Adult

The Ninety-Nine ®:
Study Guide for Canadian Family Medicine Residents

Written by Dr. Dimitre Ranev and Dr. Wahid
Pabani
2017 Edition
Exam Suggestions:
-Study•••••of course you should....cram all that knowledge into your brain so you can
regurgitate it on exam day
-Eat well....nutrition is good, or so we’ve been told
-Sleep well....you know how important it is.... especially post call
-Do as many practice questions you can
practice makes perfect....or at the very least better than before
-Visit your exam center....know how to get there, where the bathrooms are, where you can
puke if you get nervous ".don’t puke, that will make your day suck
-The night before...stay in town...don’t fight traffic...it sucks

-The night before...relax, don’t cram... watch a movie, read comic
books...do something to get you a good night’s sleep
-The night before....get a good night sleep, go to sleep early...see point 3
-On the day of, don’t do the excessive caffeine thing....you got natural
epinephrine....use it instead
-On the day of，leave early，get there on time•••••empty your bladder/bowels before the
exam....also fill your stomach on the day of.....you don’t want to be
distracted...or distract others

-After your exam weekend••…party. "it’s over••…until you have to write it again ;)
ORAL TESTING ALGORITHM
ABDOMINAL PAIN
References: Canadian Task Force for Preventative Health Care
Dynamed
Essential Evidence Plus
Uptodate
DIFFERENTIAL DIAGNOSIS
Things that are common:
GERD/gastritis/PUD, gallstones, IBD, diverticulitis,
kidney stones, ovarian cysts, UTI, gastroenteritis, pyelonephritis, IBS, PID, muscular strain,
constipation.
Things that will kill you:

cancer, ascending cholangitis, ectopic pregnancy, pancreatitis, appendicitis, perforation,
obstruction, incarcerated hernia, leaking AAA.
Other Things to Consider:
MI, pneumonia, PE, poisoning/ingestion, DKA, gynecologic issues, back pain radiation.
HISTORY AND PHYSICAL
OPQRST
Acute = rapid onset < 48hrs
Chronic = insidious onset, wks-mons
Cancer-badness Sx: early satiety, weight loss, pm sweats, changes in stool habit, bleeding.
Ask LNMP (for females)
Physical: Look for jaundice/weight loss. Abdo exam + a system above and below (thoracic and
pelvic exam). Surgical abdomen: rebound tenderness, guarding, bulging flanks, distended/hard,
etc.
*** Always check Vitals, do pelvic exams in reproductive women and PR
Lifestyle related issues:
EtOH = GERD/PUD/ gastritis;
Cigarettes = ischemic gut, CA
Med causes: NSAIDs = GERD/gastritis/PUD
Past Surgeries: obstruction, hernia
SCREENING/PUBLIC HEALTH (see cancer section)
Colon Ca = screening q2 years if >50yo
Cervical Ca = screening q3 year if >25yo
WORKUP (Based on History and Exam)
Upper GI issues: endoscopy, urea breath test, U/S, H. pylori Ab, ERCP
Lower GI issues: colonoscopy, FOBT, anoscopy, AXR (free air, stool), CT scan
OB/Gyn cause: U/S, Pap, Endometrial biopsy, Preg test
Of course don't forget to check the blood for stuff like LFTs, lipase, Cr, etc.
MANAGEMENT:
Will patient croak? if so call for help，get your surgeon.
For acute/urgent things: check ABCs, start IV fluids, put on O2/monitors, consult Surg. May
need NG tube or be NPO.
Chronic Abdominal Pain: lots of follow-up, serial exams, investigations as needed. Watch for
changes in signs or Sx
Gall stone pancreatitis: ERCP
Referrals as needed: GI, Surg., Urology, OB/Gyn. **remember Cancer Tx**
Medications:
Proton pump inhibitors: Rabeprazole 20mg PO daily. (Pantoprazole in IV form)
ABx: Ciprofloxacin and Metronidazole for perforation, obstruction or foreign body.

(triple therapy for H.pylori = see section on infections)
Pain management: Opiates (can cause constipation), NSAIDs (can cause PUD), Acetominophen
(can cause liver issues)
SPECIAL SECTION ON IBD: Crohn’s & UC
Intestinal Manifestations: bloody or loose stools, FMHx, constitutional Sx
Extraintestinal Manifestations: Weight loss, poor growth, primary sclerosing cholangitis,
episcleritis/scleritis/uveitis, arthritis, erythema nodosum, clubbing, perianal disease, strictures,
abscesses.
Medsfor UC: 5-ASA, Salazopyrin, steroids
Meds for Crohn’s: 5-ASA, Azathioprine, ABx(Metronidazole), 6-Mercaptopurine, MTX.
OTHER INFO:
Cholecystitis: colic waxes and wanes, cystitis comes with pain/fever/jaundice, angitis comes
with sepsis/decreased LOC - see hepatitis section.
Pancreatitis: Caused by EtOH, gall stones, Ca2+, triglycerides, poor kidney function, infections,
trauma, drugs (HIV meds, HTN meds, ABx, "water pills", hormones)
GERD/PUD: covered in Dyspepsia section
IBS: covered in Diarrhea section
THE BOTTOM LINE
DON’T MISS: Ectopic pregnancy，AAA，Perforation， Obstruction, Cancer signs!
Recognize a surgical abdomen and act on it!

Study up on IBD!
ADVANCED CARDIAC LIFE SUPPORT
References:
http://www.med.uottawa.ca/emergencymedicine/orcca/eng/acls_resources.html
www.acls-algorithms.com
American heart association Guidelines (2015)
NEW THINGS (in 2015):

Continue C-A-B instead of A-B-C except for newborns: Most people requiring ACLS have VF/VT.
These people require early CPR and shocks. Bystanders found the A and B components hard so
switching order to CAB ensures more people will at least attempt to do CPR. In newborns,
arrest is most likely of respiratory aetiology, so the ABC sequence should be maintained.
Compression Rate 100-120/min at depth of 5-6cm. Give naloxone 0.4mg if suspected opioid
overdose.
ETHICAL CONSIDERATIONS:
No current recommendations as to when to cease ACLS. Discuss with patients about their
wishes before the need for ACLS. New technologies muddy the water too.
PEDIATRICS:
Majority of arrests are due to asphyxia, but CAB sequence recommended.
Remember to dose drugs based on weight.
NEONATES:
Almost all arrests are due to asphyxia, so use ABC.
Remember to dose based on weight: Can use a Breslow Tape for this = Color coded to tell you
what size equipment and dose drug to use.
(Breslow tape – a color-coded tape measure the height of the child to a particular color code
and then help to give the estimated dosage quickly without actually weigh the child.)
TACHYCARDIAS = HR>100 bpm
VF/ Pulseless VT:
1) Start CPR then shock after one cycle. **shock first in witnessed arrest**
SHOCK = 200J Biphasic setting
2) CPR for 2 min then check pulse 10sec.
3) SHOCK = 200J Biphasic then repeat steps 1-3
4) EPINEPHRINE 1:1000 1 mg IV (q3_5min)
5) AMIODARONE 300 mg dose 1，150mg dose 2 if Epinephrine not working
6) Continue to cycle steps 1-3

Wide Complex Tachycardia TYT. SuperVT)
STABLE:
1) AMIODARONE 150 mg if likely VT or ADENOSINE 6mg if SVT or SYNCHRONIZED
CARDIOVERSION
2) Meds work only 30% of the time, if one fails: cardiovert
UNSTABLE (CF, ↓BP, ↓LOC, etc.):
Synchronized Cardioversion = Biphasic 100-200J or Monophasic 200-360J

Narrow Complex Tachycardia (AFib, SuperVT such as AVRT)
STABLE:
1) VAGAL MANEUVER
2) ADENOSINE 6mg (if regular/monomorphic)
3) DILTIAZEM (CCB) or VERAPAMIL (CCB) or METOPROLOL (b-blocker)
UNSTABLE (CF, SOB, ↓BP, ↓ LOC, etc.):
SYNCHRONIZED CARDIOVERSION Consider premedication

BRADYCARDIA = HR <60bpm
Unstable Narrow complex Bradycardia:
ATROPINE 0.5mg q5min --> TRANSCUTANEOUS PACING—> TRANSVENOUS PACING — >
Dopamine or Epinephrine infusion
Wide complex (2nd degree AV block type II, 3rd degree heart block)
TRANSCUTANEOUS PACING —> TRANSVENOUS PACING—> Dopamine or Epinephrine infusion
Asystole
If Witnessed Arrest then start CPR (w/monitors, IV access, etc.)
1) EPINEPHRINE 1mg q3_5min
2) CPR 2min then pulse check - no shocks to be administered
If unwitnessed consider pronouncing death
TREAT REVERISIBLE CAUSES

Hs and Ts
Hypovolemia
Hyper/Hypokalemia
Hypoxia
Hypothermia
Hypoglycemia (taken off list but still important)
H+ ion (acidosis)
Tension pneumothorax
Tamponade
Thrombus (MI)
Thrombus (PE)
Toxins
Trauma (taken off list but still important)
NEONATAL RESUCITATION PROGRAM (NRP^:
Cause (respiratory > cardiac > other)
Brain: Improves with oxygen. Culprit includes opiates.
Heart: Cyanosis from tetrology, tricuspid atresia, transposition of great vessels, total anomaly of
pulmonary connection
Lung: Improves with oxygen. Culprits include meconium aspiration, pneumonia, neonatal
respiratory distress syndrome.
ALLERGY
References:
Management of anaphylaxis in primary care: Canadian expert consensus recommendations
(2010)， Canadian clinical practice guidelines for acute and chronic rhinosinusitis (2011)
Emergency treatment of anaphylaxis in infants and children: Canadian Pediatric Society

Guidelines (2011)
Uptodate.com
BACKGROUND
Epidemiology: 0.5-2.5% of people have food allergies. Nuts, fish, shellfish, milk, eggs common.
***Anaphylaxis more common in young people and in men. ***
If you had once, chance of second with same exposure = 50-60%
Pathophysiology:
Four types =
1) IgE mediated: immediate, mast cells/histamine release, eg. Angioedema from ACEI
2) Antibody cytotoxicity: Ab rejects chemical, eg. Heparin induced thrombocytopenia
3) Immune complex disease: Ab/antigen complexes causing complement activation, eg.
Drug fever or serum sickness
4) T-cell mediated: delayed onset, associated with viral illness, eg. Contact dermatitis
True allergy vs. Pseudo allergy (“anaphylactoid”reaction, looks like allergy but documented
SE of med, i.e vanco and red man syndrome), Autoimmunity (meds causing lupus reaction),
Food intolerance,
Fixed drug eruption (smaller spot, same rash every time).
Ânaphylaxis is life threatening^ characterized by allergic reaction affecting 2 systems or
causing patient instability
Possible systems:
Skin findings = flushing, itching, rash, swelling
Respiratory findings = hoarseness, wheezing, SOB
GI findings = nausea, vomiting, diarrhea, pain
CV issues =个 HR, hypotension
**Vitals** can’t miss anaphylaxis
always inquire about any allergy and clearly document it in the chart
See if we can determine causative agent and clarify symptoms to tease out above differential
WORKUP
History is key (new exposures, circumstances of allergy, symptoms experienced).
Get the allergy testing if you want/unsure of Dx.
MANAGEMENT
Prevention
-An Epinephrine autoinjector to every patient who has a history of, or is at risk for, anaphylaxis
(kids < 30kg = 0.15mg，anyone >30kg = 0.3mg of 1:1000 epi).
-Educate patients and families about the symptoms of anaphylaxis and epinephrine
administration.
-Immediate assessment and treatment if anaphylaxis develops or if epinephrine has been used.
-For children with an anaphylactic reaction to food: epinephrine everywhere they go and advise
the family to educate the child, teachers, and caretakers about signs and symptoms of
anaphylaxis, and about when and how to use the autoinjector.
-Advise patients with known drug allergy or major allergic reaction to get a MedicAlert bracelet.
Acute Intervention:
SOB = Ventolin q15 min, nebs or puffers
Rash= Benadryl 50mg TID-QID, antihistamines
Steroids = Methylprednisolone 125mg IV, Prednisone 50mg PO, Hydrocortisone 40-60mg q6h
Anaphylaxis
Steroids + Epinephrine 1:1000 0.3-0.5mg IM/SC or 1:10 000 0.1mg IV
Fluids for CV collapse (20-60cc/kg for children)
***consider intubating anyone with respiratory findings or throat swelling***
Post Reaction
In patients with anaphylaxis of unclear etiology refer to an allergist after for clarification of the
cause
ALLERGIC RHINITIS
Hx/Px: post nasal drip, watery eyes, sneezing, runny nose (clinical diagnosis)
Acute <7 days, chronic > 7 days (more likely allergic)
Sinusitis = facial congestion/pain/pressure, nasal obstruction, ↓smell, discharge
Pathology: IgE mediated, elevated IgE
Treatment:
Lifestyle = trigger avoidance (contacts, occupational, etc.), saline rinses
Medications = Intranasal steroids (Budesonide etc.), antihistamines (Cetirizine, Loratidine, etc.),
leukotriene antagonist (Montelukast), decongestants(Pseudoephedrine) as last line
Referral = ENT for polyps/sinusitis, Allergist
THE BOTTOM LINE
-Never miss anaphylaxis, treat right away
-Always clarify what the reaction actually was, is it a real allergy?
-Epinephrine injectors for everyone, make sure they know how to use it
ANEMIA
References: Uptodate
ARUP Consult
Mosby’s family practice sourcebook
Essential evidence plus
DIAGNOSIS
Hgb of <130 males, <120 females
Classified as micro/macro/normocytic.
Look for anemia in appropriate pts or in pts w/? hemolysis (mechanical valves), w/ new or
worsening Sx of angina or CHF. As part of well-baby care, consider anemia in 个 risk populations
or in 个 risk pts. If a pt has slightly low Hgb ,don't assume this is normal for them, look for
cause.
***ARUP CONSULT HAS A TERRIFIC ALGORITHM ON ANEMIA***
HISTORY AND PHYSICAL:
-biggest Sx is fatigue
-iron-deficient patients may have pica.
-melena and blood in the stools?
-heavy menstrual periods.
-family history of anemia = thalassemia, sickle cell, G6PD, etc -acute bleeding?
-haemolytic anemia/sickle cell = jaundice & dark urine from 个 unconjugated bilirubin，
pigmented gallstones & splenomegaly.
TREATMENT (general anemia)
*** ensure stability，don’t forget ABCs***
-Treat the underlying disorder

-Transfusion guideline change with disease state. Transfuse to keep patient asymptomatic or
other diseases in check.
-General rule, transfuse if HgB <70-80g/L
MICROCYTIC ANEMIA (MCV <80)
**Suspect colorectal cancer in elderly **
TYPES: ↓iron, thalassemia, blood loss, kidney failure?
-a-thalassemia: 4a alleles. Babies stillborn w/ hydrops fetalis or die shortly after birth if all 4
affected. HbH disease = 3 affected alleles = chronic hemolytic microcytic anemia/splenomegaly.
1-2 affected alleles are usually asymptomatic.
-b-thalassemia: 2 b-globin alleles. Major = homozygous (only HbA2 made), Sx: growth
retardation, bony deformities, hepatosplenomegaly and jaundice. Minor (heterozygous) is less
severe, diagnosed by a 个 HbA2 on electrophoresis.
TREATMENT: check iron stores and replace if needed. Identify the site of blood loss and initiate
oral iron supplementation therapy. TX should be continued 3-6 months after lab values are
normal to help replenish stores.
-epo used by nephro if required for CKD
-Treat underlying cause of Anemia. In anemic patients with menorrhagia, see if there may be
another cause
MACROCYTIC ANEMIA (MCV > 100)
Types: ↓ Folate, ↓ B12, liver disease,↓thyroid, EtOH abuse, drugs, myelodysplasia.
-Dx: blood smear to look for megaloblastic anemia, which shows oval macrocytes and
hypersegmented neutrophils. If ↓ B12 suspected, check intrinsic factor Ab and anti-parietal cell
Ab. A Schilling test may be used to confirm the cause.
-Sx: Of ↓B12 would have some neurologic issues (neuropathy, parasthesias, numbness,
unsteady gait, dementia, etc.)
NORMOCYTIC ANEMIA (MCV of 80-100)
blood loss (hemorrhage), hemolysis, or ↓ production.

-Iinitial workup = retic. count, creatinine, hemolysis labs, and blood smear.
-Normal reticulocyte count = Anemia of chronic disease or chronic renal failure.
- increase retic count, ↑ LDH, ↑ unconjugated bilirubin, and ↓ haptoglobin = Hemolysis.
TREATMENT for Macro/Normocytic Anemia: treat underlying cause
Hemolysis
Hereditary spherocytosis: Blood smear = spherocytes, a (+) FmHx & a (+) Coombs’ test. May
need splenectomy.
Autoimmune hemolytic anemia: Marked by spherocytes w/ (+)Coombs, test. Tx= steroids, IVIG,
immunosuppressants
Cold agglutinin disease: Acrocyanosis in cold exposure. The cold agglutinin test is +. Seen with
mycoplasmal & mononucleosis.
G6PD deficiency: Hemolysis in the presence of infection or drugs (primarily sulfa drugs). Blood
smear =bite cells.
Paroxysmal nocturnal hemoglobinuria (PNH): Intravascular hemolysis (with ensuing
hemoglobinuria) and recurrent thrombosis. May involve pancytopenia.
MICROANGIOPATHIC HEMOLYTIC ANEMIA
**Constitutes a medical emergency. *** intravascular hemolysis with fragmented RBCs
(schistocytes & helmet cells on smear).
DIC: Overwhelming systemic activation of the coagulation system stimulated by serious illness.
Causes =sepsis, shock, malignancy, trauma, obstetric complications. Treat underlying cause,
consider FFP/cryoprecipitate.
HUS: Renal failure, hemolytic anemia, thrombocytopenia. Causes: viral illness and E. coli
Oi57:H7. May need dialysis.
TTP: Pentad of the HUS triad + fever and fluctuating LOC, although patients may not have all.
Causes: HIV, pregnancy, OCP. Tx = plasmapheresis. *no platelets to be given*
SICKLE CELL ANEMIA

Autosomal-recessive Dz.
-Blood smear = sickled cells, Howell-Jolly bodies, and evidence of hemolysis. Dx via Hemoglobin
electrophoresis.
-Tx: folic acid, avoid dehydration, hypoxia, intense exercise, and 个 altitudes. Vaccinate for
encapsulated organisms
transfusions for severe anemia, crisis, priapism. If frequent pain crisis, hydroxyurea or bone
marrow transplantation should be considered.
Pancytopenia: toxins, drugs, infection, myelodysplasia, malignancy, radiation, | vitamin
Bi2/folate, SLE.
Other points:
ANTIBIOTICS
References: Rxfiles
Canadian Anti-infective Guidelines (2013)
*** avoid prescribing antibiotics for viral infections***
***Investigate what pts describe as allergies - true allergies vs. side effects***
*** In urgent situations (e.g., cases of meningitis, septic shock, febrile neutropenia), do not
delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis)
***
***In pts requiring Abx therapy, make rational choices (use first-line therapies, know local
resistance patterns, order cultures when applicable)***
ANXIETY
Canadian guidelines for the management of anxiety, posttraumatic stress and OCD (2014)
Mosby’s Family Practice Sourcebook
BACKGROUND
GAD = Lifetime prevalence is 5%; the male-to-female ratio is 1:2
OCD = Lifetime prevalence is 1-3%
Panic Disorder = Lifetime prevalence 〜5%
Phobias = Lifetime prevalence 〜10%
PTSD = Lifetime prevalence 6-9%

