance barrier function of the skin:
o Regularly apply moisturizers, avoid stressors and irritants
- Anti-inflammatory therapies:
o Topical corticosteroids
 Effective rapid symptomatic relief of acute flares

17 COMMON PROBLEMS
  Side effects: skin atrophy, purpura, striae, steroid acne
o Topical immunomodulators:
 Long-term management
 Calcineurin inhibitors (i.e. tacrolimus, pimecrolimus)
 Side effects: transient irritations, skin burning
- Complications  infections
o Antibiotics:
 Topical mupirocin or fusidic acid
 Oral antibiotics (i.e. cephalexin) for widespread S. aureus
infections

Source: Canadian Dermatology Association (2015). Eczema. http://www.dermatology.ca/skin-hair-

nails/skin/eczema/#!/skin-hair-nails/skin/eczema/dealing-with-dry-skin/
Woodford, C, Yau C. Toronto Notes – Comprehensive Medical Reference & Review for MCCQE I and
USMLE II. Toronto, Canada: Toronto notes for Medical Students Inc; 2013

Gout
Treatment of Acute Gout
Step-wise Approach to the Treatment of Acute Gout

1. Confirm the diagnosis

- monosodium urate crystals in synovial fluid
- classical arthritis in patients with history of crystal-proven gout
2. Evaluate for NSAID risk factors
- Age > 65 years (relative risk factor)
- CrCl < 50 mL/min (0.84 mL/s)
- Poorly compensated CHF
- History of or active PUD
- Anticoagulation therapy
- Hepatic dysfunction
3. If no risk factors, treat with NSAIDs, colchicine or systemic corticosteroids within 24 hours of
onset
- Certain combinations can be employed for severe or refractory attacks
4. If NSAID risk factors, assess number of joints involved.
- If only 1 joint is involved and joint is accessible to injection, consider intra-articular
corticosteroid injection
- If more than 1 joint is involved, consider contra-indications to steroids
5. Patient education: including diet and lifestyle modifications (weight loss, smoking cessation,
increase exercise, avoid high-purine meats, avoid alcohol overuse)
6. Consider pharmacologic anti-inflammatory prophylaxis for all gout patients when
pharmacological urate lowering is initiated (i.e. Xanthine oxidase inhibitor with either allopurinol
or febuxostat)
- Target urate lowering: serum urate level should be lowered < 5-6 mg/dl
- Oral colchicine
- Low-dose NSAIDs
Source: Harris, M.D., Siegel, L.R., & Alloway, J.A. (1999). Gout and Hyperuricemia. Am Fam Physician,
59(4), 925-934. (http://www.aafp.org/afp/990215ap/925.html)
Khanna, D., Khanna P.P., Fitzgerald J.D., et al. (2012). 2012 American College of Rheumatology
Guidelines for Management of Gout. Part 2: Therapy and Anti-inflammatory Prophylaxis of Acute Gouty

COMMON PROBLEMS 18
 Arthritis. Arthritis Care & Research, 64 (10), 1447-1461
Gout

Khanna, D., Fitzgerald J.D., Khanna P.P., et al. (2012). 2012 American College of Rheumatology
Guidelines for Management of Gout. Part 1: Systemic Non-pharmacological and Pharmacological
Therapeutic Approaches to Hyperuricemia. Arthritis Care & Research, 64(10), 1431-1446

Headaches - Red Flags

Headaches

Red Flags Differential diagnosis Possible work-up

Headache beginning after Temporal arteritis ESR, neuroimaging

50 yearsonset
Sudden of ageheadache Mass lesion hemorrhage
Subarachnoid Neuroimaging

Pituitary apoplexy hemorrhage into a mass LP if neuroimaging negative

Headaches of increasing lesionlesion

Mass or vascular malformation Neuroimaging, drug screen
frequency and severity
Mass lesion
Subdural (esp. posterior fossa mass)
hematoma
New-onset headache in a Meningitis (chronic or carcinomatous) Neuroimaging
patient with risk factors for Medication
Brain overuse
abscess (incl. toxoplasmosis)
HIV or cancer Metastasis LP if neuroimaging negative
Headache with signs of Meningitis Neuroimaging, LP, serology
systemic illness (fever, stiff Encephalitis
neck, rash) Lyme disease

Systemic infection
Focal neurological signs or Mass lesion Neuroimaging, collagen
symptoms of disease (other Collagen vascular disease vascular evaluation (including
than typical aura) Vascular malformation antiphospholipid antibodies)

Papilledema Strokelesion
Mass Neuroimaging, LP
Pseudotumor cerebrii
Meningitis
Collagen vascular disease
Headache subsequent to Intracranial hemorrhage Neuroimaging of brain, skull
head trauma Subdural hematoma and possibly cervical spine
Epidural Hematoma

Post-traumatic headache
Source: Clinch,C.R.(2001). Evaluations of Acute Headaches in Adults. Am Fam Physician,
63(4),685-693. (http://www.aafp.org/afp/2001/0215/p685.html)

19 COMMON PROBLEMS
 Hypertension
Non-pharmacological Treatment of Hypertension
Recommended Lifestyle Changes for Patients
with Hypertension

Reduce foods with added sodium < 2300 mg /day

Weight loss BMI <25 kg/m2
Alcohol restriction < 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist circumference Men <102 cm; Women <88 cm

Source: Hypertension Canada. 2012 Canadian Hypertension Education Program (CHEP)

Recommendations: Treatment
(http://www.hypertension.ca/images/2012_CHEP_Treatment_EN_Apr30.ppt). Re-printed with
permission of the Canadian Hypertension Education Program.

Hypertension Diagnosis

 Reprinted with permission of the Canadian Hypertension Education Program

 Preliminary investigations of patients with hypertension: Urinalysis, Blood chemistry
(potassium, sodium and creatinine), Fasting blood glucose and/or glycated
hemoglobin (A1c), Fasting total cholesterol and high density lipoprotein cholesterol
(HDL), low density lipoprotein cholesterol (LDL), triglycerides, Standard 12-lead ECG
 Target BP < 140/90

COMMON PROBLEMS 20
 Initial Treatment and Monotherapy for Hypertension
Hypertension

Lifestyle modification AND

 Thiazide/Thiazide-like Diuretic OR
o Example: Hydrochlorothiazide 12.5mg PO daily
 ACE-I OR
o Contraindicated in pregnancy, caution in women of child bearing
age
o Example: Ramipril 2.5mg PO daily
 ARB OR
o Contraindicated in pregnancy, caution in women of child bearing
age
o Example: Losartan 25mg PO daily
 CCB OR
o Example: Amlodipine 5mg PO daily
 Beta-blocker
o Not indicated as first line therapy for age > 60
o Example: Metoprolol 50mg PO BID, Atenolol 50mg PO daily

A combination of two first-line drugs may be considered as initial therapy if the blood
pressure is ≥ 20 mmHg systolic or ≥10 mmHg diastolic above target.

21 COMMON PROBLEMS
 Hypertension
Health Behaviour Modifications to Prevent and Treat
Hypertension
Estimated BP
Objective Recommendation Comment
Reduction

An accumulation of 30-60 minutes of

dynamic exercise of moderate intensity (such
as walking, cycling, swimming) four to seven Should be prescribed
days per week in addition to the routine to both hypertensive
Being More activities of daily living. Higher intensities of and normotensive
exercise are no more effective at BP lowering
Physically but may produce other cardiovascular
individuals for -4.9/-3.7 mmHg
Active benefits. For non-hypertensive or stage prevention and
1 hypertensive individuals, the use of management of
resistance or weight training exercise (such as hypertension.
free weight lifting, fixed weight lifting, or hand
grip exercise) does not adversely influence BP.