Anxiety D/Os: panic disorder, OCD, phobias, GAD, PTSD.
Other Psych D/Os: depression, hypochondriasis, somatization disorder, schizophrenia,
obsessive- compulsive personality disorder, avoidant and schizoid personality disorders,
borderline personality disorder, factitious disorders.
Other things to consider: Drug intoxication/withdrawal, factitious D/0, malingering, brain
tumor.
^Medical conditions (ALWAYS R/0): PE, MI, Thyroid dysfunction, angina, hypoglycemia^^
GAD = Anxiety/worry on most days for at least six months +Three or more somatic symptoms;
including restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep
disturbance. Difficult to control worry about everyday things.
OCD = Obsessions (thoughts) and/or Compulsions (actions) are recognized at some point as
excessive or unreasonable, cause marked anxiety/distress, and are time- consuming (take > l
hour/day).
Panic Disorder = Recurrent, unexpected panic attacks followed by at least one month of worry
about attacks and/or maladaptive behaviours to avoid panic attacks.
PANIC ATTACKS: discrete periods of intense fear or discomfort in which at least four of the
following symptoms develop abruptly and peak within few minutes; Palpitations, Sweating,
Trembling, Shortness of breath, Chest pain, Nausea, Dizziness, Numbness, Depersonalization,
Fear of losing control, choking, feeling of impending death/doom.
Phobias = duration is six or more months SOCIAL is characterized by unreasonable, marked, and
persistent fear of scrutiny and embarrassment in social or performance situations (also referred
to as social anxiety disorder.). Must impair function of everyday life and out of proportion to
actual threat.
SPECIFIC is immediately cued by an object or a situation (e.g., spiders, animals, heights).
AGORAPHOBIA is being in public spaces in fear of being trapped or unable to escape if
panic attack. Must happen always when encountering same situation.
PTSD = Exposure to life threatening event/sexual violation/serious injury and > l month of the
following:
-intrusion Sx (flashbacks etc.)
-avoidance of stimuli related to trauma (people, places, etc.)
-negative alterations of cognition or mood (depression, | memory, etc.)
-alteration of arousability (sleep disturbance, hyperarousal, etc.)
ACUTE STRESS: Symptoms are the same as similar to those of PTSD but last < l month and occur
within one month of a trauma emphasizing dissociative symptoms.
ADJUSTMENT D/O w/ ANXIETY: Emotional or behavioral symptoms within three months of a
stressor; lasts <6 months.
**When interviewing a patient, screen for SUICIDALITY, ABUSE, SUBSTANCES**
WORKUP:
All the anxiety disorders are clinical diagnoses.
**R/o pathology, especially those with previous diagnosis of psych issues and new
symptoms**
MANAGEMENT
GAD = SSRI/SNRI + psychotherapy. Benzos offer acute relief but watch for dependence and
tolerance. Pregabalin can be first line. If refractory change to another first line.
OCD = Pharmacotherapy (e.g., SSRIs/SNRIs or clomipramine) + behavioral therapy (e.g.,
exposure and response prevention CBT). CBT better or equal to pharm therapy.
Panic Disorder = CBT + Pharmacotherapy (SSRIs, alone or in combo with benzos sort term).
TCAs are second line after two first line agents are not tolerated or are ineffective.
PTSD = CBT + SSRIs; CBT is first line, if SSRIs are not tolerated or are ineffective, TCAs, MAOIs,
Second-generation antipsychotics (risperidone, quetiapine) or anticonvulsants (Topiramate) can
be used third line. Benzos are not recommended for treatment.
Phobias = CBT + pharmacotherapy (e.g.， SSRIs) are effective for social phobias. B-blockers
have been found effective in performance related social phobias. Behavioral therapy that uses
exposure and desensitization is best for specific phobia. Treat Agoraphobia as you would a
panic disorder.
***Box breathing exercises for all!!***
Typical Benzo doses:
Be wary about dependence. Long term therapy not recommended generally with
benzodiazepines.
Alprazolam (xanax) 0.125-0.25mg TID/QID
Clonazepam 0.5mg BID/TID
Diazepam (valium) 2-10mg BID/TID/QID
Lorazepam (ativan) 2-3mg/day divided in 3 doses
THE BOTTOM LINE
-donJt assume people have an anxiety disorder without ruling out real pathology
-screen for suicide
-figure out which disorder it is then treat appropriately
ASTHMA
References: CTS 2012 Guidelines update
Asthma Action Plan
CTS 2010: Consensus Guidelines,
BC Guidelines: Asthma - Diagnosis and Management (2015)
DEFINITION:
Inflammatory d/o of the airways characterized by paroxysmal or persistent Sx such as dyspnea,
chest tightness, wheezing, sputum production & cough. Associated with variable airflow
limitation & degree of 个 responsiveness of airways to endogenous or exogenous stimuli.
Reversible，Obstructive，Chronic，Reactive
EPIDEMIOLOGY: 7-10% adults and 10-15% children, most children improve in teens.
SIGNS AND SYMPTOMS:
-Frequent episodes of breathlessness, chest tightness, wheezing or cough
-Sx ↑in pm, in the early am, in young children after playing or laughing
-Triggers: URTI, weather (cold, humidity), allergens (pet dander, dust, molds,), irritants (smoke,
pollution), exercise, emotional stress, GERD, drugs (NSAIDs, P- blockers), preservatives
(sulphites, MSG). Sx ↓with bronchodilators or steroids
Association: Atopy in family (eczema, allergic rhinitis, asthma) and occupational asthma
(chemicals, animals, etc)
lx: CHILDREN < 6yo: Can't use PFTs for Dx. Must use criteria: Major = Atopy Sx, 3 eps. of
wheezing < 3 yo. Minor = Classic Sx. as above, ↓ Sx with bronchodilators. Clear improvement
with Tx in i-5yo confirms Dx.
PULMONARY FUNCTION:
Acute Care Management (in ER):

O2, Fluids, SABA @ 0.03cc/kg in 3cc NS q20min by mask until improved,
Atrovent if severe: 1cc added to each of first 3 Ventolin masks
Steroids: Prednisone (2mg/kg in ER, then 1mg/kg daily x 4 days) or Dexamethasone
(0.3mg/kg/day)
Hospitalize if: -Pre-treatment O2 < 92% sat，past hx of ICU admission, unable to stabilize with
q4h masks, family’s ability to cope and environmental exposure.
Chronic Care Management:

Nortpharm: Written action plan = Self-management education, trigger avoidance, Inhaler
technique, adherence
***QUIT SMOKING***
Chronic care Pharm: Daily controller therapy - ICS is first line, 2nd line is increase ICS (<12yo) or
add LABA (>12yo), then add LTRA (could use as second line).Last line: anti-IgE, oral Prednisone
(see resp by now)
-Reliever therapy (fast-acting bronchodilator for PRN use) eg. SABAs
MEDICATION EXAMPLES:
LTRA = Motelukast (Singulair)
ICS = Fluticasone (Flovent)
SABA = Salbutamol (Ventolin)
LABA = Formoterol
ASTHMA CONTROL
-assessed at each visit including at least l measure of lung function:
Daytime Sx < 4 days a week
Nighttime Sx < 1 night a week
Normal physical activity
Infrequent exacerbations
Need for SABA <4 a week
FEVi > 90% of best
If above not fulfilled，continue to 个 Tx
Bronchiolitis
-1st episode of wheezing associated with URTI & signs of Resp. distress.
-Peak incidence winter and spring Caused by RSV >50% of time.
Sx: cough, fever, irritability, wheezing, Resp. distress, Tachypnea, tachycardia, retractions, poor
air entry lasting 5-6 days.
Tx: Epinephrine, thick feeds, nasal suction Hospitalize in appropriate setting if resp. distress,
family issues, need for 02.
ATRIAL FIBRILLATION
References: Canadian Cardiovascular Society Atrial Fibrillation Guidelines (2010)
Focused update of the Canadian Cardiovascular Society Guidelines for the management of atrial
fibrillation (2016)
BC Guidelines: Atrial Fibrilliation (2015)
DIFFERENTIAL Dx: (Causes for Afib)
Common causes: HHIITSS. (Hypertension/Heart failure, Ischemic heart disease/Idiopathic,
Thyrotoxicosis, Sarcoidosis/alcoholS)
Dangerous causes: MI, Wolff-Parkinson-White, Sick Sinus Syndrome. Thyroid storm
Others: COPD, drugs, electrolyte changes, infections, PE
BACKGROUND
Epidemiology: 个 with age, no sex preference. (5-10% of >65yo)
Pathophysiology: Usually 2nd to dilation of atria causing a 个 chance for electrical impulses not
generated by the SA node which take over as pacemakers resulting in irregular contractions of
the atria
Hx/Px: OPQRST
Onset really important (but difficult) to determine, need to estimate if Afib <48 hours
-Heart Hx: palpitations, chest tightness/chest pain, dyspnea (exertional vs non exertional),
orthopnea, paroxysmal nocturnal dyspnea, pre-syncope, syncope
Stable vs. Unstable AF: any of the above heart symptoms plus altered level of consciousness
or poor vitals.
-Drugs: Always ask about EtOH -PMHx: hx of DVT/PE, heart valve issues.
Px: LOC, Vitals (BP, HR plus rhythm, 02), lungs & heart to look for CHF, Aortic Stenosis
WORKUP if stable: suggested by CCS
To diagnose/determine etiology: ECG/Holter (if ECG neg.)/Echo, CBC, TSH
Baseline for medications: Coagulation profile (PT/INR, PTT), Serum Creatinine, LFT5s (albumin,
bilirubin), AST/ALT,
Assess cardiovascular risk: Lipid Profile, Fasting glucose/HBAiC
MANAGEMENT:
New onset Afib or flutter (Afl) -From CCS guidelines: First ABCs then:
Drugs you should know:

Rate Control:
-CCB (Diltiazem) 10 mg slow IV push, then 20 mg in 15 min, then 30 mg orally OD (Use if
COPD/Asthma)
-b-Blocker (Metoprolol) 5 mg slow IV push over 2 min, x3 (Use if CAD)
Rhythm Control:
-Digoxin if CHF or need rhythm Control
-Electrical Cardioversion, use 20oJ biphasic
-Amiodarone 150 mg iv over 10 min，X3
Chronic TX(more relevant to primary care)

Anticoagulation: Need to determine risk
CCS 2014: if >65yo, DM, CHF, HTN, Previous CVA or TIA = Start OAC or Warfarin
If CAD or vascular disease = start ASA 8img
If none of the above = no anticoagulation
CHADS2 risk score for stroke (previous guide):
CHF = 1, HTN = 1, Age > 75yo = 1, DM = 1, Previous Stroke/TIA = 2
Score 0-1: Start ASA 81 mg. Risk of stroke 〜2-3%. Reduces risk of stroke by 1/3
Score >1： Start oral anticoagulants (OAC) or Warfarin. Risk of stroke 〜3-25%. Reduces risk of
stroke by 2/3.
OAC = Warfarin in effectiveness but requires no monitoring. Reversal agents on their way. In
trials bleeding risk equivocal Canadian agency for drugs reccs: Warfarin over OAC. CCS reccs:
OAC over Warfarin.
Rate or Rhythm control:
NO EVIDENCE THAT RHYTHM CONTROL IS BETTER THAN RATE CONTROL. RHYTHM CONTROL
DRUGS ARE MORE TOXIC
Consider all Afib/Afl patients for catheter ablations - especially if risk of surgery low or
CAD/valve issues.
THE BOTTOM LINE:
-Common condition, try to find cause
-If acute need to know >48hours (Rate control if >48hours, Rhythm control if <48 hours),
- stable vs unstable
-Chronic therapy to prevent CVA
BAD NEWS
References: Mosby’s Family Practice Sourcebook
AAFP: Breaking Bad News (2001)
How to Break Bad News? —SPIKE Model
STEP 1： S-SETTING UP the Interview

Arrange for some privacy.
Involve significant others (Most patients want to have someone else with them but this should
be the patient's choice).
Sit down (Sitting down relaxes the patient and is also a sign that you will not rush)
Make connection with the patient. (ie good eye contact; caring touch, if appropriate).
Set aside appropriate amount of time, try to avoid interruptions.
STEP 2: P—Assessing the Patient's PERCEPTION
-“What have you been told about your medical situation so far?” or “What is your
understanding of the reasons we did the MR!?”.
-correct misinformation and tailor the bad news to what the patient understands.
STEP 3:1-Obtaining the Patient's INVITATION
While a majority of patients express a desire for full information about their diagnosis,
prognosis, and details of their illness, some patients do not.
-How would you like me to give the information about the test results? Would you like me to
give you all the information or sketch out the results and spend more time discussing the
treatment plan?.
-offer to answer any questions they may have.
STEP 4： K-Giving KNOWLEDGE and Information to the Patient

-Use language at appropriate level for patient comprehension, no jargon.
-Avoid blunt ness (ie. “You have very bad cancer and unless you get treatment immediately you
are going to die.”).
-give information in small chunks.
STEP 5: E—Addressing the Patient's EMOTIONS with Empathic Responses
-Observe patient’s emotion; identify the emotion and reason for emotion.
-make empathizing statement based on this (ie. aI know that this isn't what you wanted to
hear. I wish the news were better.”
STEP 6: S-STRATEGY and SUMMARY
-summarize the meeting
-let pt know support resources
(ABODE model) from AAFP:
Advance preparation
Build a therapeutic environment/relationship Communicate well
Deal with patient and family reactions Encourage and validate emotions
BEHAVIOURAL PROBLEMS
References: CADDRA (2011),
Child Behaviour PBSG
RX Files
Learning disabilities association of Canada
EPIDEMIOLOGY:
Prevalence of behavioural and emotional problems in children and youth today are common 〜
20%.
Normal variation (development)
□ specific behavior problems (impairment, but does not meet DSM)
□ disruptive behavioural (DSM criteria met).
DIFFERENTIAL Dx:
Medical - hearing/vision impairment, hematologic (anemia), metabolic (thyroid), endocrine
(DM), infectious (hepatitis, etc), sleep disorder
Psychiatric- depression, anxiety, bipolar, psychotic d/o, eating disorder
Pervasive developmental- autism, AspergerJs, RhettJs, learning disorder
Disruptive Behavioural disorders- ADHD, ODD, CD
Psychosocial- abuse, substances, peer issues, family/parenting issues, temperament mismatch
HISTORY
***ALWAYS get collaborative info - child, parents, teacher, etc***
-Description of behaviours, duration, onset, timing, frequency, stressors
-Behaviour in different spheres- home, school, peers -Child’s functioning
-TEENS = HEEADSS (home, education, employment, activities, diet, drugs, suicidality, sex)
Risk assessment: abuse, suicidality, aggression, homicidal ideation, risky behavior, SES, parental
discord, past psych hx, brief developmental hx
ADHD/ADD
Epidemiology: 4-9% school age children. M: F = 4:1 (M: usually impulsive /hyperactive, F:
usually inattentive). 5% of adults. Average onset age 3
-FHx important. Comorbidity rate high!!! (40-50% learning disability, 20-30% depression, 20-
30% anxiety, 30% ODD, 20% CD, 15-20% drug abuse)
-Formal scales useful – Conner’s teacher/parent rating scales (costs money, shows trends),
SNAPIV (free, time consuming)
MANAGEMENT: Behavioural
-Counseling, including CBT (eg, goal-setting, self-monitoring, modeling, role-playing) often
effective.
-Structure and routines are essential Consistency, parental limits.
-Classroom behavior improved by environmental control of noise and visual stimulation,
appropriate task length, novelty, coaching, and teacher proximity Psychoeducational
assessment (RO learning dx).
-Family therapy, social skills training etc.
Pharmacologic:
Stimulants Long acting as 1st line. S/E insomnia, ↓ appetite, GI S/E, abuse risk, CVS (↑QT
interval/HR, HTN), ↓ seizure threshold, psychosis, caution in severe depression/ anxiety
MethyIphenidate (Ritalin [SR]=short [intermediate] acting, Biphentin = biphasic/can sprinkle,
Concerta = biphasic).
Dextroamphetamine (Adderall XR = biphasic, Dexedrine = short acting, Dexedrine capsule = can
sprinkle)
Lisdexamfetamine (Vyvanse = long acting, newer.? More S/E)
Nonstimulant SNRI: use if nonresponsive, Cl stimulants, substance abuse potential, anxiety, tics
Atomoxetfne (Strattera = long，SE =个 suicidal ideation (not completion), CV dz, liver dz, |
appetite, GI issues)
Other Disruptive Behavioural Disorders
Behaviours in Dementia: Covered in ’’Dementia” section

BOTTOM LINE:
-Behaviour problems are common (-20% adolescents)
-Keep Broad differential
-use Pharm/Non pharm Tx
-Always get collaborative info
-ALWAYS RO suicidality/aggression/drugs
-MANY comorbidities!!!!!
BREAST LUMP
References: Toronto Notes
Canadian Task Force for Preventative Health (2011)
Uptodate
Canadian Cancer Society
BC Guidelines: Breast cancer Mangement and Followup (2015)
EPIDEMIOLOGY:
Breast Cancer is 2nd leading cause cancer mortality in women (1 in 27 of Canadian women will
die from it)
RISK FACTORS:
most breast cancer occurs with NO FHx
-Increasing age (80% of breast masses malignant if >50yo)
-Female gender
-Genetics (BRCAl or 2), 1st degree relative with breast cancer
-Previous breast CA or specific benign breast dz (hyperplasia, atypical hyperplasia, sclerosing
adenosis, papilloma)
-Unopposed estrogen exposure- early menarche (<12yo), late menopause (>55yo), nulliparous,
1st preg >30yo, >5years HR
-Radiation, Alcohol (>1 standard drink/day), Overweight/obese, postmenopausal
SCREENING:
Canadian Task Force: Mammography from age 50-74, q2-3yrs (weak reccs)
(Fails to detect 10-15% breastCA)
↑ Risk: mammography from age 30-74 (loyears earlier than youngest relative)
(Gene carrier = BRCAl/2 etc, 1st degree relative of gene carrier, high risk assessment by
geneticist, chest radiation before age 30)
Physician and self-breast exam- no evidence of good, do as you wish.
OPQRST
-AGE
-nipple discharge (colour), breast pain, skin changes, symmetry between breasts, association
with menses
-growth of breast mass, duration, fevers/swelling/redness, constitutional symptoms -
reproductive Hx- menarche, menses cycles, menopause, pregnancy
-FHx, PMHx cancer (breast/ovarian, etc)
-meds- ?HRT/OCP
-psychosocial impact of testing/cancer dx
Invasive Breast CA skin changes
Paget’s disease- ductal carcinoma invades nipple-scaling, eczema-like lesion
Inflammatory carcinoma- duct carcinoma invades lymphatics- peau d’orange (advanced), skin
edema/erythema / induration
DIAGNOSTICS:
Mammogram (diagnosis vs screening) - best for age>30yo
U/S- use if <3〇yo or pregnant or palpable mass - differentiate solid vs cystic
Needle aspiration- for fluid/cysts (for cytology) = blood is bad, straw like you follow
Fine Needle aspiration (FNA)- for solid lesions (send for pathology)
U/S guided core needle biopsy- larger sample than FNA
Excisional biopsy- definitive diagnosis
***If Mass palpated usual course of action is mammogram + U/S and refer to surgeon if
badness detected***
DIFFERENTIAL OF BENIGN CAUSES
*** Cancer is on differential***
Management and Followup after Breast Cancer
Dx:
-When Dx made - send to surgeon (士 Oncology- surgeon will do this after likely)
-consider sending for genetic counselling/fertility experts if younger side/FHx
-Tx usually done in CA centre - support pts through this
-Breast exam/mammo q6-12month post Tx for 5 years, then routine (no mammo on
mastectomy needed unless suspicious lesions)
-If any sign of mets/recurrence - lx early (back pain, seizures/headache, liver issues, coughs,
lumps, etc.)
-Assist in Tx of SE from meds/chemo (hot flashes, nausea，vaginal dryness, sexual
dysfunction，etc.)
-Refer to appropriate community supports (Cancer societies, home care, support groups, etc.)
BOTTOM LINE
-AGE!!!! (>50yo) is biggest risk factor!!!
-SCREEN with mammo q2-3yr age 50-74 (Grade D). NO Self exam
-Be aware high risk individuals may need mammo earlier (age 30)，or U/S if <3〇yo/pregnant
-Fibroadenoma and fibrocystic changes COMMON in younger ages
-Overlying skin changes = BAD!
CANCER
References: Cancer Care Manitoba (2013)
SOGC guidelines for cervical cancer screening (2013)
Canadian Task Force on Preventive Health Care
Cancer Care Ontario
PRIMARY PREVENTION:
-smoking/alcohol cessation
-protected sexual intercourse -HPV vaccination - Gardasil and Cervarix

General Screening issues:
-Benefits of screening = J, mortality (hopefully), early detection
-Harm of screening = false (+) can lead to harmful testing, anxiety/depression. False (-) would
cause overconfidence.
Ovarian Cancer (CTFPHC 2014): Recommended not to screen general public by Canadian &
American task forces.个 risk in those w/ family Hx, early menarche, late menopause, nulliparity,
Jewish, BRCA mutations, ?HRT usage. OCPs protective. Transvaginal US to detect.
Endometrial Cancer: No routine screening for general public, fin HRT with estrogen only, FHx,
radiation exposure in childhood, Tamoxifen, Obesity. Check in any postmenopausal ? with
vaginal bleeding. Use endometrial biopsy & transvaginal US to detect.
Breast Cancer (CTFPHC 2011^ - see Breast Lump Objective . Mammography q2_3 years in 5〇-7
〇yo of average risk.
Cervical Cancer (CTFPHC 2013V Malignancy of cells lining the surface of cervix.〜80% are
squamous cell carcinomas. PAP screening | cervical CA by 75%. Invasive cervical CA incidence
for ? 2〇-69yo was
1/10,000. Înitiation/cessation of screening varies by province** CTFPHC and SOGC disagree:
-start screening @ 2i-25y〇 based on sexual activity -Cervical cytology screening q3yrs or
sooner if abnormalities found.
-Screening may be DC'd after 7〇yo if there is an adequate negative screening history in the
previous 10 years (〜3 or more negative tests).
-Screening can be DCJd in ? w/ total hysterectomy for benign causes w/ no Hx of cervical
dysplasia or HPV infection.
-Indications for screening frequency for pregnant women should be the same as for women
who are not pregnant.
-? who have sex with ? should follow the same cervical screening regimen as ? who have sex
with 6 . Immunocompromised or HIV + ? should receive annual screening.
What to do with pap results:
NEGATIVE:
Repeat pap in 3 yrs. No transformation
:one? It’s ok
HSIL/ASC High grade Refer for colposcopy
Atypical Cilandular cells：
Refer for
endocervical
curettage
Anything that sounds like Cancer；
Refer to specialists
ASCUS/LSIL： -Repeat pap in 6 mons
-Ifsecond pap not negative, refer for colposcopy -Ifsecond pap negîve, repeat pap in 6 mons.
-Ifthird pap not negative, refer for colposcopy.
If third pap negative, back to regular screening.
Prostate Cancer (CTFPHC 2014) - See prostate objective
-No population-wide screening, the importance of informed choice is recommended. Benefit of
PSA is unproven as a population based screening test and $ should be advised of the availability
& reliability of PSA testing, and the potential risks & benefits of testing -If proceeding with
testing, then both DRE and PSA should be performed
Lung Cancer (CTFPHC 2016^
Screening those at 个 risk (>3〇pack years in lifetime, current smoker or quit < I5year ago). Low
dose chest CT yearly x 3 starting at 55yo.
Colon Cancer (CTFPHC 2016^