Encourage
A healthy BMI (18.5 -24.9 kg/m2) multidisciplinary
and waist circumference (<102 cm approach to weight -7.2 I -5.9 mmHg for
Weight
for men and <88 cm for women) is loss, including dietary every 4.5 kg weight
Reduction
recommended for non-hypertensive education, increased loss
individuals to prevent hypertension physical activity and
behavior modification.
Should be prescribed
to both hypertensive
Limited consumption: 0-2 standard
Moderation and normotensive
drinks/day
in Alcohol individuals for -3.9 I -2.4 mmHg
Men: < 14 drinks/week
Intake prevention and
Women: < 9 drinks/week
management of
hypertension
DASH-like diet: -11.4 I -5.5 mmHg
• High in fresh fruits, vegetables, dietary Should be prescribed for hypertensive
Eating fibre, non-animal protein (e.g. soy) and to both hypertensive patients on the
Healthier and low-fat dairy products. Low in saturated and normotensive DASH diet
Reducing fat and cholesterol. individuals for
Sodium prevention/ -5.4 I -2.8 mmHg
Intake • To decrease BP, consider reducing management of with a 1700 mg/d
dietary sodium intake towards 2000 mg hypertension. sodium
per day. reduction in
hypertensive
Individualized cognitive behavior patients
For selected patients in
Reducing interventions are more likely to be
whom stress plays a role -6.1I -4.3 mmHg
Stress effective when relaxation techniques are
in elevating BP.
employed.
Smoking Abstinence from smoking. A smoke-free A global cardiovascular
n/a
Cessation environment. risk reduction strategy.

COMMON PROBLEMS 22
 - Reprinted with permission of the Canadian Hypertension Education Program

Sources:
Canadian Hypertension Education Program. 2014 Canadian Recommendations for the Treatment of
Hypertension. Retrieved from
https://www.hypertension.ca/images/CHEP_2014/2014_CHEPBooklet_EN_
HCP1030.pdf

Red Flags and Assessment

Lower Back Pain (Acute)

This evidence-informed guideline is for non-specific, non-malignant low back pain in adults only

Source: Toward Optimized Practice. (2011). A Summary of the Guideline for the Evidence-

23 COMMON PROBLEMS
Informed Primary Care Management of Low Back Pain, 2nd Edition. Edmonton, AB: Toward
Optimized Practice.
(http://www.topalbertadoctors.org/download/573/LBPSUMMARYnov24.pdf)

Indications for Diagnostic Imaging

Lower Back Pain (Acute)

Indications for Radiographs in the Patient with Acute Low Back Pain
• History of significant trauma
• Neurologic deficits
• Systemic symptoms
• Temperature greater than 38°C
• Unexplained weight loss
• Medical history of cancer, corticosteroid use, drug or alcohol abuse
• Ankylosing spondylitis suspected

Source: Patel, A.T. (2000) Diagnosis and Management of Acute Low Back Pain. Am Fam Physician, 61(6),
1779-
1786.(http://www.aafp.org/afp/20000315/1779.html)

Diagnosis and Management Recommendations for AOM

Otitis Media
To properly diagnose AOM, there must be signs of a middle ear effusion (TM immobile with
or without opacification, loss of bony landmarks, or ruptured TM with fluid in external ear
canal), middle ear inflammation (bulging/discolored TM) and an acute onset of symptoms
(rapid onset of ear pain or unexplained irritability in a preverbal child)
Observation for 48 h to 72 h without antimicrobial agents is appropriate in the following instances:
 The child is older than six months of age
 The child does not have immunodeficiency, chronic cardiac or pulmonary disease,
anatomical abnormalities of the head or neck, or a history of complicated otitis media
(otitis media accompanied by suppurative complications or chronic perforation), or Down
syndrome
 The illness is not severe – otalgia appears to be mild and fever is lower than 39°C in the
absence of antipyretics
 Parents are capable of recognizing signs of worsening illness and can readily access medical
care if the child does not improve
If the child’s status worsens or does not improve during the observation period, and the primary
diagnosis still appears to be acute otitis media, antimicrobial therapy must be started
If a decision is made to treat with antimicrobials, high dose amoxicillin (75 mg/kg/day to 90
mg/kg/day) is the first choice for AOM therapy. A five-day course is appropriate for most children
older than two years of age, with a 10-day course being reserved for younger children or those
with complicated or frequently recurrent AOM.

Source: Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Management
of acute otitis media. Paediatr Child Health 2009;14(7):457-60. For more information on child and
youth health and well-being, visit www.cps.ca. (http://www.cps.ca/english/statements/id/id09-
01.htm)

COMMON PROBLEMS 24
 Indications for Surgical Referral
Osteoarthritis

Indications for Surgical Referral in patients with OA

1. Failure of a non-operative program
a. inadequate pain control
b. increasing need for narcotic medications
c. significant pain on motion, resting pain, presence of night pain
2. Increasing functional restrictions
a. inability to walk without significant pain
b. significantly modified ADLs (i.e. putting on shoes, climbing stairs, squatting and bending)
c. increasing threat to patient’s ability to work or live independently
3. Significant abnormal findings on examination
a. of the knee
i. progressing deformity, esp. when valgus > 15° or varus > 5°
ii. loss of extension by 10°-15°
iii. loss of flexion to less than 110°
b. of the hip
i. decreasing range of motion; internal rotation of less than 5° measured in flexion
ii. notable leg length discrepancy
4. Progression of disease on X-ray (weight-bearing for knee)
a. evidence of progressive bone loss
b. advanced loss of joint space in association with moderate to severe pain
c. evidence of increasing acetabular protrusion or femoral head collapse in hip
Source: Guidelines and Protocols Advisory Committee. (Sept 15, 2008) Osteoarthritis in
Peripheral Joints – Diagnosis and Treatment. (http://www.bcguidelines.ca/pdf/oa.pdf)
Osteoporosis
Osteoporosis

Clinical Assessment
History Identify risk factors for low BMD, fractures and falls
Physical Measure weight (loss of >10% since age 25 is significant)
Examination Measure height annually (loss >2 cm, or historical loss >6 cm)
Measure rib to pelvis distance (≤2 finger breadths)
Measure occiput-to-wall distance (>5 cm)
Assess fall risk using Get-Up-And-Go test
Biochemical Calcium, corrected for albumin TSH
Tests CBC Serum protein electrophoresis (for patients
Cr with vertebral fractures)
ALP 25-hydroxy vitamin D
Indications All women and men age ≥ 65 Women and men <50 with any of the
for BMD Menopausal women, and men 50-64 following:
Testing with clinical risk factors for fractures: - Fragility fracture
- Fragility fracture after age 40 - Prolonged glucocorticoid use
- Prolonged glucocorticoid - Use of other high-risk medications
use* - Hypogonadism or premature
- Use of other high-risk menopause
medications** - Malabsorption syndrome
- Parental hip fracture - Primary hyperparathyroidism
- Vertebral fracture or - Other disorders strongly
osteopenia on radiographs associated with rapid bone loss
- Current smoking and/or fracture (COPD, chronic
- High alcohol use (≥ 3 liver disease, etc)
units/day) * ≥3 months cumulative therapy in the previous

25
COMMON PROBLEMS
 Osteoporosis
- Low body weight (<60 kg) year at a prednisone equivalent dose ≥7.5 mg
- Major weight loss (>10%) daily
- Rheumatoid arthritis ** Aromatase inhibitors, androgen deprivation
- Other disorders strongly therapy
associated with osteoporosis

Assessment of 10-year Fracture Risk: CAROC or FRAX tool

Pharmacotherapy
First line therapies Vertebral Hip Other
fracture fracture
RANKL inhibitor   
Denosumab (Prolia) 60 mg SC twice yearly   
Bisphosphonates*   
Alendronate (Fosamax) 10 mg daily, 70 mg weekly   
Risedronate (Actonel) 5 mg daily, 35 mg weekly,   
  