-2nd leading cause of CA death and the 3rd most
common CA diagnosed
Screen age 50-74. How to screen:
GENERAL TREATMENT SUGGESTIONS for anyone Dx with CA:

-Offer ongoing follow up and support and remain involved in the treatment plan, in
collaboration with specialists (DonJt lose track of your patient during cancer care)
-Assess pt’s ability to cope and actively inquire about personal and social consequences of the
illness, ie loss of job, family issues
-Inquire and manage side effects or complications of cancer treatment: Constipation, nausea /
vomiting (opioid induced, gastroparesis, motion induced), sedation (usually from meds),
delirium (infection, urinary retention, dehydration，electrolyte imbalance, drug interactions),
dyspnea/respiratory secretions, myoclonus, seizures, anorexia， mouth symptoms (thrush,
ulceration, crusting), skin (pruritis, jaundice, wound pain, malodour, ascites)
-In pts with a distant Hx of CA who present with new Sx (SOB, neurologic Sxs, etc.), include
recurrence or metastatic dz in the DDx - lx early and refer vigilantly -In a pt Dx w/CA, be realistic
and honest when discussing prognosis (Say when you don’t know)
-Refer to appropriate systems (Home care, cancer societies, support groups)
CHEST PAIN
References: BC Guidelines: Chronic Heart Failure (2015)
Mosby's Family Practice Sourcebook
CCS heart failure companion (2016)
Thrombosis Canada (2013)
BACKGROUND:
Epidemiology: Very common! Remember that the ambulatory non-ED presenter is less likely to
have life- threatening processes.
Pathophysiology: Think in terms of anatomy: chest wall, pericardium, heart, major vessels,
lungs, pleura, GI system.
DIFFERENTIAL DIAGNOSIS:
Things that are common: Ischemia (angina to stemi), Pneumonia, Musculoskeletal, PE, GERD,
Psych.
Things that will kill you: MI, Pericardial effusion/ tamponade, Aortic Dissection, PE,
Pneumothorax, Lung Ca (chronic), Esophageal perforation.
-OPQRST for chest pain and palpitations, Presyncope, SOB, productive cough +/- hemoptysis -Px
has little diagnostic value in acute chest pain. Your money should be on Hx.
-Cardio and abdo exams. ABCs!
Red flags and what NOT to miss: Progressive, Exertional, Pleuritic, Accompanying SOB, changed
cough in a smoker, constitutional symptoms.
MI presents differently in old people, diabetic & femalesl
SCREENING/PUBLIC HEALTH:
5 Key Risk factors for CAD: HTN, DM, Lipids, Smoking, Family History. Check periodic health
screening section.
WORKUP (use these in context of index of suspicion):
EKG: rule-in/out NSTEMI/STEMI Troponins: Now and 8hrs later (depending on your location,
timing may change); for ischemia, can be up in kidney disease
iXDi.mer*: low risk (not “no risk”）of DVT/PE - check Well’s score
CXR: pneumonia, pneumothorax

CT (for PE or other): PE, lung CA, Effusion, Aortic
dissection, Esophageal perforation.
Stress Test, Perfusion Studies, Angiography (see “Ischemic Heart Disease”）

Pneumonia = see pneumonia section
MANAGEMENT: Medications
ACS = ASA i6〇-3〇〇mg chewed stat if suspecting MI + Clopidogrel 3〇o-6oomg.
Atorvastatin 8〇mg. Nitro spray/Morphine for pain.
May need to give thrombolytics if not close to a cardiac center.

Serious or common side effects: No aspirin if l) Allergies or 2) GI bleeding issues. Use regular
heparin if renal impairment.
When and Who to Refer:
Cardiology urgent if abnormal stress test or perfusion studies.
Cardiac on call if EKG shows STEM I (or strange things) Thoracic if ?lung CA.
Thrombosis Service/Internal medicine if PE Gastroenterology/ General Surgery if GI causes
(?need scope or intervention).
OTHER THINGS:
ACS Classifications: NSTEMI = ftrops + CP,
STEMI = EKG changes + CP, Unstable Angina = great story, lx normal, clinical Dx
Pericarditis = |PR and |ST segments on ECG in all leads. Also T wave inversions.
Treat with high dose ASA (if ECG leads 1 & 2 have ST
elevations, think pericarditis)

Aortic Dissection: May hear bruits, have asymmetric BPs in each arm. Pain radiates to back.
Caused by HTN, marfans S}nidrome and ehlers-danlos syndrome. Treat with emergency surgery
Congestive Heart Failure:
Hx: swelling, orthopnea, paroxysmal nocturnal
dyspnea, SOB, CP
PHx: HTN, CAD, AFib, valvular dysfunction, DM, bad lung diseases or drugs. Anything that
affected the heart really.
Px: pitting edema, rales/crackles on lung exam, dyspnea, S3 on heart exam, abnormal 02
saturations lx: Echo is must, will help delineate type. Also BNP useful for acute. ECG, CXR, LFTS,
Creatinine, Trop, TSH for underlying causes. Need lytes for medication initiation.
Acute Tx: Of course start w/ABCs. Treat w/pressers or BiPAP/CPAP if required. Treat with
Furosemide to reduce fluid burden and fix underlying cause. May use Metolazone if really
overloaded (watch for |K+/renal issues). Also nitrates help assuming they can keep
SBP>ioommHg. If needing
Chronic Tx: If EF low (<40%), Tx with ACEI (or ARB but not all equal) + P-Blocker titrated to
target dose or SE/VS. Manage cardiac risk factors chronically. Immunize against all lung issues.
If worsened or becomes stage 2-4 (look up NYH heart classifications) may use Hydralazine &
Nitroprusside or Spironolactone if needed. Digoxin prevents symptoms but does not
change course of disease. Chronic Furosemide may keep people out of hospital if titrated to
weight.
If preserved EF (>40% on echo), no meds to change mortality, just Sx management.
-FU q3-6months, ensure lifestyle management/compliance
Pulmonary Embolism
see DVT section for pathophysiology/risk factors. Exactly the same.
Sx: SOB, CP, risk factors (Well's criteria outlined in DVT section).
Dx: using CT-PE protocol or V/Q scan. ECG may show S1Q3T3 pattern. CXR very rarely seen
westermark sign or hampton's hump.
Tx: Start with ABCs, ICU with 02 support if needed. May need thrombolytics if unstable. If
stable, either LMWH or heparin bridged to Warfarin for 3-6 months (depends on risk factors -
see dvt section). NOACs can now be used instead, directly (no bridging, Rivaroxaban approved
2013).
THE BOTTOM LINE
-Always consider The bad five (MI, PE, pneumothorax, Aortic aneurysm, esophageal rupture)
killers.
-Know your historical red flags!!
-Don’t forget GI causes!!
CHRONIC DISEASE
References: Canadian Opiate guidelines for non cancer pain (2011)
Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome (2012)
Things to Know:
1) When dealing with patients with chronic diseases, take a thorough Hx/Px to determine
whether an acute process is related or not. DO NOT assume it's the same process.
2) Ensure appropriate follow up and monitoring when people have chronic diseases (i.e.
every 3 months for DM, 6-12 months for HTN, etc.) see sections for each chronic disease.
3) When chronic disease patients come for follow up, ensure appropriate monitoring and
treatment is administered.
4) FIFE EVERYONE!! (feelings, ideas, function, expectations).
5) Try to determine cause of non-compliance and assist the patient to improve if possible.
CHRONIC PAIN
-Chronic diseases come with pain. Âlways ask**
-Try to determine cause of pain since management varies
-Different management guidelines for cancer vs. non cancer pain
-First line treatment of somatic pain = acetaminophen and NSAIDs
-First line treatment of neuropathic pain = TCAs and
Anticonvulsants
-Opiates indicated as second line in somatic pain and possibly neuropathic pain (Tramadol),
unlikely to work in neuropathic pain
-Before initiating opioid therapy, ensure comprehensive documentation of the patient^ pain
condition, general medical condition and psychosocial history, psychiatric status, and substance
use history-A treatment agreement may be helpful, particularly for patients not well known to
the physician or at higher risk for opioid misuse
-For patients taking benzodiazepines, particularly for elderly patients, consider a trial of
tapering. If a trial of tapering is not indicated or is unsuccessful, opioids should be titrated more
slowly and at lower doses -Chronic non-cancer pain can be managed effectively in most
patients with dosages at or below 200 mg/day of morphine or equivalent
-Try to find non pharmacological therapies □ counseling, OT, exercise, YOGA, etc
FIBROMYALGIA
Dx: diffuse body pain > 3mons，associated with sleep/mood disturbances, fatigue and possibly
cognitive dysfunction. Must not be explained by anything else. Criteria from American College
of Rheumatology (2010). No longer need tender point examination
DDx: associated with depression, chronic fatigue syndrome, IBS, migraines, interstitial cystitis
Pharm Tx: NSAIDs, tylenol, SNRIs (Cymbalta), TCAs (Elavil), Tramadol - stay away from heavy
opiates Nonpharm Tx: CBT，relaxation techniques, group
counseling, exercise, Tai Chi/yoga
comprehensive ( 、 Proceed w/Opiates?
Patient presents assessment

-risk of abuse/misuse? -consider risks vs. benefits. SE, medical
w/chronic non-cancer -urine drug screen complications
pain applicable? -agree with goals of
-would opiates work? opioid therapy
\ J
Always look
for alternative
therapies
Continually
-mointorfor effect SE,
complications
-monitor for misuse/abuse
-titrate dose accordingly
Conduct opiate trial
-caution of driving
-pick appropriate opiate
-titrate to appropriate
dose
-reassess regularly
-if causing
complications or
safety concerns,
D/C opiates
-if signs of
abuse/misuse. taper
and discontinue
opiates
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
References:
GOLD guidelines (2016)
BC Guidelines (2011)
Prevention of Acute Exacerbations of CO PD: American College
of Chest Physicians and Canadian Thoracic Society Guideline
(2015)
DEFINITION:
Progressive, incompletely reversible airflow obstruction.个 Frequency of exacerbations as time

progresses.
Chronic bronchitis
>3mons/yr for 2yrs
chronic cough + sputum
EPIDEMIOLOGY:
4th leading cause of death, 4.4% of Canadians, ? > 6
RISK FACTORS:
15% of smokers/ex-smokers (85-90% COPD).
? risk to second hand smoke
Inhaled chemicals
Alpha 1 antitrypsin deficiency
SCREENING:
Spirometry in all smokers/ex-smokers >4〇yrs w/: Persistent

cough/phlegm/wheeze/recurrent
URTI/exertional SOB
DIFFERENTIAL:
CHF, GERD, TB, Bronchiolitis (obliterative + diffuse panbronchiolitis), Alpha 1 antitrypsin
deficiency (see cough section), PE.
DIAGNOSIS:
Spirometry: FEVi/FVC < 0.7
Exclude other diagnosis with appropriate lx. Consider PFTs/Stress T est / ABG / Echo /Sputum
/alphaiantitrypsin serum level/CT-PE protocol.
Classifications
Mild = SOB with hurried walk, FEVi >80%
Moderate = SOB requiring rest 〜loom (few min)，FEVi 50-80%
Severe = Breathless after dressing, resp/cardiac failure,
FEVl < 50%

ROUTINE MANAGEMENT FOR ALL COPD:
Smoking cessation = single most effective intervention Annual influenza + pneumococcal (—
booster @5yrs) vaccine
Review puffer technique + action plan Negative repercussions of inactivity
CHRONIC MEDICAL MANAGEMENT:
Bronchodilators to reduce air trapping (hyperinflation), SOB and improve exercise capacity.
Guide management by Sx, >1 exacerbation/yr consider long
acting puffers.
iVO 7GS (/Zoueny as monot/zempy -个 risk of infections
No SAAC + LAAC if you can help it, ++SE

NON PHARM Tx: Multidisciplinary team, pulmonary
rehab, exercise
Figure 1: Effects of smoking and stopping smoking on FEV1
25 SO 75
A£e(y«ars»
PULMONARY REHAB:
For clinically stable, on optimal pharm Tx, but remains dyspneic patient.
ACUTE EXACERBATION (AECOPD^
Sustained worsening of Sx (dyspnea, sputum volume, purulence)
Causes =infection (50%, bugs = H. influenza, S.pneumonia, morcocella catarrhalis)
Also CHF, irritants, PE, MI, anemia **Find and Tx these as well**
AECOPD MANAGEMENT:
Use SABA +SAAC
If fin 2 or 3 Sx above or infections signs use Abx (penicillins, quinolones, macrolides)
Moderate to severe: Oral steroid x 5-i4d, no taper
needed in short Tx. Hospitalize if applicable. 02 as needed, BIPAP/CPAP etc. if needed.

CHRONIC COMPLICATIONS:
Skeletal muscle deconditioning, right heart failure, secondary polycythemia, poor nutrition,
depression.
Oxygen: goal sats >90%, survival advantage if 02 for > I5hrs a day
Qualify for home 02 if arterial oxygen tension <55mmHg on air (<6〇mmHg if heart condition)
or Hct> 56 or POx <87% for imin. during 6min. walk test. If C02 retainer (on BW), may consider
02 levels 88-92% to reduce oxygen toxicity.
Referral: diagnosis uncertain, symptoms
severe/incongruent to spirometry, accelerated decline of lung function, onset sooner than 40
years old, failure to respond to therapy, severe/recurrent exacerbation, complex comorbidities,
assessment for pulmonary rehabilitation, home oxygen,?surgical therapy.
In patients with end-stage COPD, especially those who are currently stable, discuss, document,
and periodically re-evaluate wishes about aggressive treatment interventions. Tx palliatively at
the end.
CONTRACEPTION
References: SOGC Guidelines: Canadian Contraception Consensus (2015-2016)
Mosby's family practice sourcebook
EPIDEMIOLOGY:
41-51 % of pregnancies are unplanned
SCREENING: w/ all pts, especially adolescents, young S, postpartum & perimenopausal 9，

advise about adequate contraception when opportunities arise
ASSESSMENT:
-patient preference
-sexual Hx + risk of STI exposure
-menstrual Hx, obstetrical Hx, contraception Hx and sexual abuse Hx -plans for future fertility -
efficacy, SE and Cl of individual methods -discussion of post-coital/emergency contraception
AVAILABLE METHODS:
Natural Family Planning: Calendar method, basal body temp., cervical mucus method, coitus
interruptus, and lactational amenorrhea method. POOR RELIABILITY!
Barrier Contraceptives:
6 condoms = | transmission of STIs (Lambskin = not against viruses). Cons: User-dependent
(breakage, slippage), weakened by lubricants & vaginal products. Theoretical pregnancy rate
3%/year, typical pregnancy rate 14 %/year
? condoms = insert before sex, remove after. Not be used with a $ condom. Protects against
STIs. Reusable but expensive. Theoretical pregnancy rate 6%/year, typical pregnancy rate
20%/year Diaphragms= Use with spermicide, leave in place 6hrs
post sex. Cons: T risk of HIV，BV & UTI. Theoretical pregnancy rate 6 %/year, typical pregnancy
rate 20%/year
Spermicidal Contraceptives:
Foams, creams, gels. Inserted before sex. No STI protection. Not for sex multiple times/day.
Causes vaginal irritation. Theoretical pregnancy rate 6%/year, typical pregnancy rate 26%/year
Hormonal Contraceptives COCS): combined OCS= combinations of estradiol (| follicle selection)
and a progestin (| ovulation & 个 cervical mucus). Theoretical pregnancy rate 0.1%/year, typical
pregnancy rate 6-8%/year
Pros: I DUB, dysmenorrhea, peri-menopausal hot flashes, acne, benign breast dz, ovarian cysts,
ovarian CA, endometrial CA (in older OCs > 4yrs of use), | ectopic pregnancy.
Risks:个 risk of ischemic stroke & subarachnoid hemorrhage, especially if age >35, smoker,
obesity, migraine or HTN.个 risk of venous thromboembolism 3- 4x in OC users,个 risk of MI if
smoker or HTN. Risk of breast CA is controversial
SIDE EFFECTS OF OCS:
nausea, breast tenderness, bloating, weight gain, fatigue, and headache. Breakthrough bleeding
occurs in 10-30%, and usually resolves by 3 months ABSOLUTE Cl FOR OCS:
<6 weeks post-partum & breast-feeding, >35yo smoker), HTN (SBP >160 or DBP >100), Hx of
venous thromboembolism, CAD or complicated valvular heart
disease, Hx of CVA, migraine headache with focal neurological symptoms, breast CA, DM with
vascular damage, severe cirrhosis or liver tumor
Relative Cl (per WHO/SOGC): controlled HTN, migraine headache, >35yo, symptomatic
gallbladder disease or Hx of OC-related cholestasis, meds that may interfere w/OC metabolism
Initiation of OCs: Same-day once pregnancy ruled out. Use continuously (no pill-free week) for
menstrual migraine, dysmenorrhea, mood swings
Missed pills: l - take as soon as possible 2 or more - take l ASAP, then finish pack (need back up
contraception for 7 days, skip sugar pills if in 2nd or 3rd week)
Contraceptive patch, contraceptive ring: Same efficacy, same Cl as OCS
Progestin-only pills: Used in patients with contraindication to estrogen (smokers >age 35,
breast-feeding, migraine with aura, history of VTE, HTN).Must be taken within ^ hours of the
same time every day. Irregular bleeding common. Theoretical pregnancy rate 0.5%/year, typical
pregnancy rate 5- 10%/year. i risk of Ovarian/Uterine CA
Depo-provera: Injection qi2 weeks. Administered when pregnancy ruled out. Irregular bleeding
common, Issues with bone density, re-establishment of menses after DC takes 6-24 months
IUDs:
Complications =? PID and uterine perforation (〜1/1000). ? screen for STIs
copper* il/D: effective 〜5 years. Can 个 vaginal bleeding and menstrual pain.
Theoretical pregnancy rate <2%/year Levonorgestrel IUD: effective ~ 5 years. Effective for
dysfunctional uterine bleeding. Theoretical pregnancy rate 0.09%/year (equivalent to tubal
ligation). Same issues as OCS.
STERILIZATION:
Tubal sterilization:? reversible, can have regret. Theoretical pregnancy rate 0%, typical
pregnancy rate 1.85%/year
Vasectomy: back-up contraception for 20-30
ejaculations. Failure rate 1/1200. Need semen analysis conducted lowks post-op. Chronic pain
in 1-2%
EMERGENCY CONTRACEPTION TSOGC 2012I:
COPPER IUD METHOD - good for 5 years, less complications, 99% effective if placed in 7 days
only one indicated if BMI > 30.
Yuzpe method: 2 Ovral tabs (Ethinyl estradiol 100 meg + levonorgestrel 500 meg), repeat in I2h.
Some OCs can be substituted for Orval at varying doses I success with time. Give w/ anti-emetic
Plan B: Levonorgestrel 750 meg, repeat in I2h, effectiveness = 95% @ 24hrs, 85% @ 48hrs, and
58% @ 72 hours. Effects continue to 120 hours, more expensive, | nausea/vomiting than
others.
COUGH
References: Essential Evidence Plus
CTS Cough: Etiology, evaluation and treatments (2012)
Uptodate
COUGH TYPES:
Acute < 3 wks, Subacute = 3-8 wks, Chronic > 8 wks
Acute Cough (<3weeks)
Do Hx/Px/lx as appropriate
v J
/\
Serious
condition?
^ J / \ Not Life threatening?
V- J
Pneumonia,
Asthma/COPD
exacerbation,
PE, CHFor others
^J ? Infection: upper or lower resp. Tract treat ^ accordingly y Environmental
issues? r \ Exacerbation of pre¬existing condition: CHRCOPD. Asthma, Bronchiectasis, Upper
airway cough syndrome
VV
Treat
accordingly
Most often caused by URTI, but must r/o PE, CHF, pneumonia, pneumothorax. May also
consider asthma, COPD, sinusitis
Subacute Cough (3-8wks)
Post Infectious cause?
'v J New
condition or exacerbation of pre¬existing one?
、 J Non-
infectious
VJ
Pn6umo 门 i3
or other serious illness -> treat

accordingly Pertussis,
Bronchitis
VJ r \ COPD, CHF, Bronchiectasis, Asthma, GERD, Upper airway cough syndrome v J /* N
Evaluate like chronic cough
VJ
Things to consider on Hx in Dx cause of cough: Timing, Age toxic exposures, immunizations,
smoking!!!,? post nasal drip, nasal congestion, allergies/eczema, wheezing, SOB, orthopnea,
chest tightness, palpitations, heartburn, sputum, facial/dental pain, constitutional Sx, Meds
(ACEI), relation to food
Chronic Cough (>8wks)

Cause of cough found Smoking or ACEI usage
^ J
Treat
accordingly
LJ If cough continues or cause not found
i -J discontinue
J
r ~^ Upper airway cough syndrome: empiric treatment
Asthma: assess and treat
GERD : assess and treat
Non asthmatic eosinophilic bronchitis: (eosinophils in sputum) treat
accordingly
If inadequate response to Tx: refer to specialist or acquire
further lx (CT, Echo, Allergy studies, sinus imaging, etc.)
* if normal CXR usually rules out CA, bronchiectasis, pneumonia, sarcoidosis and TB.
* if abnormal CXR consider: CT, sputum cytology/ culture, referral
SMOKERS:
must rule out same things as in non-smoker have higher index of suspicion for lung CA and
COPD， thus consider CXR and PFT encourage smoking cessation
Chronic bronchitis - cough and sputum on most days over at least 3 months for > 2 consecutive
years in patient without other explanation for cough
Approach to chronic cough in children:
If under 18 months consider: congenital etiologies (heart defect, lung defect, cystic fibrosis, etc)
Most common causes cough: Upper & Lower RTFs, asthma, GERD.
Most common cause of chronic cough is cough variant asthma
Older kids:个 rate of cough variant asthma, psychogenic cough, & sinusitis.
Less common: Foreign body (but don^ forget to ask about this)
Rare: Aspiration, congenital abnormality, CF, environmental exposure, immunologic D/O (think
about this if recurrent infections), primary ciliary diskinesia, psychogenic, TouretteJs, TB
Treatment to Cough
Infections
(viral) First generation antihistamines + oral decongestants
If sub acute: Ipratropium and short-acting steroids are both good choices
Sinusitis antihistamines + oral decongestants + Abx PRN
Pertussis Antibiotic (macrolide) - isolate for 5 days
COPD/Asthma See COPD and Asthma sections
Bronchiectasis Bronchial toilet, bronchodilators, Tx of
secondary infections, surgeiy if localized and infections a re frequent
Non-asthmatic
eosinophilic
bronchitis Inhaled corticosteroids
Upper airway
cough
syndrome First-generation antihistamines + oral decongestants or nasal Ipratropium
Allergic
rhinitis Topical nasal steroids, latest-generation antihistamine
Non-allerg ic rhinitis Inhaled nasal steroids, nasal Ipratropium
Chronic
Sinusitis Inhaled nasal steroids, ENT assessment (surgery?)
GERD See dyspepsia section
Post infectious cough May resolve on its own Frst-genecation antihistamines + oral
decongestants, inhaled steroids or nasal Ipratropium may help
Psychogenic/ Habit cough Psychotherapy, non-specific antitussive treatment for a short
period
COUNSELLING
References: Uptodate Toronto Notes
Psychoanalysis: “Freudian”，self-revelation & insight. Intensive, over years. For pts who can
tolerate ambiguity in exploration of emotions
Interpersonal therapy (IPT): Short-term Tx, teaching coping mechanisms, focus on current
situation/social context of behavior. Therapist often very directive
Supportive therapy (STV Non-directive, elicit pt's feelings. Goal is | anxiety and strengthening
mechanisms to assist in daily functioning, no insight.
Hypnosis: For pain, phobias，anxiety，smoking cessation
Dialectical behavioural therapy (DBTV For

Borderline personality
Cognitive therapy (CT) - “Moods/feelings are influenced by oneJs thoughts,J. Depression,
anxiety, self¬esteem. Be aware of automatic thoughts & assumptions/errors
Behavior therapy (BT): Modification of behaviour to control/maintain emotional distress.
Anxiety/phobias, substance abuse, paraphilias. Set clearly defined goals in behavioral terms
(actions), for eg. begin favorite
hobby on regular basis

Systemic desensitization: Gradual approach to feared stimulus
Flooding: Confront feared stimulus for prolonged periods
Positive reinforcement: Reward good behaviour Negative reinforcement: Removing a noxious
stimulus for good behaviour
Extinction: Diminish behaviour by not responding to it Aversion/punishment: Applying noxious
stimulus to negative behaviour
INDICATIONS FOR COUNSELLING:
Depression: BT/CBT, really any. Combination of meds + CBT is more effective than either Tx
alone.
Anxiety: GAD: CBT, ST Panic DO: CBT, ST
OCD: CBT/BT, desensitization, flooding, aversion PTSD: CBT, desensitization
Phobia- CBT/ST for social phobia. BT/exposure for others
Schizophrenia: ST, IPT, CBT - see Schizophrenia section
Bipolar: CBT, ST
Eating disorders: CBT (ist line for bulimia), family ST Relationship with therapist
Transference- patient subconsciously reacts to the therapist
Counter-transference- therapist’s transference to the patient
Bottom line:
-counselling a Tx option for all health

-allow proper time to evaluate and perform counselling
-remember your limitation and expertise
-know your boundaries
CRISIS
• Be prepared for emergencies, both in office and elsewhere.
• If there are acute crisis going on, take your time and help the patient.
• Identify patient’s supports and resources to help them out.
• Know your local community resources to help out your patients.
• MAKE SURE ABOUT SUICIDALITY/HOMICIDALITY.
• Make sure others involved are helped if applicable.
• Do not jump to medications unless indicated.
參 Assess unhealthy coping strategies.
• DO NOT CROSS BOUNDARIES.
• Stay calm and collected, think things through when dealing with a crisis.
CROUP
References: TOP Alberta guidelines: Guideline for the Diagnosis and Management of Croup
(2013)
Nelson Textbook of Pediatrics
DEFINITION:
Childhood respiratory illness caused by a variety of viruses. Usually contracted in autumn and
winter months. Characterized by abrupt onset of a barky cough, frequently associated with
inspiratory stridor (noisy breathing on inspiration), hoarseness, and respiratory distress.
Mild: occasional barky cough, no audible stridor at rest, and mild suprasternal and/or
intercostal indrawing (retractions of the skin of the chest wall). Moderate: frequent barky
cough, easily audible stridor at rest, and suprasternal and sternal wall retraction at rest, but no
or little distress or agitation.
Severe: frequent barky cough, prominent inspiratory and occasionally expiratory stridor,
marked sternal wall retractions, and significant distress and agitation.
RESPIRATORY FAILURE:
barky cough (often not prominent), audible stridor at rest, sternal wall retractions (may not be
marked), lethargy or J, LOC, and often dusky appearance without supplemental 02.
• DYSPNEA
PULMONARY CARDIAC
/OTHER
Lower
airway:
Expiratory
Wheezes
Asthma,
Bronchiloitis,
Tracheitis.
Pneumonia,
Atelectasis Upper
Airway:
Inspiratory
stridor
Foreign body, Epiglottitis, Croup Pleura:
Pleural
effusion,
pneumothorax,
empyema PE, CHF, Pulmonary H TIM，Ascites. Angina, Scoliosis
Ix: predominantly a clinical Dx

CXR is not routine (steeple sign on soft tissue xray).
Random Fact: Thumb sign found on xray for
epiglottitis.
MANAGEMENT:
Start with ABCs and determine severity Non-pharm: hand hygiene, contact avoidance, address
parental concerns (acknowledge fluctuating course of the dz), provide a plan for recurrence of
Sx.
Pharm: humidified 02 (mist Tx not indicated), Dexamethasone PO (IM if unable) l dose @ 0.15-
〇.6mg/kg, may repeat in 6-24hrs - DO NOT UNDERTREAT，epinephrine 〇.5cc/kg to max 3cc
qi- 2hr
intubation PRN.
Croup
Common condition:
fall/winter, 6mo-3yo
Parainfluenza virus (75%), influenza, RSV, Adenovirus
Seal-like barking cough, hoarse voice, inspiratory stridor worse at night，土 fever
Clinical Dx, steeple

sign on CXR
Tx: steroids,
humidified oxygen,
epinephrine
Tracheitis
Rare, no age limits
Bacterial infection
(Staph, Strep,
Pneumococcus)
Similar to croup but
rapid deterioration,
high fevers, toxic
child
Clinical Dx, can do
endoscopy
Start croup Tx, add
Abx, usually
intubated
Epiglottitis
Rare, 2-6yo
H flu. Strep
Toxic, high fevers,
rapid progression,
drooling, stridor,
tripod positioning, no
barking cough
Clinical Dx. avoid
examining throat
Intubation usually,
Abx
DEEP VEIN THROMBOSIS
References: Mosby5s Family Practice Sourcebook Essential evidence plus Thrombosis Canada
(2015)
PATHOPHYSIOLOGY: Virchow's triad fcoagulable = CA, FHx of DVTs, estrogen, smoking
Hemostasis = paralysis/immobilization, bed rest, hospital stay, estrogen, smoking Endothelial
injury = trauma, major surgery ***Wells criteria is derived from above risk factors， make sure
you look at zY***
PROPHYLAXIS:
Consider for anyone who may fulfill above criteria (long
hospital stay, major surgery, etc). Use heparin, LMWH, etc. If Cl, use compression boots
Sx/Dx: Tender, red, swollen (>3cm difference 10cm below tibial tuberosity) on one side limb.
Similar in upper limb if (+). Can't be Dx clinically so risk stratify pts to determine Dx tool
(US/BW)
WORKUP:
Low risk (Well's <i) = d dimer level (-) level = 0.5% chance of DVT if low risk on Wells score.
Moderate/high riskCWell's > 2) = US
Baseline BW = coagulation, renal and LFTs to be able to
choose Tx type.
Coagulopathy Screening:
<40% of DVT pts have thrombophillias
-major ones are protein c & s def., factor V Leiden,
antiphospholipid antibody, etc.
-no current screening guidelines however suggested to do if young, FHx, unprovoked or
recurrent pts
Tx:
if moderate-high chance, initiate Tx even without clear Dx
-proximal DVTs must be treated (popliteal, femoral and iliac DVTs most likely to cause PE), distal
ones could (20% chance of extending), but no guidelines about this
-superficial phlebitis = no Tx
-treat mostly as outpatient unless significant comorbid conditions
-if ileofemoral DVT, look for phlegmasia cerulea dolens
(they should undergo urgent surgical thrombectomy)

Pharmacologic: Start LMWH or Heparin for 5 days. Start Warfarin at same time & titrate to INR
2-3. Stop LMWH when INR stable. May use NOAC instead, look up doses.
-Tx for 3mons if risk factor temporary, 6-12 mons if severe/multiple risk factors/ idiopathic.
Forever if recurrent.
Nonpharmacologic: wgt loss, cool compress,
compression stockings
PE: In Chest pain section
DEHYDRATION
References: Mosby Family Medicine Sourcebook Washington Manual of Medical Therapeutics
Approach to Internal Medicine
Oral rehydration therapy (ORT) in children: BC advisory guidelines 2010
HISTORY:
-Intake of fluids (volume, type [hyper/hypotonic], frequency)
-Urine output, (frequency, last wet diapers, concentrated or dilute urine)
-hematuria
-Stool output (frequency, consistency, blood or mucus) -Emesis (frequency, volume, bilious or
nonbilious, hematemesis)
-Underlying illnesses
-Fever, Appetite patterns, Weight loss, Travel, Recent antibiotic use, Possible ingestions
SIGNS and Sxs:
Postural Pulse increment >3〇/min
Postural Hypotension >2〇mmHg
Dry axilla/oral & nasal mucous membrane/ tongue

Tongue with furrows, Sunken eyes
Confusion, weakness
Speech not clear/expressive
Cap refill >3 seconds
Criteria for Clinical Diagnosis of Dehydration:
1. Suspicion of f output and/or J, intake
2. >1 physiological or functional sign or symptom suggesting dehydration
3. 1 objectively meaningful sign = Creatinine/BUN ratio of < 10:1
Orthostasis (drop of SBP > 2〇mmHg on a change in position)
Pulse >100
Pulse 个 10-20 above baseline w/ position change ^Children/elderly /Pregnant may not exhibit
same signs/Sxs^*
%•% body weight lost due to dehydration Mild

<2yo5% > 2 yo 3% Moderate
<2yo10% > 2v〇 6〇〇 S»v»r«
< 2y〇 15% > 2v〇9%
HR Normal, full Rapid Rapid weak

BP Nonnal N-i Shock (i BP)
Urine Output 丄 n Anuria
Oral Mucosa Slightly dry Dry Parched

Anterior Fontanelle Normal SunkenMarkedly sunken
Eyes Normal SunkenMarkedly sunken
Skin turgor Normal 1 Tentincj
Capillary Refill Normal. < 3 sec N to T >3 sec
BW:
-CBC for hemoconcentration, infection, source of dehydration
-Na, K, Cl for abnormalities
-BUN, Cr increased in severe dehydration
-Blood gas and HCO3 for metabolic acidosis, Anion Gap
=[(Na+K) - (CI+HCO3)]
CAUSES of vomiting:
CNS (infections, space-occupying lesions, migraine, hemorrhage, etc.)
GI (gastroenteritis, obstruction, hepatitis, liver failure, appendicitis, peritonitis, intussusception,
volvulus, pyloric stenosis, toxicity [ingestion, overdose, drug effects], etc.)
Endocrine (DKA, congenital adrenal hypoplasia, Addisonian crisis, etc.)
Renal (infection, renal failure, renal tubular acidosis, etc.)
Cardiac (MI, CHF, infections, etc.)
Pulmonary (respiratory failure)
Psychiatric (psychogenic vomiting)
Pregnancy
CAUSES of diarrhea:
GI (gastroenteritis, malabsorption, intussusception,
IBS, IBD, short gut syndrome, etc.)

Renal (infection, pyelonephritis, etc.)
Infection (pneumonia, otitis, sepsis, etc.)
Psychiatric (anxiety)
Endocrine (thyrotoxicosis, congenital adrenal hypoplasia, Addisonian crisis, diabetic
enteropathy, etc.)
OTHER CAUSES of dehydration:
Renal: diuretics, renal tubular acidosis, renal failure (trauma, obstruction, salt-wasting nephritis,
etc) diabetes insipidus hypothyroidism
adrenal/mineralocorticoid insufficiency third space extravasation of intravascular fluid
(pancreatitis, peritonitis, sepsis, rhabdomyolysis, post¬op, etc.)
skin losses (burns) lung losses CHF
liver failure hemorrhage
Treatment: maintenence
Bodv Weiaht 100:50:20 Rule 4:2:1 Rule
MO kg 100 cc/kg/d 4 cc/kg/h
11-20 kg 50 cc/kg/d 2cc/kg/h
之 20 kg 20 cc/kg/d 1 cc/kg/h
1st year of life: D5W/0.2NS + 20 meq KC1

Children: D5 1/2NS + 20 mEq/L KC1
D10W used in neonates and hypoglycemia
NS as bolus to restore circulation in children, 20 ml/kg
x 3 max
NS usual fluid of choice for adults, Ringerfs lactate also good

Replacement:
Use the appropriate route (oral vs. IV). ist-line Txfor mild to moderate dehydration is oral
rehydration therapy (ORT). Replace deficit over 4-6 hrs plus ongoing losses (e.g. diarrhea). Use
breast milk or electrolyte supplement. Avoid sugary drinks, tea, homeopathic substances Mild
loss: icc/kg/5 mins Moderate loss: 2cc/kg/5 mins.
Severe loss: IV replacement calculate fluid deficit = % loss x 10 x body weight (pre-illness)
Isotonic V2 deficit over 8 ht then 1/a over 16 h
Hypotonic If Nail05, as above
Hypertonic Correct over 48-72 h, do not let Na dr 叩 >10-15mmol/d

In children, bolus 10-20 cc/kg of NS over i5_2〇mins initially, repeat until patient is
hemodynamically stable.
In adults, bolus 1-2L PRN, taking into account cardiac and renal function.
If |K+: add K+ when patient voids (no K+ in bolus). Subtract boluses from deficit calculation.
Monitor Ongoing losses: tubes (Foley, NG, surgical drains), third spacing (pleura, GI,
retroperitoneal, peritoneal, burns), blood
PREGNANCY: Treat aggressively
个 circulation (个 cardiac output, HR，blood volume with I BP)，个 physiologic reserve which
means that markers of dehydration will be delayed, and indicate greater
severity of dehydration when present

DEMENTIA
References: AlzheimerJs society
Cognitive impairment: recognition, diagnosis and
management in primary care: BC Guidelines (2014)
4th Canadian Consensus Conference on the diagnosis and treatment of dementia (2014),
DEFINITION:
Acquired, generalized and progressive impairment of cognition
Dx criteria: Two of the following cognitive domains are impaired: memory (amnesia, most
common), language (aphasia), visuospatial (apraxia) or executive function (SOAP: sequencing,
organizing, abstracting, and planning)
-Impairment causes a significant functional decline in
usual activities or
work
-Sxs are not explained by other neurologic DO (including CVA), psychiatric DO, systemic DO or
meds
DIFFERENTIAL:
D - drugs, degenerative (Alzheimer’s disease, Huntington's)
E - environmental, eyes, EtOH
M - metabolic (Na, K, Ca, Cu, BUN, GGT, creat, B12, folate, thiamine)
E - endocrine (TSH, BS, PTH), emotion (depression, delirium, psychosis, mania)
N - neoplasm, NPH
T - trauma, chronic subdural hematomas I - infection (postencephalitis, HIV), inflammation A -
anemia, arteries (vascular dementia)
HISTORY:
-Onset, duration, evolution, fluctuations, precipitating factors, associated features
(hallucinations, mood, psychosis, aggression, suicidal ideation)
-PHx re: organic causes -FHx of dementia
-Screen for geriatric giants: incontinence, falls, polypharmacy, OTC/herbal meds -Memory and
safety (driving, stove left on, finances, falls, meds, nutrition)
-ADLs (DEATH - dressing, eating, ambulating, toileting, hygiene) and IADLS (SHAFT - shopping,
housekeeping, accounting, food preparation, transportation)
-Ask caregivers about concerns/problems PHYSICAL:
-hearing, vision, LOC, orientation, attention, psychomotor disturbance, insight and judgment -
neurological exam, gait and balance -evidence of systemic dz (eg, cardiac dz)
PREVENTION:
Tx underlying conditions (thyroid, B12, EtOH), Tx vascular issues (HTN, lipids, DM, smoking,
Afib), stroke prevention!
physical activity and cognitive activity
WORKUP:
Basic BW: CBC, lytes, Ca2+, BS, TSH, creatinine, B12, RBC folate (for those with poor diet)，
Lipids 土 LP，CT， MRI
Objective testing to support Dx: mini mental state exam (MMSE), Montreal cognitive
assessment (MOCA, for MCI), Clock drawing test, Global deterioration scale (for staging)
CT Head if: <60 yo, rapid (i-2mons) unexplained | in cognition or function, short duration of
dementia (< 2yr), recent head trauma, unexplained neuro signs (hemiparesis, Babinski) or Sx
(new onset of seizures or severe headache), hx CA, anticoagulation use or bleeding DO, urinary
incontinence & gait disturbance early in dementia (NPH), unusual cognitive Sx (progressive
aphasia)
MONITORING:
objective mental status testing q3-6mo and then annually if stable. MCI: f/u q6mo, 5-15%/yr
conversion to dementia
Medication Review (reversible causes of dementia): Steroids,
Anticholinergic (Atarax, Benadryl)
Antiparkinsonians (Cogentin, Sinemet)
Antidepressants (Elavil, Prozac, Lithium) Antipsychotics (Haldol, Chlorpromazine)
Antihistamines (Cimetidine, cough and cold
preparations/decongestants)
Narcotics/benzodiazepines (Valium)
Other (alpha-blockers, Theophyline, BP meds,
antiarrhythmics, Abx, NSAID’s，muscle relaxants, anticonvulsants)
Reasons for Referral:

uncertainty of Dx, request 2nd opinion, depression, refractory to Tx, additional help in pt
management, caregiver support (Alzheimer’s society), genetic counselling (early onset < 60
years of age), research
Classification
Alzheimer’s disease (60-80%), Vascular (10-20%), Mixed (vascular and Alzheimer’s disease),
Frontotemporal (5-10%), Lewy body disease (5-15%) Mild cognitive impairment (Sx of
forgetfulness, but preserved function, normal MMSE)
Mild Cognitive Impairment (MCI)
-recognizable phase of mild cognitive decline that often precedes dementia
-high risk state for decline and dementia (5-15%/yr conversion to dementia)
-if MMSE normal (24-30) then MOCA, DemTect or CMC may be performed
-neuropsych testing recommended to aid in confirmation of Dx, differentiate between normal
aging，MCI and dementia -no evidence for cholinesterase inhibitors Alzheimer’s disease
-progressive cognitive decline (months—years) interfering with social and occupational
functioning -pathophysiology = | acetylcholine, neuritic plaques, neurofibrillary tangles; diffuse
cortical atrophy on gross pathology
(7% of Alzheimer’s disease are familial)
-Tx: see below
Frontal temporal Dementia (FTD)