150 mg monthly   
Zoledronic acid (Aclasta) 5 mg IV yearly   
Estrogen (hormone therapy)**
  
Doses vary
Selective Estrogen Receptor Modulator (SERM)

Raloxifene (Evista) 60 mg daily
Recombinant Parathyroid Hormone
 
Teriparatide (Forteo) 20 ug SC daily
* First line therapies for men requiring treatment of osteoporosis
** For menopausal women requiring treatment of osteoporosis in combination with treatment for vasomotor
symptoms
Source: CMAJ. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in
Canada: Summary
Nociceptive Pain

Pain
Step 1: Acetaminophen and NSAID Step 3: Hydromorphone, Morphine, Oxycodone
• Acetaminophen 75mg/kg (max) daily PO • Hydromorphone 2mg PO q4h or 1mg SC q4h
in • Oxycodone 5mg PO q4h
divided doses • Morphine 10mg PO q4h or 5mg SC q4h
• Can reduce the need for opioids by
50%
• Ibuprofen 600-2400mg daily PO in Step 4: Fentanyl and extended
divided release Step 3 medications
doses TID-QID Adjuvant Pain Medications:
• Naproxen 500-1000mg daily PO in • NMDA Antagonist (Ketamine, memantine)
divided • Anti-depressants (SSRI, SNRI, TCs)
doses BID-TID • Anticonvulsants (Gabapentin, pregabalin,
lamotrigine, topiramate,
Step 2: Tramadol, Tapentadol, low dose Step 3 valproic acid)
medications • Muscle relaxant (Cyclobenzaprine, baclofen)
• Tramadol 25-75mg PO q4h

COMMON PROBLEMS 26
 Psychiatry

Neuropathic Pain
Pain

Tricyclic Antidepressants
If pain localized → adjuvant topical therapy:
• Amitriptyline 25-50mg PO qhs up to
Lidocaine
150mg daily
Serotonin-Norepinephrine Reuptake
Specific diagnosis → targeted diagnosis-
Inhibitors
specific treatment
• Venlafaxine 75-225mg PO daily
Anticonvulsants
• Pregabalin (Lyrica) 75mg BID up to 300mg Nonpharmacologic Treatment:
daily Neuromodulation
• Gabapentin 300-3600mg PO daily

Sources: Rosenquist, EWK. Overview of the treatment of chronic pain. Retrieved from
http://www.uptodate. com/contents/overview of-the-treatment-ofchronic-
pain?source=search_result&search=chronic+pain&sele ctedTitle=1%7E150)

Sullivan P. Ottawa Anesthesia Primer. 1st ed. Echo book Publishing; 2013.
Psychiatry

Depression
DSM-V Criteria for Major Depressive Disorder
• 2 weeks including depressed mood OR anhedonia with functional impairment AND
• Associated with 5/9 symptoms: mood (depressed), sleep (insomnia or hypersomnia),
interest
(anhedonia), guilt/worthlessness, energy (decreased), concentration (decreased), appetite
changes,
psychomotor agitation or retardation, suicidal ideation

Management
• First line: SSRI, SNRI, NDRI, NaSSA, RIMA
o Examples: Escitaloparam (Cipralex) 10mg PO daily, Venlafaxine (Effexor) 75mg PO daily
• Second line: TCA (Nortriptyline); SARI (Trazodone), Seroquel-XR
• Third line: MAOI (Phenelzine)
• Add on Strategies
o Lithium – 600mg daily up to therapeutic serum level
o Aripiprazole (Abilify) 1-2mg up to 10mg
o Olanzapine (Zyprexa) 2.5-5 mg up to 7.5mg qhs
o Risperidone (Risperdal) 0.5-1 mg up to 1.5mg qhs

Anxiety
DSM-V Criteria for Generalized Anxiety Disorder
• Excessive anxiety and worry most days >/= 6 months about a number of events or
activities
• Worry is difficult to control
• Anxiety/worry associated with at least 3/6 symptoms: restlessness, fatigue, difficulty
concentrating,
irritability, muscle tension, insomnia

27 COMMON PROBLEMS
 Management
• First line: SSRI or SNRI ± BDZ
• Second line: TCA, MAOI, other antidepressant
• Third line: Mood stabilizers, antipsychotics
• Add on Strategies
o Serotonergic: buspirone, pindolol, tryptophan, trazodone
o Noradrenergic: desipramine, nortriptyline, bupropion, mirtazapine
o GABA/ion channels (anticonvulsants): pregabalin, gabapentin, valproate, topiramate
o Atypical antipsychotics: quetiapine, olanzapine, risperidone, aripiprazole, ziprazidone,
asenapine,
lurazidone

Common Side Effects

 SSRI and SNRI – Headache, anxiety, agitation, nausea, diarrhea, sexual dysfunction, sleep
disturbances
o SNRI: increased BP
 NDRI – Headache, rash, sleep disturbance (insomnia), shaking, anxiety, agitation, emesis,
seizures (0.1% over 400mg)
 NaSSA – weight gain, increased cholesterol, anti-cholinergic (urinary retention, dry
mouth, constipation, blurred vision), drowsiness, orthostatic hypotension
 Trazodone – sedation, vivid dreams, headache, dry mouth, priapism (1/6000)
 TCA – weight gain, sedation, anti-cholinergic, dizziness, orthostatic hypotension, QTc
prolongation
 MAOI – orthostatic hypotension, weight gain, sexual dysfunction, ankle edema
 Lithium – tremor, alopecia, GI upset, acne, weight gain, hypothyroid, muscle weakness,
ECG changes
 Atypical Antipsychotics – EPS (dystonia, parkinsonism, tardive dystonia, akathisia),
weight gain, T2DM, dyslipidemia, prolonged QTc, sedation

Sources: American Psychiatric Association. (2013). Major Depressive Disorder. In Diagnostic and
statistical manual of mental disorders (5th ed.).
Canadian Network for Mood and Anxiety Treatments. Clinical Guidelines for the Management of Major
Depressive Disorder in Adults. Retrieved from
http://www.canmat.org/resources/CANMAT%20Depression%20
Guidelines%202009.pdf
American Psychiatric Association. (2013). Generalized Anxiety Disorder. In Diagnostic and statistical
manual of mental disorders (5th ed.).
Canadian Psychiatry Association. Clinical Practice Guidelines – Management of Anxiety Disorders –
Updated
2006. Retrieved from http://publications.cpa-apc.org/media.php?mid=445

COMMON PROBLEMS 28
Skin Issues

Antibiotic Management of Common Skin Infections

Infection Recommended Antibiotic Management

Empiric treatment with a penicillinase-resistant penicillin, first-generation

Cellulitis cephalosporin, amoxicillin-clavulanate (Augmentin), macrolide, or
fluoroquinolone (adults only) is appropriate.

Erysipelas is caused almost exclusively by beta-hemolytic streptococcus and

Erysipelas thus can be treated with standard dosages of oral or intravenous penicillin.
However, most physicians treat this infection the same as cellulitis.

Impetigo
(Bullous and Non-bullous)
Folliculitis
Deep Folliculitis
(Staphylococci invasion of
deeper part of follicule)
Azithromycin (Zithromax) for five days and cephalexin (Keflex) for 10 days
have been shown to be effective and well-tolerated.
Dicloxacillin (Pathocil), oxacillin (Prostaphlin), first-generation
cephalosporins, or amoxicillin-clavulanate are also acceptable alternatives.
Broad-spectrum fluoroquinolones have also been shown to be effective.
These lesions typically resolve spontaneously.
Topical therapy with erythromycin, clindamycin, mupirocin, or benzoyl
peroxide can be administered to accelerate the healing process.
Oral antibiotics are usually used in the treatment and include first-generation
cephalosporins, penicillinase-resistant penicillins, macrolides, and
fluoroquinolones.

Loculations should be broken with a hemostat.