-primary dementia (Pick's disease, ALS, idiopathic) or secondary (EtOH, stroke, NPH, COPD with
chronic hypoxia to frontal lobes)
-insidious onset and slow progression of behavioural
changes (affective, poor insight, impulsivity,
disinhibition, neglect of hygiene/grooming, antisocial
acts, mental rigidity), speech disturbance (economy or
pressure of speech, echolalia)
memory and perception better preserved
-Tx: SSRI (sertraline or escitalopram), trazadone for
sleep
Vascular dementia
-abrupt onset, step-wise decline, emotional lability & focal deficits
-temporal relationship between cerebrovascular disease and dementia -Tx: see below
Lewy Body Dementia (LBD)
-early parkinsonism, hallucinations (detailed, visual), fluctuations in cognition, attention,
alertness; repeated falls
dementia followed by extra-pyramidal features -Tx: see below, sensitive to neuroleptic meds
TREATMENT:
Nonpharm: simplify complex actions，provide clues and reminders, exercise, correct

vision/hearing, multidisciplinary team
Medications: not cure but | decline compared to natural progression
Rivastigmine i.5-6mg bid, Galantamine 8-12 mg PO
BID
SE: poor sleep, diarrhea, urination, meiosis,
bradycardia, bronchoconstriction
-NMDA = Memantine 10 mg PO BID
-atypical antipsychotics for aggression
-Trazodone 25-ioomg or Zopiclone 5-iomg qhs for
sleep
SAFETY:
-driving (risk needs to be evaluated & ministry of transport informed, advise family & pt to
prepare for loss of license, DriveAble to risk assessment)
-wandering (Alzheimer Wandering Registry), home appliances, falls, smoking, can pt use a
phone vs lifeline?
-suicide, violence, neglect, abuse all need to be evaluated
CARETAKERS:
education，Alzheimer’s society referral， early planning (advance directives, power of

attorney, financial & legal issues, placement), ask re: burden, psych/medical problems
CAPACITY:
Pt must understand and appreciate situation. Changes w/ decision/time.
DEPRESSION
References: Major depressive disorder in adults: diagnosis & management: BC guidelines (2013)
Toronto Notes
Mosby Family Medicine Sourcebook
CANMAT guidelines for management of Major depressive disorder (2016)
CANMAT Bipolar guidelines (2013)
BACKGROUND:
Yearly prevalence 〜5%. Lifetime 〜10%. 15% of
depressed patients commit suicide Pathophysiology: caused by neurotransmitter

dysfunction (serotonin, norepinephrine, and dopamine), can be a result of genetics or
psychosocial issues
CTFPHC (2013) recommends against screening. CANMAT reccs screening in those with risk
factors:
Risk factors: PHx, FHx, poor social supports/ | SES, chronic dz (dementia, CVA/MI, etc.),
hormonal changes (peripartum), substance abuse, chronic pain, unexplained medical Sx and
frequent visits.
*** Be aware children and elderly may not present w/ typical Sxs of depression (ie more
somatic Sxs). Consider depression in anyone who comes in with Sx unexplained by lx ***
Questions of screening: 1) Have you lost interest or pleasure in things you usually like to do?
2) Have you felt sad, low, down, depressed or hopeless? Yes to either = look into this.
DIAGNOSTIC CRITERIA DSM TSIGECAPSV
Must have 5 of the following for > 2wks (1 of which
must be low mood or interest):

-Suicidality -or thoughts of death -decreased Interest -Guilty feelings/worthlessness -decreased
Energy -decreased Concentration -changes in wgt (5% either way)
-changes in Sleep
-Psychomotor retardation/agitation -depressed mood
Make sure they do not fit criteria for another psych DO and are not a result of substances or an
organic DO. You can get fancy and subtype the different depressive disorders.
It is important to screen for suicide as this may dictate whether or not treatment should be
done in inpatient or outpatient setting
DIFFERENTIAL:
-bereavement (generally lasts <3 months)
-adjustment disorder (acute stressor, lasts <6 months)
-post partum depression
-anxiety
-dysthymia (depressed mood more days than not for greater than 2 years, only has criteria for 2
of SIGECAPS)
-bipolar, schizoaffective and other psychotic D/O
-substance abuse
-organic disorders(hypothyroid, stomach CA, pancreatic CA, | Bi2/folate, dementia)
-medications (interferon, hypertensive meds, parkinson meds)
WORK-UP:
-CBC, lytes, TSH, folate, B12,
-HISTORY and PHYSICAL EXAM -ECG (for QT elongation if starting meds)
-EEG and neuro imaging if acute psychosis/organic cause?
-drug screen
-Validated questionnaire of choice to assess severity MANAGEMENT:
-psychotherapy + medication better than either individually (see counseling section re:
psychotherapy) -evidence for exercise -treat concurrent illnesses
-SSRIs = first line med, may also consider SNRI, MAOI, TCA, Buproprion, Trazodone, Mirtazapine
-If pt or family member has had a (+) response to a certain drug, select this drug
-Beware SSRIs may make bipolar pts worse (rule this out first)
Suicide and psychotic patients need to be seen in inpatient setting
FOLLOW-UP: TX 1st episode 6-12 months or lifelong if high relapse rate (must be therapeutic on
Tx for duration)
Reassess pt in 1-2 wks for SE and in 6-8 wks for efficacy^ dose to therapeutic range or until
symptom relief. If initial drug is ineffective at therapeutic dose switch to another med in same
or different class.
Considerations for refractory depression: OSCAR = Optimization, Substitution, Combination,
Augmentation, Review (is this correct Dx? Are there other co-morbid psych Dx?).
Consider psychostimulants, antipsychotics or lithium for augmentations. ECT is Tx option for
refractory depression
Referral to psych if co-morbid issues or refractory to treatment
MEDS (class) Tx dose:
Amitriptyline (TCA): ioo-25〇mg (beware of overdose potential and arrhythmias)
Buproprion: i5〇_3〇omg
Cipriani List (200g): Escitalopram (SSRI): 2〇-4〇mg Sertraline (SSRI): 5〇-i5〇mg Venlafaxine
(SNRI): 75_225mg
SSRI SE: sexual dysfunction, weight gain, GI issues, HTN, headache
BIPOLAR DISORDER: Criteria = distractibility, indiscretion, grandiosity, flight of ideas, increased
activity, less sleep, talkative. See CANMAT guidelines Tx: Lithium, Valproric acid, antipsychotic +
SSRI. Need close FU and ACT team.
Schizoaffective DO not discussed here - look it up.
DIABETES
References: CDA Guidelines (2013)
Canadian Task Force for Preventative Health Care CDA Pharmacologic Update (2016)
BACKGROUND:
Epidemiology: about 6 million Canadians w/ pre-DM, 3 million w/ DM.
个 risk in ethnic folks，$，pregnant，FHx，fat，old. PATHOPHYSIOLOGY:
Type l DM = autoimmune disease, attack of Beta cells and no insulin is made.

Type 2 DM = insulin resistance + relative insulin deficiency. Most likely represents a complex
interaction among many genes and environmental factors.
DIAGNOSTIC CRITERIA:
Depends on which patient you see:
FBG >7 (must be fasting >8hr) = DM (may need multiple tests to confirm as pt may not have
been fasting)
Oral glucose test (OGTT 75g，2hrs) or random glucose >n.i = DM HbAiC >6.5% = DM
Symptomatic (unexplained weight loss, polyuria, polydipsia) + any above = DM.
SYMPTOMS OF BAD THINGS:
advise pts on the Sx they should look for: Hypoglycemia.. shakiness, anxiety, palpitations,
sweating, pallor, coma, cold/clammy, dilated pupils, blurred vision, numbness, nausea,
vomiting, hunger, abnormal mentation, seizures
Hyperglycemia:个 urine/hunger/thirst，blurred vision, fatigue, poor wound healing, dry

mouth, itchy skin, tingling hands/feet, ED, arrhythmia, stupor/coma HHS/DKA: deep rapid
breathing (Kussmauls),
confusion/1 LOC, dehydration, fruity smelling breath, impaired cognitive function, abdominal
pain (nausea / vomiting).
1) No screening recommended for type l DM, unless symptomatic or high risk
2) CDA: Screen >4〇yo or high risk w/HbAiC or FBG q3years. CTFPHC recommends only
screening in high risk.
3) If risk factors exist and fasting glucose >6, do OGTT (may do so if suspicious)
Gestational diabetes: high risk women screen in first trimester and all women in 24-28 weeks
(CDA 2013 guideline = use 5〇g, lhr test then 75g, 2 hr test if need be. IADPSG 2010 guideline,
go straight to 75g, 2 hr test) = see perinatal services BC.
MANAGEMENT
Prevention: | in wgt (- 5%) can | progression in pre- DM <60%.
Lifestyle: Exercise (>i5〇min/wk of mod-intense
aerobic exercise, resistance exercise 3x/week). Nutrition can I HbAiC 1-2%，Use Canada’s
food guide, I fats, i glycemic index foods, eat consistent amounts of food each day. jETOH. Stop
Smoking. Inform patient about Sx of hypoglycemia and encourage keeping sugar with them just
in case {<5, not safe to drive). Motivate patients to comply with Tx.
Monitoring:
Target HbAiC level <7% fcaution if <6% as mortality 个 due to hypoglycemia and CAD). Check
q3_4 mons. FBG
target = 4-7.
Target HbAiC< 8.5% in elderly, CAD, poorly controlled for long time, hypoglycemic etc.
BP <130/80 (see HTN section for Tx)
Cholesterol target: LDL <2, ratio < 4 (see Cholesterol section for Tx options)
Baseline ECG
Cr/ACR yearly for nephropathy
Annual foot and eye exams for neuropathy/retinopathy
Pneumococcal/Flu vaccines recommended
Check wgt routinely
Refer to specialists for complications
DM type 2 Medications: If HbAiC <8.5%, lifestyle modification 土 metformin. If HbAiC >8.5%,

start medication: metformin 土 something else 士 insulin. If Sx w/ decompensation，start
insulin 土 another.
**ACEI for nephropathy**

Can use oral agents in pre DM to l progression to DM DM type 1 insulin first line, maybe orals
Other oral meds:
a glucosidase inhibitor TAcarbose) = use with another med，GI SE, poor efficacy
DPP-4 or GLP-i inhibitors Tgliptins/atides) = medium effect on DM, GI SE, wgt loss
Sulfonvlureas TGlicazide) = moderate effect on DM，个 risk of hypoglycemia
TZDs TActos) = CHF, edema, weight gain, moderate effect on DM
Meglitinides fGluconorm) = hypoglycemia，moderate effect on DM
SGLT-2 inhibitors fEmpagliflozin) = Considered second
line to metformin, best CVoutcomes, | wgt.
Urosepsis/Kidney issues, DKA without 个 sugars as major SE.
Insulin:
best Tx for all DM types. Consider D/C meds that cause hypoglycemia w/insulin initiation.
Consider if DM type 2 w/ HbAiC >8.5%. Start as basal long acting insulin (Glargine) ^3-10 units
based on wgt (| wgt =| insulin), titrate lunit/night to reach FBG 4-yand post prandial BG= 5-10.
For BID insulin use NPH mix (〜o.i- 〇.5unit/kg based on wgt), %total dose in am, V3 in pm. For
multiple injections/day, do 3 w/ meals, one at night. 60% of insulin with meals (ie.rapid acting
at 20% of daily dose for each meal), 40% long acting (total dose〜o.5unit/kg).
MANAGEMENT OF COMPLICATIONS:
Hypoglycemia (BG < 4) = treat with oral glucose if mild-mod. If severe (coma) consider Glucagon
injection (img).
DXA=(个 glucose，个 ketones，个 anion gap) = treat with fluids, insulin (o.iu/kg/hr infusion)
and potassium if needed. Must monitor anion gap!! May need to add D5W to fluids if anion gap
is not closed but hypoglycemic risk is present. Try to find out cause (did they skip insulin for
some reason，are they ill? Tx underlying causeâdvise about preventing future episodes.
Hyperosmolar hyperglycemic state is same as DKA but without ketones.
DIARRHEA
References: Mosby's Family Medicine Sourcebook
Uptodate
CDC
Canadian Anti-infective Guidelines (2013) CLASSIFICATION
By Duration By Features
Acute =14 days Secretory: doesn't resolve w/ fasting
Persistent: 14-30 Osmotic resolves w/ testing; osmotic gap days
Inflammatory; small, infrequent, blood/pus
Chronic: =30 days
Steatorrhea: high fecal fat; maldigestion/malabsorption
ACUTE DIARRHEA:
Etiology: Majority are infectious; viral (Norwalk, Rotavirus) > bacterial (Salmonella， Shigella,
Campylobacter, or C.Diff) > protozoa (Giardia， Entamoeba, Cryptosporidium)
Bloody: think E.Coli OisyiHy, consider recent travel (usually E. coli) > Shigella, Campylobacter,
Salmonella Recent ABx use or in hospital: think C.Diff
Management:
Obtain culture if: immunocompromised, differentiating between IBD flare up vs. infection,
severe/or inflammatory features, comorbidities.
Rehydration: see Dehydration section ABx generally not recommended; consider if moderate to
severe traveler’s diarrhea (> 4 unformed stools daily， fever, blood, pus, or mucus), those
with >8 stools/day, volume depletion, immunocompromised hosts w/ Sx for > 1 week,
hospitalized
Choices: quinolone or Azithromycin

For C. Diff = PO Vancomycin (Severe) or PO/IV
Metronidazole (mild to mod)
For Listeria = Amp/Gent or TMP/SMX Other: Bismuth compounds; Loperamide if
non¬inflammatory (no fever, no blood).
Some evidence for probiotic compounds.
Public health: good hand washing by patients and household members
Return to Work: no more diarrhea, no fever x 24 hrs, culture clear if bacterial.
CHRONIC DIARRHEA:
Etiology: depend upon the socioeconomic status of the population
developing countries: chronic bacterial, mycobacterial, parasitic infections; functional disorders,
malabsorption and IBD also common developed countries: IBS, IBD, malabsorption syndromes
(lactose intolerance, celiac disease, chronic pancreatitis) chronic infections
(immunocompromised pts.)
elderly: consider malignancy Features based on etiology:
IBD: abdo pain, bloody diarrhea, tenesmus, fever in flares; peri-anal involvement; nutritional
deficiencies, extra-intestinal manifestations (see abdo pain section) Malabsorption: often pale
& greasy, hard to flush, associated with weight loss Functional: similar to IBS, rule out organic
^^red flags = fevers, weight loss, night time Sx, extraintestinal features, FmHx***
Management: no guidelines, guided by Hx (focus on FHx, risk factors, malabsorption or wgt

loss, dietary Hx, meds, sexual Hx) and Px (peri-anal features,extraintestinal features,
abdominal mass, signs of anemia or nutritional deficiency)
Labs: CBC, TSH, lytes, total protein and albumin, and FOBT
Inflammatory features: fecal WBC Malabsorption features: fecal fat, tissue
transglutaminase + IgA if celiac a possibility Referral to GI for endoscopic evaluation or
unsuccessful Tx: Most patients require endoscopic evaluation and mucosal biopsy
CHILDREN:
Acute (< 5 days): Rule out life-threatening diarrhea: pseudomembranous colitis, HUS,
intussusception, appendicitis, congenital secretory disorders, toxic megacolon.
Most common cause: infectious (viral >> bacteria > parasite).Food poisoning also
Approach: Is child ill? Assess hydration status (see dehydration section)
on exam: rule out RLQ tenderness, sausage-like mass, purpura
Labs: Cxif bloody & fever; US 士 air contrast enema if intussusception, US/CT if appendix.
Tx: no need to avoid specific foods, hydrate orally if

able, avoid sugar juices
Antidiarrheals generally not recommended
Chronic: Bloody causes = milk protein intolerance, IBD Non-bloody causes = IBD, IBS, CF,
Hirschprung’s,
lactose intolerance
Check nutritional status (jwgt, failure to thrive), consider foods not tolerated
IRRITABLE BOWEL SYNDROME (IBS^:
Recurrent abdominal pain or discomfort ^ days/mons in the last 3 mons associated w/=2 of the
following:
(1) Improvement with defecation
(2) Onset associated with a change in frequency of stool
(3) Onset associated with a change in form (appearance) of stool
Subtypes of IBS were recognized:
-IBS with constipation (hard >25% of BM/ loose <25% ofBM)
-IBS with diarrhea (loose >25%/hard <5%)
-Mixed IBS (hard >25%/loose >25%)
-Unsubtyped IBS (insufficient abnormality to meet the above subtypes)
Tx Lifestyle: Fiber, exercise, avoid causative foods and peppermint oil.
Meds: TCAs/antidepressants, Loperamide, Buscopan, Domperidone.
CONSTIPATION:
Red flags: DM, hypothyroidism, wgt loss, blood,
neuropathy, no spleen, previous surgeries
Labs: AXR, blood work, colonoscopy if old or bowel Ca
risk.
Tx: Senna (stimulant), Lactulose (bulking)
DIFFICULT PATIENT
References: Mosby Family Medicine Sourcebook,

Uptodate
CMPA
15% of patients in a typical practice will be considered difficult!
PATIENT FACTORS:
Often have unrecognized psychiatric problems: Pt with mood DO often present with insomnia,
fatigue, back pain, headache. Pt with anxiety present with multiple physical complaints,
irritability, and complain not enough is being done
Pt who are borderline or alcoholic present with somatic complaints that they are sure are of a
physical nature. Often have a personality disorder (so be aware)
Update info about the pt’s life functional status, circumstances & current context
PHYSICIAN FACTORS:
Lack of experience, Uncomfortable with medical uncertainty, increased frustration towards
patients with vague Sx and no response to Tx. Identify your own attitudes & your contribution
to the situation
SYSTEM FACTORS:
Less time for visits + More pts awareness due to access to information = unmet patient
expectations and frustration
MANAGEMENT:
Remain vigilant for new Sx and Px findings
PHQ: good screen for depression, anxiety, substance
abuse, and somatoform DO
Medical Tx: Consider starting SSRIs in pts w/ Sxs of dysphoria, aggression & anxiety. Frame the
tx as useful to reduce stress due to their undiagnosed medical condition
Seek Help: Ask trusted colleagues for advice
join a Balint group, Get a psychotherapist for support
BAD STRATEGIES: Passing the buck,
Accusing pt of being problematic, telling patient nothing is wrong with them, using psychodrugs
without a clear diagnosis
WHEN TO FIRE A PT. (egs. from CMPA)
Pt fraudulently obtains narcotics Pt steals a prescription pad Pt threatening or abusive to you or
staff
-Expect difficult interactions from time to time. Be compassionate
-Establish common ground to determine the patient’s needs (eg. threatening or demanding
patients
DISABILITY
References: Mosby Family Medicine Sourcebook Uptodate
RNAO falls prevention guideline (2011)
DEFINITION: differs based on circumstances. Look for it. If there is a decline in function, find out
if it is disabling.
Screening: Do on an ongoing basis:

FALLS RPs: past Hx, lower extremity weakness, age, female, cognitive impairment, balance
issues, drugs, arthritis, CVA hx, orthostatic hypotension, dizziness, anemia.
***clarify drugs***
FALLS SCREENING: ask yearly. If Hx, many validated screening tools.
DEMENTIA SCREENS: MMSE, mocha, clocks, if family has concerns or you are suspicious
BLINDNESS: eye exams done yearly to RO cataracts, MD, etc.
OTHER THINGS: anyone with chronic disease is at risk for disability
***think long term, think multiple domains***
-screen for depression, anxiety, pain -check on social situation, supports,
suicide/sleep/substances
-assess for and diagnose disability when it is present. MANAGEMENT:
-In patients at risk for disability (e.g., those who do manual labour, the elderly, those with
mental illness), recommend primary prevention strategies (e.g.， exercises, braces, counselling,
work modification).
-offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community
support) to minimize the impact of the disability and prevent further functional deterioration.
-multidisciplinary team, PT/OT, workmans insurance boards, modified work, job retraining,
patient education
-Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a
disability for that specific patient.
-In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of
which includes finances, employment, and family).
-Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is
only part of the plan).
DIZZINESS
inferences: Uptodate AAFP
Mosby Family Medicine Sourcebook Essential Evidence Plus
Standardized Approaches to the Investigation of Syncope: Cardiovascular Society (2011)
TYPES OF DIZZINESS:
Vertigo: illusion of movement.
Presyncope/Syncope: lightheaded/feeling faint;
transient loss of consciousness without permanent neuro defect.
Disequilibrium: off-balance, gait impaired Psychogenic: can mimic many difft things = diagnosis
of exclusion
HISTORY:
Clarify type of dizziness (as above), duration, provoked by movement, associated audiologic or
neurologic symptoms, other general Sx (recent URTI, nausea/vomiting, phono/photophobia,
headache) PmHx: Cardiac, vascular, neurologic/seizure, migraines Other info: Drugs (ototoxic
aminoglycosides, ASA, antimalarials, chemotherapy, lasix, insulin Safety), Trauma, Driving, falls
Dizziness
[
VERTIGO (vestibular) NONVERTIGINOUS
-sensation of world (non vestibular)
revolving around pt or -sensation of
pt revolves around lightheaded, giddy,
space dazed, disoriented
Peripheral (85%)
inner ear, vestibular
nerve
Central (15%)
Brainstem, cerebellar
Psychogenic (Dx of
exclusion)
Idiopathic, meniere's, BPPV, acoustic Tumour, stroke, multiple
sclerosis, drugs
neuroma, trauma,
drugs, labryinthitis
Ocular (decreased
visual acurty)
Vascular (migraine, orthostatic hypotension, arrhythmia, vasovagal, CHF, metabolic cause)
PHYSICAL:
Ôrthostatic Vitals**，Cardiovascular, peripheral vascular, ENT, Neurological (Cerebellar):

Coordination, Rapid alternating movements, Balance, Gait Cranial Nerves, Nystagmus. Dix-
Hallpike Maneuver (PPV 83%, NPPV 52% for BPPV). Pt must be able to rotate neck 45〇 =
Rotatory nystagmus，Sx reproduction， fatigues with repetition, reversal upon sitting (Latency
〜2〇sec to appear)
WORKUP:
Labs: CBC, Cr, lytes, TSH, BS, B12.
Non-vertiginous ECG, Holter, stress test, carotid doppler, vertebral doppler, EEG, tilt-table
testing, MRI (include brainstem)
Vertiginous: Dix-Hallpike, audiometry (if hearing loss), MRI (include brainstem)
Neither: ECG, EEG
Peripheral VS. Central Vertigo
Differential Diagnosis of Vertigo
Condition Duration Hearing Loss Tinnitus Othor features Trestment

BPPV Seconds Neg Neg Provoked by change in position Most common cause of
vertigo Epley s Maneuver (repositions otolrth particles) 70% patients spontaneously resolve •
reassure, meds below, surgery if refractory
Meniere's Mins-hrs Uni/ bilateral Pos Episodic attacks fluctuating hearing loss,
aural fullness Bed rest, low salt diet, destroy vestibular organ with ototoxic drugs, surg tx,
meds below
Vestibular
neuronitis Hrs-days Unilateral Neg Recent URTI (30%), usually viral Bed
rest, progressive vestibular exercises, ambulation, meds below
Labyrinthitis Days Unilateral whistle Recurrent AOM,
Beware
meningitis ABx (f bacterial suspected, ± middle ear drainage Supportive if viral
Acoustic Chronic Progressive Neg Ataxia, CN VII Expectant
neuroma palsy， management, surg
excision, radiation, gamma knife Most common intracranial tumor causing

hearing loss.
Meds for Vertigo
Medication
Anticholinergics
(Scopolamine),
Antihistamines (Gravol, Betahistine),
BenzocHazeoines (Lorazepam) -BPPV, Acute Labrynthitis. Meniere's, Vestibular neuronitis
-Use benzos when anticholinergic contraindicated (asthma, prostatism)
-Caution in elderly with these (Beers list - see elderly section)
Steroids (Prednisone) •Acute Lab/rinlhttis, Vestibular Neuronitis
Diuretic (HCJZ)-Meniere's
Differential Diagnosis of Syncope
Cardiac (23%), Non-cardiac (59%), Unknown
origin (18%)
Characteristics Examples
Arrhythmia: Sudden syncope with no warning Sxs, syncope white lying down, palpitations,
injury Structural issues: Syncope on exertion, chest pain, dyspnea VTr SVT, AV block with
bradycardia (structural change, drugs). Sinus pauses (vigil, sick sinus, negative chronotropes).
pacemaker failure
HOCM, AS, aortic dissection, PE, Ml, tamponade
Reflex mechanisms: Warmth, nausea, lightheadedness, sometimes a specific trigger
Vasovagal, micturtion, defecation, swalowing, cough
Carotid Sinus issues Triggered by neck pressure or head turning Carotid sinus syndrome
Orthostatic Hypotension Triggered by positbn change, dehydration or autonomic dysfunction
(DMT neuropiitby) Dysautonomias, fluid depletion Illness, drugs (antidepressants,
sympathetic blockers)
Psychogenic: Frequent attacks Anxiety, panic
Major risk factors (Should have urgent cardiac assessment)
Abnormal ECG (any arrhythmia or conduction dz, new ischemia or old infarct), Hx of cardiac DO,
hypotension (<9〇mmHg), CHF
Minor risk factors (Could have urgent cardiac assessment)
Age (>6〇yo), dyspnea, anemia, HTN, CVA, FHx of early sudden death (<5〇yo), syncope while
supine, during exercise, or w/ no prodromal symptoms
Tx for Syncope: Tx underlying cause (see specific sections).
DOMESTIC VIOLENCE
References: SOGC guidelines (2005)
Canadian Task Force on Preventive Health Care appraisal (2013)
Doctors Opposing Violence Everywhere (DOVE)/TOP guidelines (2015)
Children's Aid Society

Definition: any action, inaction, or threat, regardless of intent or intensity that results in either
physical or psychological injury to an individual, family, or community. Includes physical,
emotional, sexual, psychological，and financial abuse
Epidemiology: Lifetime prevalence Intimate partner violence against ? : 25-30%

Annual Prevalence: 10-14%
Women 2X risk than men
Wife assault leading cause of homicide for Canadian women
MD recognition as low as 5%
Occurs in all SES, educational and cultural groups, f in pregnancy, disabled people, and 18-24 yo
HISTORY:
Consider if multiple visits to the physician with non-specific complaints (headache, chronic pain,
insomnia, GI symptoms)
Depression, anxiety, PTSD, suicide attempts/ideation, substance abuse, eating d/o, ASPD, and
non-affective psychosis
PHYSICAL:
Injuries minimized by patients/partner
Injuries may not fit history, and at different stages of
healing
Pain, bruises, injuries, broken/dislocated bones (jaw, clavicle, ribs), burns, perforated eardrums,
evidence of rape - uncommon injuries
SCREENING:
CTFPHC does not recommend screening general public for violence. Screen those at some form
of risk.
HITS: How often does your partner:
1) physically H urt you?
2) I nsult you?
3) T hreaten you with harm?
4) S cream or curse at you
rate each answer out of 5, total of >11 is significant MANAGEMENT:
Interview and examine patients ALONE (challenge from partners who will not leave patients
alone = RED FLAG!)
Risk Assessment
1. When did the violence start?
2. How often does the violence/abuse occur?
3. Has the violence increased in frequency or severity in the past year?
4. Have you recently separated from or stopped seeing your partner?
5. Have you ever felt afraid for your physical safety or life?
6. Has your partner threatened to kill you, your children, your relatives, or him/herself?
7. Has your partner planned or attempted suicide?
8. Does your partner have access to weapons? Is the weapon in the home?
9. Does your partner abuse alcohol or use drugs?
10. Is your partner violent outside the house?
11. Does your partner harm the family pet(s)?
*WREP0RT SUSPECTED or known child abuse (even witnessing violence)-it、s the law***
Emergency Escape Plan

How To Help Her:
Ask her directly what assistance she wants Provide emergency numbers, shelters, and
resources In acute care setting, consider admission or delay discharge if she is in serious danger
Ensure She Has:
Important documents, i.e., birth certificates, passports,
social insurance, health card, driver’s licence,
vaccination records, court documents
Some money, credit card, bankbooks, cheque book
Keys for house, car, and office
Medication
Familiar toy / blanket for each child Clothing for self and children Planned possible escape
routes Taught children to dial 911
Alerted a trusted and supportive family member or friend to her situation
Arranged for a neighbour to call 911 on her behalf if there are signs of violence
磁 SPOUSAL ABUSE IS A CRIMINAL ACT BUT REPORTABLE ONLY IF VICTIM CONSENTS^*
CYCLE OF DOMESTIC VIOLENCE

-Advise about the escalating nature of domestic violence
-counsel about the cycle of domestic violence and
feelings associated with it (e.g., helplessness, guilt), and its impact on children.
DYSPEPSIA
Top Alberta Docs Guideline: GERD/Chronic Dyspepsia (2009) Essential evidence plus
SPECTRUM OF STOMACH UPSET:
DYSPEPSIA — GERD — Gastritis —PUD —Scary Things
DIFFERENTIAL:
SCARY DIFFERENTIAL (in the chest):
CAD/MI, PE, Pericarditis/myocarditis, Aortic
dissection, Tamponade, Boerhaves

SCARY DIFFERENTIAL (in the gut):
Pancreatic Ca, Gastric Ca (Zollinger-Ellison), Esophageal Ca
OTHER STUFF:
Celiac dz, Achalasia, Esophageal stricture, Scleroderma HISTORY:
GERD = heartburn, regurgitation, waterbrush, dysphagia,
PUD/GASTRITIS = postprandial, worse at night CANCER BADNESS = >45yo, early satiety, weight
loss, GI Bleed
Other things (RED FLAGS FOR TESTING):
• Unintended weight loss
• Persistent vomiting
• Progressive dysphagia
• Odynophagia
• Otherwise unexplained anemia or iron deficiency
• Hematemesis
• Palpable abdominal mass or lymphadenopathy

• Family history of upper gastrointestinal cancer
• Previous gastric surgery
• Jaundice
Pt on dyspepsia causing meds:

NSAIDs, bisphosphonates, Abx
etc?
YES: Better
NO: alarm Sx? Age >50yo, wgt
loss, bleeding, dysphagia,
anemia, jaundice, abdominal
mass, persistant vomiting 广、^
ENDOSCOPY
NO: Test for H. Pylori or treat
empirically with PPI - better?
MANAGEMENT:
Straightforward GERD: no need for lx. Consider lx if not straight forward Hx: BW (LFTS, HgB, etc)
US abdo. Any red flags = SCOPE. Can biopsy for CA, assess celiac disease/IBD, look for ulcers
LIFESTYLE: stop smoking, no EtOH, no spicy meals, no coffee, no mint, reduce eating before bed
If < 45yo, classic story, no red flags, treat w/ PPiÎf not better in 4 wks, breath test for H. pylori
(Blood test only good if never been infected by H. pylori in past) MEDS: stop NSAID or
bisphosphonates.
GERD management:
if meds held?
R to quit smoking, lose wgt (if applicable), try OTC meds. Better after 4wks? /\
4
NO: Trial PPI or full dose H2
blocker BID. If improved after 1-
2mons?
YES: Continue lifestyle changes, DC meds

NO: Do BID PPI for 2-4 mons.
FU @1mons. Better?
NO: ENDOSCOPY
DYSURIA
Mosby’s Family medicine Sourcebook
DIFFERENTIAL:
l) Infection (Most Common)
All along the GU tract (Pyelonephritis, Cystitis, Prostatitis, Urethritis, Epididymitis/Orchitis,
Cervicitis, Vulvovaginitis)
Organisms: Klebsiella (rare), E.Coli (most commonly),
Enterococcus (rare), Proteus (common), Saphrophyticus (common)

Think Neiserria Gonorrhea and Chlamydia Trachomatis in infections of the genital tract Risk
factors: Women (short urethras), Sexual intercourse, Women wiping towards GU tract with
toilet paper and Malformations of the GU tract causing stasis (BPH, Urethral stricture, Urinary
divertiuclae, Neurogenic bladder = These will often get infected with bad bugs such as
Klebsiella, and Enterococcus)
2) Non infectious causes in women:
Atrophic vaginitis
Urethral trauma post sex Chemical irritation
3) Non-infectious causes in men:
BPH
Urethral Stricture
4) Malignancies:
Renal cell/Transitional cell carcinoma, penile cancer
5) Weird and Wonderful:
Spondyloarthropathies (Reiter's Syndrome)
HISTORY:
Ask about any Lower urinary tract Sx:
Frequency, Urgency, Nocturia, Dysurea, Hematuria + weak stream, hesitancy, intermittency,
post void dribble, post void fullness + Discharge, Dyspareunia
DIAGNOSIS:
Uncomplicated UTIs occur in patients who have a
normal GU tract, and have Sxs confined to the lower urinary tract
So a patient who presents with fever/CVA tenderness =Badness. More likely in pregnancy,
children, DM, nephrolithiasis, urinary tract abnormalities, CA
Classic symptoms often allow for self-diagnosis. Useful Clinical rule:
Dysuria，Frequency，and/or Hematuria + Absent Vaginal discharge and irritation =uTim
WORKUP:
Urine Dip (Leukocê Esterase is Specific and Sensitive for UTI, Nitrites are SPECIFIC for UTI). If +
send out for Urine microscopy & Culture
Other investigations: STI screen (nucleic acid
amplification test or Swab), PSA, Urine cytology
MANAGEMENT: see respective sections based on etiology (UTI, menopause, prostate sections)
INCONTINENCE:
Causes: Meds, EtOH, DM, drugs, caffeine Types:
STRESS = increased abdo pressure releases urine, such as coughing and laughing.
Tx: physiotherapy, kegel exercises, Duloxetine, estrogen cream in ?
URGE = feeling of having to go now, accidents on the way to bathroom
Tx: Oxybutynin (other anticholinergics), mirabegron, timed voiding

OVERFLOW/OBSTRUCTIVE = lower urinary tract symptoms, prostate most likely cause Tx:
underlying obstruction MIXED = a combo of above
Positive urethral
EARACHE
References: Mosby5s Family medicine Sourcebook Top Alberta Docs 2008 Essential evidence
plus
Management of acute otitis media in children six months of age and older: CPS (2016)
DIFFERENTIAL:
Normal exam Common dx -TMJ
•Pharyngitis -Tooth abscess -Eustachian tube dysfunction -cervical spine arthritis Urvcommon
dx -tumors
-neuralgias (i.e trigeminal) •Ben’s Palsy -Temporal arterlis
Abnormal exam -AOM
-otitis externa -Foreign body
-barotrauma (perfusion and blood)
Malignant (necrotizing) otitis externa
-Ramsay Hunt syndrome (herpes zoster oticus
-mastoiditis
-wegne^s
granulomatosis
4umor
HISTORY:
Diagnose AOM: fever, otalgia, irritability (sometimes: cough, vomiting, etc. can been seen with
it)
On Exam: bulging TM (yellow or red) with |mobility with pneumatoscopy (or lose bony
landmarks or cone of light)
Must be able to differentiate (with hx and exam): myringitis, otitis media with effusion (serous
otitis media) and chronic suppurative otitis media
Etiology of Acute Otitis media (AOM):
S. pneumo, M. catarrhalis, H. influenza, Group A Step, (rare)
MANAGEMENT rmedication):
Children less than 24 months old:
-Treat with antibiotics (Amoxil, macrolide) x 10 days Children aged 2 years or older:
-Most cases of AOM resolve with symptomatic treatment alone and do not require antibiotics.
-Treat symptomatically for 48 hours from Sx onset if pain/fever is manageable with systemic
analgesics, providing adequate follow-up can be assured.
-If symptoms worsen or fail to respond to symptomatic treatment with systemic analgesics
after 48-72 hours, treat with antibiotic x 5 days
Of course all kids who look toxic/sick，high fevers or uncontrolled pain require Abx Tx.
Analgesics:
Acetaminophen 15 mg /kg /dose q4-6 h Ibuprofen 10 mg /kg /dose q 8 h
Chronic Care:
If effusion present at 3 months (OME) send for hearing test, refer to ENT if hearing loss.
Management (non-meds):
stop smoking and start breast feeding
MANAGEMENT TSurgicaD:
Indications for Myringotomy and Tympanostomy Tubes in Recurrent AOM and otitis media
iv/effusion (more commonly inserted for effusion)
-Persistent effusion >3months -Lack of response to >3months of antibiotic therapy -Persistent
effusion for >3months after episode of AOM -Recurrent episodes of AOM (>3episodes in 6
mons, or >4episodes in i2mons)
-Bilateral conductive hearing loss of >2〇db
-Chronic retraction of the tympanic membrane or pars

flaccid
-Complications of AOM
-Craniofacial anomalies predisposing to middle ear infections (g. Cleft palate)

Otitis Externa:
Cause: MSSA, MRS A, psuedomonas
Dx: external ear pain, redness, swelling, maybe
exudates.
Complicated =perforation or failed therapy
Tx: avoid swimming in murky waters, control
immunosuppression
Meds: Burosol (Acetic acid) causes change in natural flora, ABx drops (Ciprofloxacin,
Polysporin), may add steroid drops (Ciprodex). ABx with steroid for complicated. Refer if
necrotic.
Mastoiditis:
***zs an emergency^**
Dx: Very toxic otitis media, tender/swelling around ear, looks like cellulitis on outside,
protruding pinna Likely refer out, need appropriate imaging (CT) and surgical intervention.
Tx: drain and IV ABx (Ceftriaxone, Vancomycin)
Decreased hearing:
Likely wax，otosclerosis, work related Always take a look before getting tested.
EATING DISORDERS
References: Academy of Eating Disorder Mosby’s Family medicine Sourcebook
Essential evidence plus BC Guidelines:Eating disorder (2012)

BACKGROUND:
均)fc/emfo/ogy: 1% of adolescents/young women (onset age 14-18)
Females: Males = 10:1, mortality 5-20% (highest of all psych disorders)

Definitions: DSM-5
Anorexia = refusal to maintain weight (<85% of ideal BMI), intense fear of gaining weight,
disturbance of body image (denial, low self-esteem) and lack of insight this is a problem.
Types: restricting and Binge/Purge
Bulimia = Recurrent episodes of binge eating with
sense of loss of control during episodes, inappropriate
compensation behaviours to prevent weight gain
(vomiting，laxatives, exercise, etc), symptoms l/wk for
3 mons” poor self-image, does not happen with

anorexia
Types: purging vs non purging Binge eating disorder = Recurrent episodes of binge eating with
sense of loss of control during episodes, l/wk for 3mons，not associated with compensatory
behaviours like anorexia/bulemia NOS = aberrant behavior not fitting one of the above criteria
RISK FACTORS:
Hx of dieting as a child
childhood preoccupation of being thin/low weight sports where leanness is emphasized (dance,
gymnastics, etc.)
first degree relatives with same D/0 other psych illness
**iVeed to RO other psych illnesses**
e.g., depression, personality DO, obsessive-compulsive
DO, anxiety DO
Need to assess amount of weight lost, behaviours being used, exercise amount, dietary intake,
menstrual history, previous psych issues
^when there are metabolic or cardiac issues otherwise not explained, explore eating disorder^*
Do postural vitals, Temp (? hypothermia) and BMI
SCREENING
**Screen young woman with the above risk factors** SOGC reccs. BMI on all <i9yo*s.
Screen questions TSCOFF)
Do you make yourself SICK because you feel uncomfortably full?
Do you worry you’ve lost CONTROL over eating?
Have you lost > ONE stone (i4lbs) in last 3 months?
Do you think you are FAT even though others donJt? Does FOOD dominate your life?
Primary Care screen
Are you satisfied with your eating habits? + = no Do you ever eat in secret? + = yes
Does your weight affect how you feel about yourself? +
= yes
Any family members with eating disorders? + = yes Do you have or ever had an eating disorder?
+ = yes
Both screens: 2 or more + means possible eating disorder
WORKUP:
CBC = ? anemia, leucopenia, thrombocytopenia
Lytes = ? hypo/hyperglycemia, hyponatremia,
hypokalemia, chloride imbalance, high BUN/Cr,
bicarbonate imbalance, low phosphate/magnesium
LFTs = albumin imbalance, liver dysfunction,
pancreatitis
TSH = hypothyroid
P~HCG = always do in woman without a period
ECG, bone mineral density
MANAGEMENT:
^beware of refeeding syndrome = fatal shift in fluids/electrolytes after feeding a malnourished
individuals**
Medications: Fluoxetine FDA approved for Bulimia only
Psychotherapy: CBT indicated always (standard of care). Family therapy for children/teens.
**get therapists involved**
Nutrition: controlled weight gain for anorexia (0.5-ilbs a week, 30- 4〇kcal/kg/day).
get dietician involved

Treat co-morbid conditions.
Beware | efficacy of meds w/ poor nutrition and liver/kidney dz.
Inpatient care: medically unstable, suicidality, very low weight, unable to do this outpatient,
lots of other psych issues, very unmotivated patient requiring structured environment
Follow-up: Tight FU required. Look for complications (e.g., tooth decay, amenorrhea, an
electrolyte imbalance). Evaluate the level of disease activity (e.g., by noting eating patterns,
exercise, laxative use).
OUTCOMES:
Anorexia = 50% recover, 25% relapse, 25% poor outcome (10-30% mortality over 10- 30 years)
Bulimia = poor recovery THE BOTTOM LINE
• This is a multidisciplinary disease requiring lots of people involved - get them
• Screen all young woman with risk factors
• Take a good history, don’t miss other psych disorders and separate out the types.
ELDERLY
References: Prescribing in the elderly PBSG.
American Geriatrics Society: Beer's criteria (2015)

EPIDEMIOLOGY:
-Patient >65 yo (elderly) represent 13% of the population and account for 35% of prescription
drug use
-Drug reactions contribute to 10-30% of hospitalizations for the elderly
Risk factors for med related problems in the elderly:
Multiple medications (>4 meds) multiple doses of medication per day patient >8syo
>6 active chronic medical diagnoses i kidney function or low BMI previous failure to take drugs
properly previous adverse drug reaction
DRUGS TO AVOID rBeer，s list、：
ALL THE ANTIs!!!