The wound may be packed (usually with iodoform gauze) to encourage
further drainage.
Furuncles and Carbuncles In severe cases, parenteral antibiotics such as cloxacillin (Tegopen), or a first-
generation cephalosporin such as cefazolin (Ancef), are required.
The physician should be aware of the potential for gas-containing abscesses
or necrotizing fasciitis, which require immediate surgical debridement.
Source: Stulberg, D.L., Penrod, M.A.,& Blatny, R.A., Common bacterial infections. Am Fam Physician,
66(1),119-125. (http://www.aafp.org/afp/2002/0701/p119.html)

29 COMMON PROBLEMS

Topicals: applied to entire affected area
Treatment
Benzoyl peroxide (BP)
Retinoids
(TRE, Adapalene, Tazarotene)
Topical Antibiotics
(Clindamycin (CLI), Erythromycin
(ERY))
Combination Topical gels
(Benzamycin = BP 5% and ERY 3%),
BenzaClin, Clindoxyl = BP 5% and CLI
1%, Stievamycin = TRE and ERY 4%)
Treatment
Oral antibiotics
(Tetracycline, Doxycycline,
Minocycline, Erythromycin)
Hormonal contraceptives
(Tri-Cyclen, Alesse, Aviane, Yasmin,
Diane-35, Cyestra-35)
Spironolactone
Isotretinoin
(Accutane, Clarus)
Source: Laubscher, T., Regier, L.,Jin, M., & Jensen, B. (2009). Taking the stress out of acne management.
Canadian Family Physician. Vol 55: March 2009. Page 268 (http://www.cfp.ca/content/55/3/266.full.pdf)
COMMON PROBLEMS
Acne Treatments
Role
- Mild to moderate acne
- Prevents bacterial resistance
- Mild to moderate acne, especially
comedonal
- First-line in some guidelines
- Mild to moderate inflammatory
acne
- Mild to moderate inflammatory
acne
- When more intensive therapy is
desired
Orals
Role
- Moderate to severe inflammatory
acne if topical agents not
effective/practical
- Use with BP
- First-line in women if also desired
for contraception
- Antiandrogen effect
- Adult or late onset acne in women
- Antiandrogen effect
- More severe acne (nodulocystic,
scarring)
Skin Issues
Notes
- Water-based formulations are less
drying
- Initial worsening for 2-4 weeks;
improvement < 3 months
- Irritating and drying (Adapalene
better tolerated)
- Initial worsening for 2-4 weeks;
improvement < 3 months
- Adverse effects subside over time
- Use in combination with BP to
minimize resistance
- Avoid long term use
- Step down to BP or retinoid only
- More effective than
monotherapy, but more
expensive
- Response in 2-3 weeks, optimal
results in 8-10 weeks
- Step down to benzoyl peroxide or
retinoid
Notes
- Little or no difference in efficacy
- Minocycline has adverse events
concerns and is expensive
- Use for 2-4 months then step
down to topical agent to
minimize resistance
- Acne might worsen early in cycle
- 3-6 months for response
- Some may make acne worse
- Daily for 21 days, then 7 days
hormone free
- 2-3 months for optimal response
- Tetratogenic (pregnancy testing and
contraception requirements)
30
 Red Eye
Red Eye
Red Eye

Bacterial (S. pneumonia, S. Gonococcal/ Viral (adenovirus most

Conjunctivitis Allergic
aureus, H. influenzae) Chlamydial common)

Sexual contact
Atopy Possible vertical
History Sick contact
Allergies transmission in
neonates
Recent URTI
Chronic, unilateral
Burning, itching,
conjunctivitis not
foreign body
Burning, tearing, foreign responsive to drops
sensation
++Itching body sensation Tearing, foreign body
Symptoms Mild photophobia
Rhinitis Mild photophobia, blurry sensation
Typically affects one
vision LUTS + new sexual
eye first, with spread
partner
to other eye after a
few days

Clear mucoid
Purulent discharge
Bilateral discharge
Papillae Mucoid discharge
Signs Watery eyes Follicles
*May progress to Follicles
Papillae Tender pre-auricular
periorbital cellulitis
lymphadenopathy

Treat for both

gonococcal and Self-limiting (resolves
chlamydial infection in 2-3 weeks)
Cool Contagious for ≥2
compresses Ceftriaxone 1g IM weeks after sx onset
Topical antibiotic x 1 week
Oral/topical once AND Azithromycin Cold/warm
Treatment antihistamie 1g PO compresses
Artificial Tears once Artificial tears

+/- topical abx Proper hand hygiene

Opthalmology
referral

Red Flags for Urgent Opthalmology Referral:

• Decreased visual acuity (infectious keratitis, iritis, angle closure glaucoma)
• Ciliary flush (infectious keratitis, iritis, angle closure glaucoma)
• Photophobia (infectious keratitis, iritis)
• Corneal Opacity (infectious keratitis)
• Fixed Pupil (angle closure glaucoma)
• Severe headache with nausea (angle closure glaucoma)
Sources:
Anti-infective Review Panel. Anti-infective Guidelines for Community Acquired Infections. Toronto: MUMS
Guideline Clearinghouse; 2013.
Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-Hill
Education; 2013.
Jacobs, DS. Conjunctivitis. Uptodate. Retrieved from http://www.uptodate.com/contents/

31 COMMON PROBLEMS
conjunctivitis?source=search_result&search=conjunctivitis&selectedTitle=1 7E150. Accessed June 2, 2014
Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal
Medicine. 18th ed. New York, NY: The McGraw-Hill Companies; 2012.

Elder Abuse Suspicion Index (EASI)
1. Have you relied on people for any of the following:
bathing, dressing, shopping, banking, or meals?
Yes No Did not answer
2. Has anyone prevented you from getting food,
clothes, medication, glasses, hearing aids or
medical care, or from being with people you
wanted to be with?
Yes No Did not answer
3. Have you been upset because someone talked
to you in a way that made you feel shamed or
threatened?
Yes No Did not answer
Elder Abuse
4. Has anyone tried to force you to sign papers
or to use your money against your will?
Yes No Did not answer
5. Has anyone made you afraid, touched you in
ways that you did not want, or hurt you
physically?
Yes No Did not answer
6. Doctor: Elder abuse may be associated with
findings such as: poor eye contact,
withdrawn nature, malnourishment,
hygiene issues, cuts, bruises, inappropriate
clothing, or medication compliance issues.
Did you notice any of these today or in the
last 12 months?
Yes No Did not answer

Q 1-5 ask of patient: Q 6 answered by doctor.

What is EASI?

The EASI was developed* to raise a doctor’s suspicion about elder abuse to a level at
which it might be reasonable to propose a referral for further evaluation by social
services, adult protective services, or equivalents. While all six questions should be
asked, a response of “yes” on one or more of questions 2 to 6 may establish concern.
The EASI was validated* for use by family practitioners of cognitively intact seniors
seen in ambulatory settings.

*Ya e MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse:
The Elder Abuse Suspicion Index (EASI) ©. Journal of Elder Abuse and Neglect
2008; 20(3) 276-300.
Haworth Press Inc: http://www.tandf.co.uk/journals/haworth-journals.asp
© The Elder Abuse Suspicion Index (EASI) was granted copyright by the Canadian Intellectual Property Office (Industry Canada)
February 21, 2006. (Registration No. 1036459)
Mark J. Ya e MD, McGill University, Montreal, Canada mark.ya e@mcgill.ca
Maxine Lithwick MSW, CSSS Cavendish, Montreal, Canada maxine.lithwick.csssamn@ssss.gouv.qc.ca
Christina Wolfson PhD, McGill University, Montreal, Canada christina.wolfson@mcgill.ca
Online copies of EASI:
http://www.mcgill.ca/files/familymed/EASI_Web.pdf

Source: National Initiative for the Care of the Elderly. Elder Abuse Suspicion Index (EASI) (http://www.
nicenet.ca/files/U_of_T_Nice_175084_EASI_Revised_5_Panel.PDF)

PROBLEMS IN THE ELDERLY 32

 Assessment and Management of Falls
Assessment and Management of Falls

Source: Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics
Society (2010). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical
Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc (2010). DOI: 10.1111/j.1532-
5415.2010.03234.x (http://www.americangeriatrics.org/files/documents/health_care_pros/
JAGS.Falls.Guidelines.pdf). Can also refer to Panel on Prevention of Falls in Older Persons, American
Geriatrics Society and British Geriatrics Society (2010). Summary of the Updated American Geriatrics
Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am
Geriatr Soc (2010). DOI:10.1111/j.1532-5415.2010.03234.x
(http://www.americangeriatrics.org/files/documents/health_care_pros/ JAGS.Falls.Guidelines.pdf)

33 PROBLEMS IN THE ELDERLY

 Indications for Breast Cancer Screening

Breast Cancer Screening

Age group Screening Indications Sc
re
• Already completed genetic testing for breast cancer and e
have received confirmation of a genetic mutation. ni
• Not completed genetic testing themselves, but who have n
a parent, sibling or child with confirmation of the genetic Breast MRI g
mutation. and
30-69
• Family history that indicates hereditary breast cancer mammograp
syndrome and who have greater than or equal to 25% hy yearly.
lifetime risk of breast cancer confirmed through a genetic
counselling.
• Received radiation therapy to the chest before 30 years
of age as treatment for another cancer or condition
Mammography every 2
50-69 • (i.e.
EveryHodgkin’s
woman in disease).
this age group regardless of risk factors.
years.

Average risk
40-49 • Routine mammography not recommended. Routine MRI, clinical
breast exams,
50-74 • Mammography every 2-3 years. breast self-exams
not recommended.
Sources:
1. Government of Ontario. Ontario Breast Cancer Screening Program
(http://www.health.gov.on.ca/en/public/
programs/breastcancer/screened.aspx#2) © Queen’s Printer for Ontario, 2008
2. The Canadian Task Force on Preventive Health Care (2011). Recommendations on screening for breast
cancer in average-risk women aged 40–74 years. CMAJ, 183 (17), 1991-2001. (http://www.cmaj.ca/
content/183/17/1991)

Cervical Cancer Screening

Recommendations for Cervical Cancer Screening
Recommendations

Cervical cytology screening should be initiated at 21 years of age for women

who are or have ever been sexually active. This includes intercourse, as well as
Screening Initiation
digital or oral sexual activity involving the genital area with a partner of either
gender.

If cytology is normal, screening should be done every 3 years. The absence

Screening Interval of T zone is not a reason to repeat a Pap test earlier than the recommended
interval.

Screening may be discontinued at the age of 70 if there is an adequate negative

Screening Cessation cytology screening history in the previous 10 years (i.e., 3 or more negative
cytology tests).

HEALTH PROMOTION AND SCREENING 34

  Women who are not sexually active by age 21 should delay cervical cancer screening until sexually
Cervical Cancer Screening

active.
 These guidelines do not apply to women who have been previously treated for dysplasia.
Screening intervals should be individualized and should likely be annual.
 Immunocompromised women should receive annual screening.
 Women who have undergone subtotal hysterectomy and retained their cervix should continue
screening according to the guidelines.
 Pregnant women should be screened according to the guidelines; however, care should be taken
not to over-screen. Only conduct Pap tests during pre-natal and post-natal visits if the woman is
otherwise due for screening.
 Women who have sex with women should follow the same cervical screening regimen as women
who have sex with men.
 Women who have received the HPV vaccine should continue with screening.
 Any visual cervical abnormalities and/or abnormal symptoms must be investigated regardless of
cytology findings.
Source: Cancer Care Ontario. Ontario Cervical Screening Cytology Guidelines Summary - Updated
May 2012 (https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104)

Indications for Colorectal Cancer Screening

Screening of individuals at average risk: Individuals age 50 - 75 with a negative family history should
Colorectal Cancer Screening

undergo screening with one of the following strategies:

• FOBT every two years
• Flexible Sigmoidoscopy every ten years
• Flexible Sigmoidoscopy Combined with FOBT every ten years
Screening of Individuals at higher risk: Some groups are at increased risk of colon cancer. Colonoscopy is
the recommended screening test for these patients who have:
• A first degree relative with the disease diagnosed before age 60 (colonoscopy every 5 years to begin at age
40 or ten years earlier than the youngest diagnosis of polyp or cancer in the family; if diagnosed after the age
of 60, then employ average risk screening to begin at age 40),
• A family history that suggests a genetic abnormality capable of causing the disease such as HNPCC
(Colonoscopy every 1-2 years beginning at age 20 years or ten years younger than the earliest case in the family),
• Familial Adenomatous Polyposis (FAP) (sigmoidoscopy annually to begin at age 10-12 years) or
• Long standing colonic inflammatory bowel disease - such as Crohn’s or Ulcerative Colitis (for pancolitis
– colitis that involves the entire colon, begin screening at 8 years after onset of disease, continue with
colonoscopy every three years in the second decade, colonoscopy every two years in the third decade and
colonoscopy every year in the fourth decade; for left sided colitis, begin screening at 15 years after onset)
Sources:
1. Canadian Association of Gastroenterology position statement on screening individuals at average risk
for developing colorectal cancer: 2010. This information was originally published in Can J Gastroenterol
2010;24(12):705-714.
(http://www.pulsus.com/journals/abstract.jsp?sCurrPg=abstract&jnlKy=2&atlKy=9870&
isuKy=954&isArt=t)
2. Colorectal Cancer Association of Canada. Canadian Association of Gastroenterology issued Guidelines
on

35 HEALTH PROMOTION AND SCREENING

 Colon Cancer Screening 2004 (http://www.colorectal-cancer.ca/en/screening/screening-tests/#II)
3. Cancer Care Ontario: Colorectal Cancer Screening (http://www.cancercare.on.ca/pcs/screening/
coloscreening/)

Periodic Health Examination

Periodic Health Examination

Labs/Investigations Immunizations
Male •Fasting lipid profile •Tetanus vaccine q10 years
•q3 years at age 40 (earlier if high risk)
•Influenza vaccine q1 year
•Fasting blood glucose
•Herpes zoster vaccine (age 60)
•q3 years at age 40 (more often if high risk)
•Pneumococcal vaccine (age 65 or earlier
•Hemoccult Multiphase
if high risk)
•q1-2 years at age 50
•or Colonoscopy q10 years or •Acellular pertussis vaccine
Sigmoidoscopy q5 years if normal and
•Varicella immunity
no polyps
•Rubella Immunity
•Bone Mineral Density
•q1-3 years if moderate risk, q5 years if •Meningococcal vaccine (if high risk age 2-25)
low risk at age 65 (earlier if at risk)

Females •Same as males except:

•Gonorrhea/Chlamydia/Syphillis/HIV/HBV •Same as males plus:
(if high risk)
•Fasting lipid profile at age 50 •Human papillomavirus vaccine 3 doses (aged
9-26)
•Mammography
•q1-2 years from ages 50-69
•Cervical Cytology
•q3 years from ages 21-69

High Risk Individuals for Early Lipid Screening:

- Diabetes
- Hypertension
- Current cigarette smoking
- Obesity
- Family history of premature CAD (<60 years in first-degree relatives)
- Inflammatory diseases (systemic lupus erythematosis, rheumatoid arthritis, psoriasis)
- Chronic renal diseases (eGFR <60 mL/min/1.73 m2)
- Evidence of atherosclerosis
- HIV infection treated with highly active antiretroviral therapy
- Erectile dysfunction
- Children with a family history of hypercholesterolemia or chylomicronemia