-Anticholinergics, antiarrhythmics, antiemetics, antihistamines, antiparkinsonian agents,
antipsychotics, antispasmodics, skeletal muscle relaxants, TCAs
-Benzodiazepines (increased risk of falls, fractures, MVCs and delirium)
-SSRIs have falls risk
DRUGS TO BE CAREFUL WITH:
-Antibiotics (especially with impaired creatinine clearance)
-NSAIDS (may worsen CHF, CRF and PUD)
-Antidepressants (especially TCAs)

-Anticonvulsants (thrombocytopenia and
hepatotoxicity)
HELPFUL THINGS TO PREVENT PROBLEMS:
-Review meds regularly, bring meds/OTCs/herbals to ALL appointments -Start low, go slow
-Try to suggest “safer” alternative drugs whenever possible
-Alert patient to warning signs and side-effects -Adjust drugs based on reduced creatinine
clearance, or hepatic failure
-Check patient's compliance and if adjustments can be made to improve.
MEDICATION CONSIDERATIONS:
*** no evidence for statins >8oyo for primary prevention^*
*** consider decreasing antihypertensives in elderly 磁
(3-Blocker: avoid if >751/0 for dizziness/falls risA:*** *** bisphosphonates- re-evaluate after 5
yr of treatment***
Aceytalcholine esterase inhibitors (eg Donepezil/Aricept):stopifMMSE<io***
*** warfarin- consider re-evaluation of RFs if >8oyom
HERBALS TAKEN BY ELDERLY:
-Ginkgo Biloba (interacts with ASA, NSAIDS, Warfarin, PPI, Trazadone, Haloperidol)
-St. John’s Wort (interacts with SSRIs, TCAs,
Cyclosporine, Tacrolimus, Warfarin, Digoxin, Simvastatin)

-Saw Palmetto (interacts with NS AIDS)
-Ginseng (interacts with warfarin, loop diuretics and phenelzine)
ELDER SCREENING:
-Screening for vision/hearing impairment/Social support- CTFPC/ Preventive Care Checklist
Form -fair evidence - annual visual acuity testing with a Snellen sight chart for >6syo, and
fundoscopy or retinal photography in elderly patients with diabetes of at least 5 years*
duration (grade B recommendation).
For patients at high risk for glaucoma (positive family history, black race, severe myopia or
diabetes) it would be prudent to have a periodic assessment by an ophthalmologist.
-fair evidence - screening >65 yo for hearing impairment by inquiring about hearing difficulty,
doing a whispered voice test or using an audioscope
ASK about social support/family/finances at every annual PEx --- discuss possibility of needing
different living arrangements or modifications to current home early on
BOTTOM LINE:
-Polypharmacy in elderly is common!! Review all meds/OTC/herbals regularly
-Is there a drug they shouldn’t be on?? Is there a drug they should be on?? Are they
compliant?? Pharmacy meds reconciliation if unsure. Consider blisterpak or family to check
pillbox
-PHE for elderly- screen for visual acuity and hearing. ASK about social/family/finance/living
arrangement- talk about living environment early -Don’t assume “old age” is the diagnosis-
always R/O medical illnesses - they don't present the same way
EPISTAXIS
References: AAFP Toronto Notes Essential evidence plus Nosebleeds - CFPC (2015)
ENT Canada
ANATOMY:
-90% are anterior source: (Kiesselbach’s plexus)- anastomose to form plexus located in Little’s
area of the branches from the external carotid & internal carotid arteries. 10% posterior source
(Sphenopalatine artery)
-bleeding above middle turbinate is from internal carotid artery and below is internal carotid
artery
Differential:
History：
-Ask about what side bleeding is coming from, duration, frequency and severity of epistaxis, FHx
of bleeding DO
INVESTIGATIONS:
-CBC，coagulation markers 土 group/screen，土 LFTs，土 Cr，土 crossmatch 2units of

packed red blood cells if significant bleed -Xray, CT as needed
General Management:
1) ABCs, patient to lean forward and minimize swallowing. Constant firm pressure applied
for >2〇min on soft part of nose
2) Assess Blood loss - VITALS, signs of shock, IV NS for hypovolemia & shock, transfusion
for blood loss
3) Determine site of bleeding - Anterior vs Posterior. Insert cotton pledget of 4% Lidocaine
土 topical decongestant (ie. Otrivin), visualize nasal cavity with speculum and aspirate excess
blood and clots. If suspicious of bleeding disorder - anticoagulation work up
4) Control Bleeding as below Anterior Epistaxis:
-topical anesthetic (4% Lidocaine) & vasoconstrictor (1:1000 Epinephrine or 1% Phenylephrine)
via spray or cotton swab
-If refractory, consider unilateral chemical cautery with silver nitrate after anesthetizing area
(bilateral septal cautery should be separated by 4-6 wks to avoid septal perforation)
-If refractory, pack nose with gauze and petroleum jelly,
sponge or inflatable pack with hydrocolloid coating. Leave in place for 2-3 days before removal.
May also consider absorbable packing material such as Surgicel or Gel-foam.
-Complications of nasal packing: septal hematoma, septal abscess, sinusitis, neurogenic syncope
during packing and pressure necrosis due to excessive tight packing
Posterior Epistaxis:
-More common in older patients
-Suspect posterior epistaxis if anterior source is not visualized, if bleeding from both nares or if
blood drains in posterior pharynx after anterior sources have been controlled
-Consider referral to ENT for posterior packing:
-place posterior pack using Foley catheter, guaze, or epistat balloon
-Abx for posterior bleeds >48hr -Admit to hospital with packs in for 3-5 days -Watch for
complications: hypoxemia, toxic shock syndrome, pharyngeal fibrosis/stenosis, septal necrosis,
aspiration
Persistent Bleeding:
-Referral to ENT for endoscopy and/or surgical ligation of arteries 土 septoplasty
-May alternatively refer to Interventional Radiology for embolization of bleeding vessels

Hospital Admission:
elderly with apneic spells，bilateral anterior packing， posterior bleed, coagulopathy,

comorbid conditions (CAD, severe HTN, significant anemia), significant bleeding
PREVENTION:
-Prevent drying of nasal mucosa with humidifiers, saline spray, topical ointments or petroleum
jelly -Avoidance of irritants
-Medical management of HTN and coagulopathies OTHER INFO:
-adolescent males with unilateral recurrent epistaxis
consider juvenile nasopharyngeal angiofibroma (JNA) -MOST BENIGN TUMOUR OF THE

NASOPHARYNX -thrombocytopenia pts - use resorbable packs to avoid risk of rebleeds when
pulling out removable packing
FAMILY ISSUES
Routinely ask about family issues to understand their impact on the patient’s illness and the
impact of the illness on the family.
Why?
Facilitates therapeutic alliance.
Identifies concerns in other patients (complaining about a spouse’s drinking).
Compliance.
ASK SPECIFICALLY:
Supports/confidants.
Power of attorney.
Conflicts in household.
Abuse - physical, sexual, verbal, financial, minors. Child-rearing.
Cultural/religious background.
Family members’ views on the patient’s medical conditions.
When?
Periodically,
At important life-cycle points (e.g., when children move out, after the birth of a baby).
When faced with problems not resolving in spite of appropriate therapeutic interventions (e.g.
medication compliance, fibromyalgia, hypertension).
FATIGUE
References: Mosby5s family Practice Sourcebook
TOP Alberta docs Guidelines: CFS (2016)
EPIDEMIOLOGY:
-?>>>$
-Females > 75% of patients with chronic fatigue syndrome
-Medical or psychiatric diagnoses can explain fatigue in approximately <50% of patients with
complaints of acute fatigue
->50% of cases no diagnosis CLASSIFICATION:
Recent fatigue = symptoms lasting <imon.
Prolonged fatigue = symptoms lasting for >imon. Chronic fatigue = symptoms lasting >6 mons.,
but does not imply chronic fatigue syndrome
DIFFERENTIAL:
Type Examples
Psychogenic
Lifestyle
Vascular
Infectious
Neoplasm
Nutntion
Drugs
Chronic disease
Autoimmune
Toxin
Endocrine
APPROACH:
Five-step approach:
Consider Red FLAGS : Fever, Night sweats, Weight loss, Neuro deficits, Ill-appearing
Review recent personal events:
accident, overwork, viral episode, new medication, occupational issues, sedentary lifestyle, etc.
Patients who are victims of domestic violence may present with symptoms of fatigue. Consider
Patient health questionnaire
General Hx :
risk for anemia, pregnancy, cardiac problems, hepatitis, or other chronic infection,
mononucleosis, HIV, etc
Consider mental health diagnosis: depression, anxiety, and/or drug dependency. Fatigue vs
“overwhelming weakness” - to rule out electrolyte d/o, hypoglycemia or neuromuscular disease
A thorough evaluation of medications, both prescribed
Depression, Anxiety. CFS
Sedentaiy
Stroke
Mononucleosis: Tuberculosis, HIV
Al CA
Anemia, B12 deficiency
Benzos. Antiepileptics, Anticholinergics, Antihistamines
CHF, COPD, Liver/Renal disease. Sleep apnea SLE, RA, MS
^DhLHeavy metals
Thyroid. DM, Pregnancy, Adrenal dysfunction
and over the counter, should be undertaken
Take a sleep history for insomnia, apnea, and/or movement d/o R/O CFS (See below)
Patients with organ-based medical illness often associate their fatigue with activities they are
unable to complete. In contrast, patients with fatigue that is not organ-based are tired all the
time; their fatigue is not necessarily related to exertion, nor does it improve with rest.
WORKUP:
Order tests depending on patient Hx/presentation. Reasonable initial studies to obtain include:
-CBC, ESR, ferritin, lytes, BS, renal function & LFTs -TSH if associated Sx
-Creatinine kinase if pain or muscle weakness -HIV testing and tuberculosis placement should
be considered if appropriate based upon the history -Routine test not recommended: infection
(ie, EBV, CMV, or Lyme titers), immunological deficiency (ie, immunoglobulins), inflammatory
disease (ANA, RF), or celiac disease without other features suggesting related conditions
2/3 of patients with fatigue will acknowledge a psychosocial contribution to symptoms. > 50%
of patients with chronic fatigue, attribute their fatigue to mainly psychological causes
Psychiatric illness present in 60-80% of patients with chronic fatigue, major depression, panic
disorder and somatization disorder most often
MANAGEMENT:
-Treat cause if found -Graded exercise therapy -CBT/Supportive counselling
-Find a common ground in terms of investigations and management and be realistic.
-The doctor-patient relationship is of profound importance = acknowledge the patient's
complaints as real and potentially debilitating -Antidepressants if needed for psych DO -Sleep
Hygiene
GOALS OF CARE:
Accomplishing the activities of daily living Returning to work
Maintaining interpersonal relationships
CHRONIC FATIGUE SYNDROME (CFSV MYALGIC ENCEPHALOMYELITIS
Institute of medicine Dx Criteria (2015 - updated from Fukuda criteria) must have the following:
1) A substantial reduction or impairment in the ability to engage in pre-illness levels of
occupational, educational, social, or personal activities, that persists for more than 6 months
and is accompanied by fatigue, which is often profound, is of new or definite onset (not
lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by
rest
2) Post exertional malaise
3) Un-refreshing sleep
4) One of cognitive impairment OR orthostatic imbalance
5) Not due to organic or other psychological dz.
Epidemiology: ? > $， Caucasians > other groups, majority in their 30-50S, <5% of patients
presenting with fatigue have CFS (^1.4% of Canadian population)
PROGNOSIS:
After one year 4% no longer fatigued
Median recovery rate 〜5% and Median improvement
rate 〜39.5%
TREATMENT:
-Treat Sx indivdually. See appropriate section for tx options.
-Treat comorbid conditions/psych disorders -TCAs may help w/pain/headache Sxs.
-CBT of benefit if tolerated.
-Modafinil for cognitive issues?
-Exercise perhaps?
Really nothing great to help
FEVER
References: Uptodate Essential evidence plus
Alberta health services guidelines for febrile neutropenia (2014)
DEFINITION:
Rectal or Ear >38°C
Oral or Axillary 2 37.5 ± o.30C
Rectal best in kids < 6yo
Oral best if > 6yo
Axillary best 2nd option
REASON TO WORRY:
Serious Bacterial Infection (SBI) = meningitis, sepsis, bone/joint infections in children
Fever in o-i mo (Risk of SBI 15%, high risk of occult bacteremia) therefore always require full
septic workup (LP, Blood Cx, Urine Cx, CXR)
Treatment: Ampicillin + Gentamycin for Tx (think group B strep, Listeria, and E.Coli) + admit
Fever 1-3 mo : Need to determine Risk of SBI using the Rochester and Baker criteria In general,
criteria are based on:
History: Pre Delivery (GTPAL) Maternal Infections (HIV, Hepatitis, GBS status, Syphilis,
Chlamydia, Gonorrhea, Herpes)
Maternal Complications: (DM, PIH, Hypothyroid), blood type, Rh factor, Drugs, Smoking, EtOH
Delivery: (Gestational age < 37wks = bad), ROM (>i8h bad), Maternal Fever, Type of Delivery,
APGAR scores, Complications (Resuscitation needed?),
Post Delivery: Prolonged Hospital Stay, Jaundice (physiologic vs pathologic), Antibiotics (at any
point), Other illnesses
Physical: Toxic or not Temperature >38°C Labs: WBC, Bands, Urine leukocytes, Stool WBC (if
diarrhea), New Additions are Prolactinonin, C-reactive protein and interluekin-6
Tx: If deemed High risk for SBI then full septic work up and ABx (Ceftriaxone 土 Ampicillin).
If deemed Low risk for SBI: no full workup, Discharge with 24 hour FU, no ABx
If 111 = full septic workup FU in 24I1，consider
Ceftriaxone 50 mg/kg IM
Fever 3-36 mo: Most Common infections are Viruses,
UTI, Pneumonia, Bacteremia (worried about risk of
occult bacteremia). Most common bug is S. Pneumonia
(decreased rates due to vaccination)
lx: If Temp >39°C, order WBC. Also urine Cx if <iyo or
uncircumcised Males or females <2 yo. CXR If resp
symptoms, blood Culture if WBC > 15 (个 chance of
bacteremia), Stool Culture if blood in stool

TX: If Child = Toxic Admit to hospital, full septic
workup and ABx.
If Child = Non Toxic and temp < 39°C, conservative TX towards cause.
FEVER IN ELDERLY:
Two Key things to remember
1) Elderly may often not produce an appropriate febrile response
2) Elderly may often not produce an appropriate immune response (WBC may be normal)
so a WBC elevation is more important than WBC level.
Non Infectious causes of Fever
Overdressing, Hyperthermia, Drugs Malignant Neuroleptic Syndrome (caused by antipsychotics)
= Hyperthermia, Rigidity, Autonomic dysregulation
Treatment: Fluids, Bromocriptine/or Dantrolene
FEVER OF UNKNOWN ORIGIN:
Di fferential Diagnosis (4 broad categories)
Infection: Tuberculosis, Intra-abdominal abscess (2nd
to appendicitis, diverticulitis), Dental abscess, Endocarditis, Meningitis

Malignant: Hematologic (Leukemia, Lymphoma), Non- Hematologic (Renal Cell Carcinoma,
Metastatic disease)
Autoimmune: Temporal Arteritis, PMR, Rheumatoid Arthritis, IBD
Other: Drugs, Hepatitis, DVT
Classic: • Infection, cancer, collagen vascular disease
Temp>38.30C, Duration > 3wks
Nosocomial: • C. enterocolitis, drug induced, PE, septic thrombophlebitis, sinusitis
Temp >38.3°C, Hospitalized but no fever on admission
Immune Deficient:
Temp>38.3°C, Neutrophils <500 • Opportunistic bacterial infections, Aspergilosis,
Candidiasis, Herpes
HIV Associated:
Temp >38.3°C HIV infection, duration > 4wks • Cytomegalovirus, Mycobacterium avium-
intracellulare complex, Pneumocystis caninii pneumonia, drug induced, Kaposi’s sarcoma,
lymphoma
FEBRILE NEUTROPENIA:
Fever > 38°C for >1 hour Neutrophils < 0.5 x 109 cells/L
Medical Emergency with 20% death rate if not treated. Chemotherapy is the cause in 90% of all
cases: BE VIGILANT IN CHEMO PATIENTS GI bacteria seeding into blood most common cause of
infection
WORKUP:
These people need full Hx and Px (AVOID RECTAL EXAM DUE TO RISK OF BACTEREMIA), CBC,
Lytes, BUN, Cr, LFTs
Blood/Urine cultures, CXR

Avoid LP routinely
Tx: If no source can use Tazocin.
If allergic to p-lactams cans use Vancomycin 土 Cefipime or others.
Treatment of FEVER:
Non Pharmacologic = Reassurance, Oral Rehydration, Sponging
Pharmacologic = Acetaminophen 650 mg q4-6h (Adults), 15 mg/kg q4-6h (Kids)
Ibuprofen 400 mg q4_6h (Adults)，10 mg/kg q4-6h (Kids)
Ibuprofen better than Acetaminophen at reducing fever. Can alternate between two, or take
them at the same time
BOTTOM LINE
-In febrile pts w/ a viral infection, do NOT prescribe antibiotics.
-In febrile pts requiring Abx tx, prescribe the appropriate Abx according to likely causative
organism(s) and local resistance patterns.
-Aggressively and immediately treat pts who have fever resulting from serious causes before
confirming the dx, whether these are infectious or non-infectious
FRACTURES
BC Guidelines: Ankle injury (2014)

PRIMARY WORKUP for any TRAUMA:
A - Airway and cervical spine protection B - Breathing and ventilation C - Circulations and
hemorrhage control D - Disability (neurologic evaluation)
E - Exposure/ environment control In secondary survey perform head to toe exam to assess for
fractures and consider xray imaging. Pts under the influence of illicit drugs/ EtOH may not feel
pain so thorough head-toe exam is important
。patients with a fracture, assess
neurovascular status and examine the joint above and

below the injury
-Assess and document neurovascular status every time
you assess joint or limb.
-Remember the 6 P5s: Pain, Pallor, Polar, Paresthesias,
Paralysis, Pulselessness (all are signs of badness)
-Remember to revaluate pulses frequently if no pulses
or no cap refill; a surgical emergency exists
-review joint and peripheral nerve exams
OPEN FRACTURE:
-Don’t probe wound;个 risk of infection. Open fractures
require referral to Ortho. Continue to assess NVS,