HEALTH PROMOTION AND SCREENING 36

 Risk Factors for More Frequent Diabetes Screening:
Periodic Health Examination

- First-degree relative with DM

- Presence of complications associated with DM
- Hypertension
- Dyslipidemia
- Overweight or Abdominal obesity
- Member of high-risk population (Aboriginal, Hispanic, Asian, South Asian or African descent)
- History of impaired glucose tolerance or impaired fasting glucose
- History of gestational DM or macrosomic infant
- Schizophrenia
- Polycystic ovarian syndrome

High Risk Individuals for BMD Screening:

- Menopausal women and men age 50-64 years:
- Fragility fracture after age 40 years
- Prolonged use of glucocorticoids
- Use of other high-risk medications
- Parental hip fracture
- Vertebral fracture or osteopenia identified on radiography
- Current smoking
- High alcohol intake
- Low body weight (< 60 kg) or major weight loss (> 10% of body weight at age 25 yr)
- Rheumatoid arthritis
- Other disorders strongly associated with osteoporosis
- Under 50
- Fragility fracture
- Prolonged use of glucocorticoids
- Use of other high-risk medications
- Hypogonadism or premature menopause (age<45 yr)
- Malabsorption syndrome
- Primary hyperparathyroidism
- Other disorders strongly associated with rapid bone loss and/or fracture

High Risk Individuals for Pneumococcal Vaccine:

- All persons >5 years of age with:
- Sickle cell disease,
- Asplenia, splenic dysfunction
- Chronic cardiorespiratory disease (except asthma)
- Cirrhosis, alcoholism
- Chronic renal disease
- Nephrotic syndrome
- Diabetes mellitus
- Chronic CSF leak
- HIV infection
- Smokers
- Homeless
- Injection drug users
- Conditions associated with immunosuppression (Hodgkin’s, lymphoma, multiple myeloma,

37 HEALTH PROMOTION AND SCREENING

 induced immunosuppression for organ transplantation)

Recommendations for Skin Cancer Screening

Skin Cancer Screening

Target population
Very high risk of skin cancer
Individuals with ANY of the following risk factors:
• on immunosuppresive therapy after organ transplantation
• personal history of skin cancer
• 2 or more first-degree relatives with melanoma
• more than 100 nevi in total or 5+ atypical nevi
• have received more than 250 treatments of
psoralen ultraviolet A radiation (PUVA) for psoriasis
• received radiotherapy for cancer as a child
Recommendations
• Should be identified and offered total body
skin examination by a dermatologist or a
trained health care provider on a yearly basis
• Should be counselled about skin self-
examination and skin cancer prevention by a
health care provider
• In the case of childhood cancer survivors, the
site of radiation therapy should be monitored

High risk of skin cancer

Individuals with TWO OR MORE of the following risk factors:
• a first-degree relative with melanoma
• many (50-100) nevi
• one or more atypical (dysplastic) nevi
• naturally red or blond hair
• a tendency to freckle
• skin that burns easily and tans poorly or not at all
• Should be identified and counselled about skin
self-examination (specifically focused on the
site of radiation for those having therapeutic
radiation) and skin cancer prevention by a
health care provider
• Should be seen once a year by a health care
provider trained in screening for skin cancers

Note: The general population is not at increased risk of skin cancer

• At this time there is no evidence for or against skin cancer screening of the general
population at average risk of developing skin cancer
• Based on limited evidence available at present, routine total body examination or
routine counselling on skin self-examination by primary care providers is NOT
RECOMMENDED for individuals at AVERAGE OR LOW RISK for skin cancer

Source: From, L., Marrett, L., Rosen, C., Zwaal, C., Johnston, M., Bak, K., Sibbald, G., Fong, J., & Mai, V.
(2007) Screening for Skin Cancer : A Clinical Practice Guideline A Quality Initiative of the Program in
Evidence-
based Care (PEBC), Cancer Care Ontario (CCO). (http://www.cancercare.on.ca/common/pages/UserFile.
aspx?fileId=13942)

HEALTH PROMOTION AND SCREENING 38

 Smoking Cessation Medications
Smoking Cessation

Medication Dosing Adverse Effects

Nicotine Replacement Therapy

1st cigarette ≤30 minutes after waking: 4 mg

- Mouth/jaw soreness
1st cigarette >30 minutes after waking: 2 mg
- Hiccups
Weeks 1–6:
- Dyspepsia
1 piece q 1–2 hours
- Hypersalivation
Weeks 7–9:
Gum - Effects associated with incorrect
1 piece q 2–4 hours
chewing technique:
Weeks 10–12:
- Lightheadedness
1 piece q 4–8 hours
- Nausea/vomiting
- Maximum, 24 pieces/day
- Throat and mouth irritation
- Chew and park
1st cigarette ≤30 minutes after waking: 4 mg
1st cigarette >30 minutes after waking: 2 mg - Nausea
Weeks 1–6: - Hiccups
1 lozenge q 1–2 hours - Cough
Lozenge Weeks 7–9: - Heartburn
1 lozenge q 2–4 hours - Headache
Weeks 10–12: - Flatulence
1 lozenge q 4–8 hours - Insomnia
- Maximum, 20 lozenges/day
- Local skin reactions (erythema,
>10 cigarettes/day: pruritus, burning)
- 21 mg/day x 4 weeks - Headache
- 14 mg/day x 2 weeks - Sleep disturbances (insomnia,
Transdermal
- 7 mg/day x 2 weeks abnormal/vivid dreams): associated
Patch
≤10 cigarettes/day: with nocturnal nicotine absorption
- 14 mg/day x 6 weeks *May wear patch for 16 hours
- 7 mg/day x 2 weeks if patient experiences sleep
disturbances (remove at bedtime)
- Nasal and/or throat irritation (hot,
1–2 doses/hour peppery, or burning sensation)
(8–40 doses/day) - Rhinitis
Nasal Spray *One dose = 2 sprays (one in each nostril) - Tearing
- Maximum: 5 doses/hour or 40 doses/day - Sneezing
- Duration: 3–6 months - Cough
- Headache
Oral Inhaler 6–16 cartridges/day
- Mouth and/or throat irritation
Individualize dosing; initially
- Cough
use 1 cartridge q 1–2 hours
- Headache
- Best effects with continuous puffing for 20 minutes
- Rhinitis
- Do NOT inhale into the lungs (like a cigarette) but
- Dyspepsia
“puff” as if lighting a pipe
- Hiccups
- Duration: 3–6 months

HEALTH PROMOTION AND SCREENING

39
 Smoking Cessation
Smoking Cessation Medications cont’d
Medication Dosing Adverse Effects
Others
Bupropion 150 mg po q AM x 3 days, then - Insomnia

150 mg po bid - Dry mouth

- Do not exceed 300 mg/day - Nervousness/difficulty

- Begin therapy 1–2 weeks prior to quit date concentrating

Varenicline Days 1–3: 0.5 mg po q AM - Nausea
-Days
Can 4–7:
be used safely
0.5 mg po with
bid NRT - Rash
Weeks 2–12: 1 mg po bid - Sleep disturbances
- Duration: 7–12 weeks (+/- maintenance up to 6 months) - Constipation
- Begin therapy 1 week prior to quit date (insomnia, abnormal/vivid dreams)
- Seizures (risk is 0.1%)
- Duration: 12 weeks (+/- additional 12-weeks) - Constipation
- Neuropsychiatric symptoms
- Flatulence
Source: Rx for Change. Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation.
- Vomiting
Updated March 1, 2012. Copyright © 1999–2012 The Regents of the University of California.

Smoking Cessation Flow Sheet - Neuropsychiatric symptoms

HEALTH PROMOTION AND SCREENING 40

 Smoking Cessation Flow Sheet
Smoking Cessation

Source: CTI (2008). Smoking Progress Notes – Annual Patient Profile. (http://www.ctica.org/Smoking_
Cessation_Guideline_Flow_Sheet_updated_Jan2008.pdf)

41 HEALTH PROMOTION AND SCREENING

 Contraceptive Options

Contraceptive Options
Method Advantages Disadvantages
Combined OCP Effectiveness (99.7% - perfect use, Irregular bleeding/spotting
(Daily) 92% - typical use) Breast tenderness, nausea, headache
Cycle control ↑ VTE risk
↓ dysmenorrhea, Slight ↑ risk of breast cancer
↓ menstrual flow
↓ perimenopausal and PMS symptoms
↓ risk of ovarian, endometrial,
possibly colorectal cancer
↓ ovarian cysts
↓ acne and hirsutism
↑ bone density
Transdermal Effectiveness (99.7% – perfect use, Same as OCP
Contraceptive Patch 92% - typical use) Skin irritation
(Weekly) Same as OCP Patch detachment (uncommon)
48-hour “window of forgiveness” Less effective if >90kg
Vaginal Contraceptive Effectiveness (99.7% - perfect use, Same as OCP
Ring 92% - typical use) Vaginitis
(Monthly) Same as OCP Vaginal discomfort
1-week “window of forgiveness” Expulsion (uncommon)
Progestin Only Pill Effectiveness (99.7% - perfect use, Irregular bleeding
(Daily) 92% - typical use) Headache, bloating, acne, breast
Can be used post-partum tenderness
Must take at same time everyday
No pill-free interval
Depot medroxy- Effectiveness (99.7% - perfect use, Irregular bleeding Delayed return
progesterone acetate 97% - typical use) of fertility Headache, ↓ libido,
(DMPA) ↓ menstrual flow or nausea, breast
Amenorrhea tenderness, weight gain, mood effects
(IM progesterone ↓ risk of endometrial cancer Weight gain
injection every 12-13 ↓ endometriosis symptoms ↓ Bone mineral density
weeks) ↓ PMS and chronic pelvic pain symptoms
↓ Seizures
Possible ↓ risk of PID and sickle-cell crises
6-day “window of forgiveness”
Copper Intrauterine Effectiveness (99.4% - perfect use, Irregular bleeding
Device 99.2% - typical use) ↑Menstrual flow
(5 years) Possible ↓ risk of endometrial cancer Dysmenorrhea
Can be used as emergency Perforation
contraception Expulsion
Increased risk of PID for first 20 days

FAMILY PLANNING 42
 Hormonal Effectiveness (99.9% - perfect use, Irregular bleeding
Contraceptive Options

Intrauterine Device 99.9% - typical use) Systemic hormonal side effects

(5 years) ↓ Menstrual flow/ Amenorrhea Functional cysts
↓ dysmenorrhea Perforation
May protect against endometrial Expulsion
hyperplasia Increased risk of PID for first 20 days
Male Condom Effectiveness (98%- perfect use,
(one-time use) 85% - typical use)
Protects against STIs
No prescription required
Female Condom Effectiveness (95%- perfect use, Can be noisy during intercourse
(one-time use) 79% - typical use) Can be difficult to insert
Same as male condom Can cause discomfort during intercourse
Female controlled
Diaphragm Effectiveness (94%- perfect use, Can be difficult to insert
(one-time use) 84% - typical use) Must be left in for 6 hours after intercourse
Some protection against STIs Must be used with spermicide
Can be used during menses Does not protect against HIV
Latex or spermicide allergy
Must be fitted by health care provider
May ↑ risk of UTI,
Sponge Effectiveness (Nulliparous: ↑ risk
Can beof toxic shock
difficult syndrome
to insert with wearing
and remove
(one-time use) 91% - perfect use, 84% - typical use; > 24 hours
Must be left in for 6 hours after intercourse
Parous: 80% - perfect use, 68% - Should not
Possible spermicide
be used with
sensitivity
oil-based lubricants
typical use) Should not be used during menstruation
One size fits all Less effective in multiparous women
No prescription required
Fertility Awareness Effectiveness (91-99% - perfect use, High probability of failure if not used
and 80% - typical use) consistently and correctly
Symptothermal Greater awareness of gynaecological
Method health
Lactational Effectiveness 98% Menses must have not returned
Amenorrhea Must be fully/nearly fully breastfeeding
Method Baby must be < 6 months of age
Coitus Interruptus Effectiveness (96% - perfect use, High probably of failure with typical use
(Withdrawal) 81% - typical use) Theoretical ↓ in risk of HIV
When religious considerations
preclude the use of other methods
Abstinence Effectiveness 100% May be too restrictive for some couples
No STI risk if no exchange of body Can cause frustration
fluids Does not encourage use of other methods of
contraception, if behaviour changes
Sources:
1. Fisher, W.A., Black, A (March 27, 2007). Contraception in Canada: a review of method choices,
characteristics,adherence and approaches to counseling. CMAJ. 176(7), 953-961.
(http://www.cmaj.ca/content/176/7/953.full.pdf)
2. Black, A., Francoeur, D., Rowe, T. (April 2004) SOGC Canadian Contraception Consensus. Part 3 of 3. No.

43 FAMILY PLANNING
14, 348-387. (http://www.sogc.org/guidelines/public/143E-CPG3-April2004.pdf)

Commonly Used Antibiotics in Primary Care

Common Antibiotics

Condition Microorganism First Line Antibiotic Regimen

Community S. pneumonia Clarithromycin 500mg BID or 1000mg

Acquired M. pneumonia (extended release) once daily x 7-14 days
Pneumonia - Adult C. pneumonia Amoxicillin 1g TID x7-14 days
(outpatient without Azithromycin 500mg on first day then 250mg
comorbidities) x 4 day
Community 1 – 3 months: RSV, viruses 1-3 months: no antibiotic indicated
Acquired 3 months – 5 years: S. pneumo, s. 3 months – 5 years: Amoxicillin 80mg/kg/day
Pneumonia aureas, GAS, H. influenza divided TID x 7-10 days
– Children 5 – 18 years: M. pneumonia, C. 5 – 18 years: Clarithromycin 15mg/kg/day
(outpatient without pneumonia, S. pneumonia, influenza divided BID x 7-10 days
comorbidities) A or B
Acute Pharyngitis Group A Strep Adults: Penicillin V 600mg BID x 10 day
Children: < 27 kg – Penicillin V 40mg/kg/day
divided BID-TID
>27 kg – same as adults
Otitis Media S. pneumonia Adults: Amoxicillin 500mg TID
H. Influenza Children: Amoxicillin 80-90mg/kg/day divided
M. catarrhalis BID or TID (max 3g/day) x5-10 days

Otitis Externa P. aeruginosa, Coliforms, S. aureus Ciprodex 4 drops BID

Bacterial Sinusitis S. pneumonia Adults: Amoxicillin/Clavulanate 500mg TID x
H. influenza 5-7 days
M. catarrhalis Children: Amoxicillin/Clavulanate 40-80mg/
S. aureus kg/day divided BID

Bacterial S. aureus Erythromycin 0.5 ointment 1/2 inch QID x5-7

Conjunctivitis S. pneumonia day
H. influenza Contact lens users: Ciprofloxacin 0.3% drops
M. catarrhalis 1-2 drops QID x 5-7 days

Urinary Tract E.coli TMP/SMX 1DS tab BID x 3 days Nitrofurantoin

Infection S. saprophyticus 100mg BID x 5 days Pseudamonas:
Other gram –ve bacilli Ciprofloxacin 500mg (extended
release) daily

Pyelonephritis E. coli Ciprofloxacin 500mg BID x 7 days

K. pneumonia
P. mirabilis

QUICK REFERENCE GUIDE 44

 Urethritis N. gonorrhea Cefixime 400-800mg once
C. trachomatis AND Azithromycin 1g once

Bacterial Vaginosis Overgrowth of G. vaginalis, M. Metronidazole 500mg BID PO x 7 days

hominis, Anaerobes
Commonly Used Antivirals in Primary Care

Common Antivirals
Condition Microorganism Antiviral Regimen
Mucocutaneous Herpes Simplex type 1 or 2 Valacyclovir 2g BID once
herpes (>3/year)
Famciclovir 500mg BID x 7 days
Genital Herpes Herpes Simplex type 1 or 2 Acyclovir 400mg TID x 5-7 days

Shingles (initiate Varicella Zoster Valacyclovir 1g TID x 7 days

within 72 hours of
rash onset) Famciclovir 500mg TID x 7 days

Chicken Pox (initiate Varicella Zoster Valacyclovir 1g TID

within 24 hours of Famciclovir 500mg TID
rash onset) Prevention: Chickenpox vaccine

Genital Warts Human Papilloma Virus Cryotherapy (liquid nitrogen q1-2 weeks)

Influenza Influenza A or B Oseltamivir (Tamiflu) 75mg daily x 10 days (must

begin within 48 hours of exposure/symptoms)

Reference: Anti-infective Review Panel. Anti-infective Guidelines for Community Acquired Infections.
Toronto: MUMS Guideline Clearinghouse; 2013.

45
QUICK REFERENCE GUIDE
 Immunization Schedule
Immunization Schedule

Source: Government of Ontario. Publicly Funded Immunization Schedules for Ontario – August 2011.
© Queen’s Printer for Ontario, 2008
(http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedule.pdf

1. DTaP-IPV-Hib: Diptheria, Tetanus, Pertussis, Polio, Haemophilus influenza type B vaccine

2. Pneu-C-13: Pneumococcal conjugate vaccine
3. Rot-1: Rotavirus vaccine
4. Men-C-C: Meningococcal conjugate vaccine
5. MMR: Measles, Mumps and Rubella vaccine
6. Var: Varicella (chickenpox) vaccine
7. MMRV: Measles, Mumps, Rubella and Varicella vaccine
8. Men-C-ACYW: Meningococcal conjugate vaccine
9. HB: Hepatitis B vaccine
10. HPV-4: Human papilloma virus vaccine
11. Tdap: Tentatus, Diptheria and Pertussis vaccine
12. Inf: Influenza vaccine

46
QUICK REFERENCE GUIDE
 Developmental Milestones
Developmental Milestones

Age Gross Motor Fine Motor Language Social/Cognition

1 month Lifts head to 45 Follow to midline Startles to loud noise Smiles
degrees spontaneously
2 months Lifts head up when Follows past midline Coos (gurgly Smiles
on stomach sounds), squeals, responsively,
laughs recognizes
caregivers
6 months Sits without Transfers between Babbles, uses Feeds self, stranger
support, rolls from hands dada/mama non anxiety
back to side specifically
9 months Pulls to stand Thumb-finger grasp, Uses dada/mama Waves bye, plays
bangs 2 cubes held specifically pat-a-cake,
in hand indicates wants
12 months Stands alone, walks Puts block in cup, 2-3 words Imitates activity,
scribbles play ball
18 months Walks up steps, Builds tower of 4 Combines words, Wash and dry
kicks ball cubes speech half hands, brush teeth
understandable with help
2 years Jumps, throws ball Builds tower of 6 Knows 6 body parts, Names friend, puts
overhand cubes names 1 picture on clothing
Sources:
Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. New York, NY: McGraw-Hill
Education; 2013.
Frankenburg, W.K., et al.: The DENVER II: A major revision and restandardization of the Denver
Developmental Screening Test.Pediatrics, 89:91-97, 1992
Frankenburg, W.K., et al.: The DENVER II Technical Manual 1996, Denver Developmental Materials,
Denver, Co.
Rourke, L., Leduc, D., Rourke, J. (2014). Rourke Baby Record: Evidence-Based Infant/Child Health
Maintenance.Retrieved fromhttp://www.rourkebabyrecord.ca/pdf/RBR2014Ont_Eng.pdf

47 QUICK REFERENCE GUIDE

 Dermatology Glossary
Dermatology Glossary
Term Characteristics Diameter Example
Macule Flat, non-palpable, change in <1cm Freckles
Patch color of skin >1cm Vitiligo
Solid raised lesion, well
Papule <1cm Nevi
circumscribed
Solid raised lesion, well
Plaque circumscribed, superficial, may >1cm Psoriasis
be flat topped or rounded
Nodule Solid palpable lesion, <1cm Dermatofibroma
height>width, appreciable
depth. Usually found in dermal
Tumour or subcutaneous tissue and the >1cm Lipoma
lesion may be above level with
or below the skin surface
Vesicle <1cm HSV
Raised, fluid-filled lesion
Bulla >1cm Burns
Pustule Raised, pus-filled lesion <1cm Pustullar psoriasis
Transient, circumscribed
elevated papules or plaques
Wheal often with erythematous
Allergic reaction
(Hive/Urticaria) borders and pale centres. Often
pruritic, formed by edema in the
dermis
Superficial break in the skin due
to loss of part or all of the
Erosion
epidermis; heals without
scarring
Loss of epidermis and at least
Ulcer part of dermis; heals with
scarring
Break in the skin extending from
Fissure
epidermis to dermis
Telegiectasia Foci of visibly dilated capillaries Rosacea
Red or purple macule or patch
Purpura that is non-blancheable; area of Coagulopathies
hemorrhage
Diffuse thickening of the
Lichenification epidermis, accentuating normal Eczema
skin markings
Dried exudate of serum, pus or
Crust Impetigo
blood originating from a lesion
Scales A dry build-up of dead skin cells Psorasis
Atrophy Thinning of the skin Chronic sun exposure
Sources: MacNeal, RJ. (2015). Description of Skin Lesions
(https://www.merckmanuals.com/professional/dermatologic-disorders/approach-to-the-
dermatologic-patient/description-of-skin-lesions)

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 Woodford, C, Yau C. Toronto Notes – Comprehensive Medical Reference & Review for MCCQE I and
USMLE II. Toronto, Canada: Toronto notes for Medical Students Inc; 2013

Antenatal Care Timelines

Antenatal Care Timelines

Frequency of visits:
 Advise 1st visit 8-10 weeks GA
 Every 4 weeks for the first 28 weeks
 Every 2-3 weeks until 36 weeks GA
 Weekly after 36 weeks GA

Add to Antenatal Form 2 at each subsequent visit following initial visit

-Complete Antenatal Form 1 and 2

-Initiate antenatal bloodwork
CBC, Type + Screen, VDRL, Hepatitis B,
Initial Visit Rubella, HIV
(Recommended 8-10 weeks GA) Pap (if indicated), Chlamydia/Gonorrhea
swab
Urine C+S and dip
-Initiate prenatal vitamins if not yet started
-Integrated Pregnancy Screening (IPS) U/S and 1st
11-14 weeks GA
set of bloodwork (PAPP-A)
11-13 weeks GA -Chorionic Villous Sampling (if indicated)
12 weeks GA + -Fetal heart rate (FHR) with doppler
15-20 weeks GA -2nd set of IPS bloodwork (MSS)
15-22 weeks GA -Amniocentesis (if indicated)
18-20 weeks GA -U/S for fetal morphology recommended
20 weeks GA+ -Symphysial fundal height (SFH)
-Gestational diabetes screen: Glucose tolerance
24-28 weeks GA test (50-gram)
If >7.8 a 2nd test is required (75-gram)
28 weeks GA -Winrho injection for Rh(-) patients
32-34 weeks GA -U/S for fetal growth is recommended
-Group B Strep (GBS) swab
35-37 weeks GA
-Determine fetal lie by palpation
40 weeks GA+ -U/S for fetal growth and BPP
Source: Summary of ACOG Guidelines for Perinatal Care 7th Edition. (2012).

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