-Consider tetanus and ABx. Often require surgical
debridement.
COMPARTMENT SYNDROME:
-Common in crush injuries; but can happen in
atraumatic situations
-Loosen any tight clothing, braces or casts
-Diagnosis: 6 P’s
-Surgical emergency as leads to hypoxia and necrosis; referral to surgery
OCCULT INJURIES:
Scaphoid fractures in wrist injuries, elbow fractures, growth plate fracture in kids, stress
fractures can be occult on xray so manage according to clinical suspicion.
*** CAST OR IMMOBILIZE THESE FRACTURES ON Hx & Px ALONE. ALSO APPLIES TO C-SPINE
INJURIES, i.e. if you suspect an injury; keep immobilized***
Elderly patients with an acute change in mobility may require more than xrays to RO fractures.
Osteoporosis, myeloma, bone mets are more common in the elderly and may make pts more
prone to fractures.
-Consider CT or bone scan in the above cases.
MANAGEMENT:
-Cover open wounds with sterile dressing; ensure tetanus up to date. Immobilize joints above
and below site. Add extra padding to bony prominences to avoid rubbing and ensure splint is
not too tight to prevent compartment syndrome. Splint limb for imaging in position if needed.
-If no neurovascular Sx in unstable fracture; may try to reduce/realign once; if no improvement,
urgent ortho consult.
-If reduction of joint is required; apply gentle traction- counter traction until cast is placed then
reimage to
confirm placement. Reassess NVS anytime manipulation is performed.
Spinal fractures require immediate immobilization!!! ** pelvic and femoral fractures are also
considered emergencies due to their high propensity for blood loss and fat emboli**
-In assessing patients with suspected fractures, provide timely analgesia
-Consider opiates (oral or IV), do not give narcotics to
someone with decreased LOC
-consider local (nerve/hematoma blocks)
Ottawa rules: Don’t forget to assess for debilitating ligament tears (ie. lisfranc and ankle
instability) before releasing Pts
Ankle X-ray is required only if there is any pain in malleolar zone and any of these findings:
bone tenderness at A, bone tenderness at B, inability to weight bear both immediately and in
the casualty department.
Foot x-ray is required if there is any pain in the midfoot zone and any of these findings: bone
tenderness at C, bone tenderness at D, inability to weight bear both immediately and in the
casualty department.
Lateral Ve«w
A
Poslenor edge
or bp of
nulleotus
C
baseoTStti
metatarsal
Ns^tcular
Poslenor edge or ttpo( medial maleolus
Ankle X-ray is required only if there is any pain in malleolar zone and any of these findings:
bone tenderness at A, bone tenderness at B，inability to weight bear both immediately and in
the casualty department.
Foot x-ray is required if there is any pain in the midfoot zone and any of these findings: bone
tenderness at C, bone tenderness at D, inability to weight bear both immediately and in the
casualty department.
A knee x-ray is only required for knee injury patients with any of these findings:
age 55 〇r over, isolated tenderness of the patella (no bone tenderness of the knee other than
the patella), tenderness at the head of the fibula, inability to flex to 90 degrees, inability to
weight bear both immediately and in the casualty department (4 steps - unable to transfer
weight twice onto each lower limb regardless of limping).
C-Spine RULES
LOW RISK FACTOR ALLOWING
FOR SAFE ASSESSM ENT：
Simple rear end car accident OR

Sitting in ER OR Ambulatory any
time OR Absence of midline
tenderness OR delayed neck pain
NC
ANY HIGH RISK FACTOR:
Age >65yo OR Dangerous
mechanism OP Paresthesias o 门
extremities
YES
RADIOGRAPHY
-Need lateral, odontoid, oblique views; if canJt view Cy may need swimmer’s view
-if normal xray but concerning Sxs; don't immobilize
get additional xrays or CT
GENDER SPECIFIC ISSUES
References: MosbyJs family Practice Sourcebook
Uptodate
Toronto Notes
OFFICE POLICIES:
Ensure comfort and choice, especially with sensitive examinations:
1. Pap - good draping, covering all genitals for as long as possible/afterwards
2. Breast exam - only expose one at a time
3. ask all patients “comfortable if I do this”
4* should offer to all patients (regardless of same of opposite gender) to have another person
in the room when performing PAPs, Breast exams, DRE and prostate exams
Clinical problems that may present differently in men and women:
CAD in females
-Leading cause of death in ? in North America, - 2x CA related deaths
-atypical CP presentation, females more likely to die of their Mis than males;
-exercise stress test not the best diagnostic test in females, should screen with nuclear stress
tests
Depression in males
-should screen for with sexual dysfunction, low interest
in activities, may not be as forthcoming -males more likely to commit suicide than females (4:1)
second most common cause of death for ages 15-
24
EtOH/Street drugs (see substance abuse)
tend to consider more in males than females but 10-
15% of females are problem drinkers
? > 9 drinks/week, 6 > 14 drinks/week
Osteoporosis in males - see osteoporosis section Eating disorders in Males
-should consider in males as well, ? : $ is 10:1, high incidence in athlete
Andropause
controversy if this is actually a syndrome or depression
Domestic Violence (see domestic violence)
-can occur in both males and females
Stress related Role-balancing Issues
Gender specific roles no longer the norm, many
households share, split etc.
-discuss what both roles are and how each person contributes
-what the person likes the other to do
EBM: Be aware of who a study is targeting males, females or both. Apply accordingly.
GASTROINTESTINAL BLEED
References: Mosby5s family Practice Sourcebook Uptodate
Canadian Association of Gastroenterology Guideline on Upper GI bleed (2004)
Etiology of Upper GI Bleed (UGIBV
PUD (45%), varices (20%), gastritis (15%), esophagitis (10%), Mallory-Weiss tear (8%),
coagulopathy (renal, liver, drugs), vascular malformation, epistaxis, cancer, fistula (if previous
graft)
Etiology of Lower GI Bleed (LGIBV
Diverticular (33%), colitis (20%), cancer (18%), angiodysplasia (8%), infectious, ischemic,
anorectal /hemorrhoid, IBD (colitis > chron's),
Other causes for Melena:
Black licorice, blueberries, lead, Pepto-bismol, Fe supplementation, red meat, cantaloupe and
other melon, grapefruit, figs, broccoli, turnips, radishes, horseradish
HISTORY:
Even if there are known hemorrhoids or on warfarin, MUST RULE OUT BAD THINGS!!!!!!
[cancer, varices, perforated ulcers, IBD]
Bleeding episodes- acute or chronic, number of episodes, severity, location, description of
blood General- Sx of anemia, fatigue, syncope, weight loss, nightsweats (RED FLAGS)
GI- GERD, abdominal pain, anorexia, nausea/vomiting CVS- SOB, CP, palpitations
Clinical Upper Cl Bleed Lower Cl Bleed

Hematemesis/ Coffee grounds
Melena (above R colon) Almost certain Rare
Probable Possible/ rare
Hematochezia Possible Probable
Blood streaked stool Rare {beware rapid UGIB) Almost certain
Likelihood 75% of all GI B, proximal to ligament of treltz 25% of all GIB
Risk Factors
MODIFY if possible, SO ALWAYS ASK -NSAIDS, ASA, WARFARIN -Smoking, EtOH
-Liver disease, cirrhosis, portal HTN
-Cancer, coagulopathy, IBD
-age >7〇yo
-recently in ICU
-previous bleed
-H.pylori infection
MANAGEMENT:
*** HEMODYNAMICALLY UNSTABLE = DO ABCs FIRST 磁 -Monitored setting.
-NPO 土 NG tube (if hematemesis)
-2 large bore IVs, hang NS, get labs (below)

-02, secure airway
-Monitor 02 sat, BP, ECG, Foley
-Cross + type 2u pRBC - transfuse if necessary
Treatment: Non-variceal bleeds = IV/PO PPI (Pantoprazole 8〇mg IV bolus, then 8mg/h
infusion) Variceal bleed = Octreotide 5〇mcg IV bolus, then 5mcg/h infusion
Cirrhosis present = consider IV ABx (ceftriaxone lg IV x 5days)
STOP Warfarin, ASA, Heparin

Correct coagulopathies:
packed RBC transfusion if Hgb | & symptomatic,
unstable or high risk (eg CAD)
platelets to keep count >50
Fresh frozen plasma to normalize INR
Vitamin K to reverse Coumadin effects
Consult Gl/Surg - urgent endoscopy or sigmoidoscopy
if unstable
Does this patient need surgery???
Investigations:
CBC, lytes, BUN, Cr, INR, PTT, LFTs Repeat labs PRN to follow clinical course.
Type and cross ECG，AXR(freeair?) 土 CXR
SURGICAL MANAGEMENT
Upper Bleed BUN Cr ratio=10:1t +NG aspirate, upper endoscopv/Qastroscopy
Lower Bleed sigmoidoscopy on unprepared bowel, colonoscopy, tagged RBC scanr
exploratory laparoscopy
Variceal Bleeds: usually massive upper GI bleeds [15% will die from it]
Almost always due to portal HTN, often accompanied by varices in stomach
Complication of cirrhosis [found in 50% of all cases] Screening: all those with cirrhosis should
have endoscopy: if no varices, repeat q3 years. If varices, repeat qi_3year
Primary prevention: P-Blocker (Propanolol) or
variceal band ligation. EtOH abstinence. Weight loss Acfiue bfeec/: Octreotide 土 band
ligation/sclerotherapy
土 balloon tamponade 土 TIPS [intrahepatic portosystemic shunt, bridge to liver transplant]
Px if suspect varices: Jaundice, telangiectasia, gynecomastia , fetor hepaticus (sweet, fecal

smell), palmar erythema, ascites, caput medusa, splenomegaly, liver may be small, testicular
atrophy, venous hums - continuous noise as a result of rapid turbulent flow in collateral veins
BOTTOM LINE:
-Nonvariceal = PPL Variceal = Octreotide IV. Cirrhosis present = add ceftriaxone IV -Differentiate
upper and lower and get appropriate SCOPES
-Identify and modify Risk factors
-Don’t attribute bleeds to hemorrhoids or warfarin- ALWAYS R/O BAD STUFF
-Variceal bleeds are SCARY and COMMON in setting of cirrhosis!!!! DO SOMETHING BEFORE
they bleed
GRIEF
References: Mosby5s family Practice Sourcebook Uptodate
AAPC -bereavement
BC Guidelines: Grief in palliative care (2011) EPIDEMIOLOGY:
5-10% of people have a loss in a given year
Normal Grief:
-Immediately following death, survivors experience feelings of numbness, shock, and disbelief.
—Intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization,
and emptiness commonly arise in the weeks after the death.
-May include “searching behavior” including hallucinations of the deceased.
-May include somatic complaints such as chest tightness, abdominal pain, etc
Kubler-ross model 5 stages: denial, anger, bargaining, depression, and acceptance ^Symptoms
resolve by 6 mons**
^When people present as above, look for any potential loss in their life, may not be the typical
things**
Abnormal Grief:
-More than 6 months and 4 of the following; difficulty moving on, numbness/detachment,
bitterness, empty life feeling, trouble accepting death, future holds no meaning, agitated/on
edge, difficulty trusting others
DSM-5 eliminating grief exclusion from MDD criteria. Complicated grief criteria still in works -
proposal to have above criteria + impairment of normal function >imons is considered
complicated grief reaction **Screen for Depression and Suicidality**
Children/Elderlv and Grief:
Present with more somatic complaints. Kids do not understand concept of death until about
8yo. May act out, decline in normal function, anger
**/n unexplained Sx, ask about social circumstances**

MANAGEMENT:
Normal grief = Counselling, encourage normal routine, short term hypnotics
Abnormal grief = grief therapy/psych referral, support groups.
Children = encourage family to share, speak to child at
age appropriate level
Treat anxiety, depression, etc.
BOTTOM LINE:
1) Screen for depression and suicide
2) Be there for patients experiencing grief
3) Identify complicated grief, grief in children/elderly and refer appropriately
HEADACHE
References: Mosby5s family Practice Sourcebook Headache Network Canada: Migraine
guidelines (2012) TOP Alberta docs guidelines: Headache in adults (2015) Uptodate
DIFFERENTIAL:
Primary Headache disorders: Migraine 土 Aura Tension type headache Cluster headache
Secondary Headache disorders:

Space Occupying Lesion (tumor, abscess, bleed) Subarachnoid Haemorrhage Stroke (Ischemic vs
Hemorrhagic)
Subdural Haemorrhage
Pseudotumor cerebri
Infection (Meningitis/Encephalitis)
Temporal arteritis
Glaucoma
Red Flags on Hx
Systemic symptoms/Stiffness of neck/Systemic disease (tumor, AIDS)
Neurological Sxs (weakness, parenthesis, numbness, ataxia, aphasia, diplopia)
Onset Sudden (Thunderclap)/Ocular symptoms Pattern change (new onset, increasing in
frequency and severity), esp if >5〇yo (Chronic subdural hematoma, Temporal Arteritis)
Other things on Hx: onset, location, duration, coexisting conditions, precipitating factors,
severity
PHYSICAL:
Blood pressure, Neuro exam, Neck exam (stiffness, jolt accentuation), Eye and Temporal exam
Investigations:
Neuroimaging: Order if red flags on Hx and/or neuro findings on Px. CT (non contrast best initial
study if suspect bleed) or MRI Consider: ESR, LP, other BW as indicated
MIGRAINES:
Aura absent or present
Pulsatile, photophobia, phonophobia

Onset gradual
Unilateral
N/V
Debilitating and duration 4 to 72I1
Dx: 2 of photophobia, nausea, interference of daily
function
Prevention:
Non-Pharm = Trigger identification/ avoidance
(Migraine Diary), HTN Tx (Important risk factor for migraines), Sleep Hygiene, Rehydration, stop
smoking, |EtOH & Caffeine, |Stress,! Exercise, |Weight Pharm prophylaxis = if 23 attacks per
month 土 functional impairment or using too many meds. Trial for 4-8wk then reassess.
Options: TCAs (Nortriptyline), P-Blockers (Propranolol, SAFEst in PREGNANCY), Anticonvulsants

(Topiramate). Herbals and acupuncture indicated as well
2nd line = Candesartan, Venlafaxine, Gabapentin Refer to Neuro if resistant to treatment Acute
Tx:
Non -Pharm = Stay in quiet dark room Pharm =
Mild: NSAIDS (Naproxen), Acetaminophen (rebound headache & dependency risk)
Mod to severe:
1st line = Triptans (Sumatriptan, “ZOMIG”，can be given nasally) Cl: Pregnancy, CAD/HTN.
Triptan + NSAID stronger than Triptan alone.
Ergots out of favour, heavy SE, may use if unable to do triptans
Other Acute Pharm Tx:

Metoclopramide IV GOOD FOR PREGNANCY (or other antiemetics, give with Benadryl to
prevent dystonia) AVOID NARCOTICS & BARBITUATES (4-5th line)
TENSION HEADACHES:
Bilateral pressing headache which is non pulsatile. Most common type of primary headache
Triggers: Stress, sleep deprivation, caffeine, EtOH Dx: 2 of non-pulsitle, bilateral, doesn't change
with exercise, mild to moderate intensity.
Tx:
Non-pharm: Trigger identification/avoidance
Pharm: NS AIDS (Ibuprofen) or Acetaminophen 土
caffeine
AVOID NARCOTICS & BARBITUATES. Can’t use triptans
Prophylaxis: TCAs (Nortriptyline), Venlafaxine,
Mirtazapine. CBT, exercise, physio and acupuncture can have roles.
CLUSTER HEADACHES:
Severe unilateral pain (usually around eyes) associated with lacrimation, ptosis & rhinorrhea.
<3hrs, comes in clusters
Males at 个 risk, often triggered by EtOH
Tx: Non-pharm: Trigger identification/ avoidance, sleep hygiene

Pharm: Oxygen, Triptans (Sumatriptan)
Prevention: Verapamil, Lithium - referral to specialist as this is quite rare.
MEDICATION OVERUSE HEADACHE:

Follow “12 days each month” rule to avoid this complication. Any abortive or analgesic
medication taken on >12 days/month may produce rebound headaches. Triptans and Opiates
are both high risk for rebound headaches. Suspect this in chronic headache not responding to
Tx.
Tx: Stop analgesia. Can consider migraine prophylaxis med while off analgesias.
TEMPORAL ARTERITIS:
Age >5〇yo, scalp tenderness Jaw and tongue claudication Visual Changes, constitutional Sx
elevated ESR (>50)
Diagnose by Temporal Artery Biopsy. Doppler U/S (Specific, not Sensitive)
Needs urgent treatment, can cause blindness- Tx before diagnosis if suspecting
Tx: Prednisone 50 mg x 2 mo, then taper 土 ASA 81 mg
SUBARACHNOID HEMORRHAGE:
Sudden onset of severe thunderclap headache. High risk in ? who smoke, drink, and have HTN
CT sensitivity is highest at 12-24 hours, then decreases. If CT is negative, and you still suspect it,
then you need to do an LP (RBC, Xhanthochromia, Bilirubin).
Tx: Send to neurosurgeon.
PSEUDOTUMOR CEREBRI
headache with visual Sx, mostly middle aged ?. Ask about pregnancy/weight gain
Risks: DM, PCOS, iron deficiency, IBD, SLE Px: Papilledema，个 CSF pressure
Tx: LP to relieve pressure, Azetazolamide, Steroids, Topiramate

Meningitis covered in own section.
HEPATITIS
References: An update on the management of chronic hepatitis C (2015)
Public Health Guideline for Management of Hepatitis B (2013) Diagnosis and Management of
Hemochromatosis: Liver.ca (2011)
Diagnosis and Management of Non-alcoholic Fatty Liver Disease: Liver, ca (2012)
Liver Function Test: INR，Bilirubin, Albumin & Liver Enzymes Liver Enzymes:
AST = in liver parenchyma, cardiac & skeletal muscle, RBC

ALT = present in hepatocytes ONLY
ALP = biliary duct cells, bone, placenta
GGT =T sensitive than ALP in detecting cholestatic
damage;个 in subclinical liver dysfunction
AST/ALT >2 = ETOH hepatitis

AST or ALT >1000 = acute causes: blocked duct, virus,
drugs, ischemia, autoimmune
ALP or Bilirubin 个=cholestatic problems
Isolated Bilirubin 个=hemolysis/jaundice
Obstructive Hepatitis:
Painful (stone) vs painless (Mass), or acute acalculous cholecystitis (in critically ill).
Hx: Jaundice, pale stool, dark urine, itching, abdo pain relating to food
Ascending cholangitis (Charcofs Triad) = right upper quadrant pain, jaundice, fever/chills. Sepsis
(Reynolds pentad): Charcot’s + |LOC + |BP.
Ix: CBC, LFTs, amylase/lipase, ECG Imaging: U/S, ERCP (best), MRI/MRCP Tx: Pain control =
morphine over meperidine ERCP vs Surgery (Open vs laparoscopic)
Drugs: Ursodiol/Chenodiol (Tx 6-12 mons)
Observation for asymptomatic stones. Abx for cholangitis (E.Coli, Enterobacter) =
Metronidazole + Cefazolin
Complications of gall bladder dz: Empyema, abscess,
gangrene, rupture, ileus, hepatitis
pancreatitis.
ACUTE HEPATITIS: <6mons Causes: Infectious, Stones, Drugs, NASH,
hemochromatosis, Wilson’s dz, EtOH, Alpha-1 Antitrypsin def., Primary biliary cirrhosis,
Sclerosing biliary cholangitis
***North America: EtOH abuse and viral are primary causes of cirrhosis***
EtOH Hepatitis: caused by EtOH Abuse, >8og EtOH/day (8xi2〇z. beer, lL wine, or V2 pint
whisky). Has macrocytic anemia，个 WBC，个 enzymes (ALT & AST -300-600, AST/ALT>2,),
tplts
Prognosis: Fatty liver is reversible if stopped. 5yr
mortality - 30% if D/C EtOH, or 70% if continue EtOH.
NASH: most common liver dz; middle aged, over-wgt, ?，DM，associated w/个 TG，个
cholesterol & insulin resistance.
Dx: US 土 biopsy (for prognosis) = micro (early) & macrovascular (late)
TX: Losing weight beneficial, no Tx yet

Wilsons Dz: recessive genetic defect in copper metabolism.
Leads to liver cirrhosis, fulminant hepatitis, | risk for liver CA.
(need 2): | ceruloplasmin/1 serum copper，个 urine copper;个 liver copper on biopsy，Kayser-
Fleischer rings Tx: Chelators (zinc acetate), transplant, specialists
ifemochromatosfs:个 iron level
Primary: genetic (1/500 of European Ancestry).

Secondary: iron overload.
Sx: chronic hemolysis, liver cirrhosis, bronze DM,
pancreatitis, arthralgias, liver CA
Dx:个 ferritin /or transferrin，Genetic studies
Tx: phlebotomy, Desferoxamine

Drug Induced: Acetaminophen (most common), Chlorpromazine, Isoniazid, MTX, Amiodarone,
Azoles, Statins, Methyldopa, Phenytoin, Rifampin, sulphonamides, tetracyclines
Infectious: most often viral (Hepatitis virus, CMV, HIV, EBV)
Transmission: Oral-Fecal = A, E; All Acute!

Blood Borne = B, C, D; Can be chronic!
Risk of Infection from Needle Puncture: HBV 30-60% HCV HIV 〜0.3%
Tx: Acute viral hepatitis = conservative. 90% resolve, 1% fulminant (HAV and HBV usually, HCV
rare). Can become chronic (HCV ^80%, HBV ^5%).
Check for HIV!!!!
HEPATITS A (HAV): 3-20/1000 travellers/mon. Fulminant hepatitis in 0.1%.
Ix: IgM Anti-HAV
Tx: Get immunized beforehand. If not can get it after.
HEPATITIS B (HBV): Co-infection of chronic HBV w/HAV can result in Fulminant hepatitis.
5 Patterns (on lx): ACUTE HBV: + HBsAg, HBeAg (marker of replication), IgM anti-HBc. Chronic
HBV (f infectivity): + HBsAg, HBeAg, IgG anti-HBc, |AST/ ALT.
Chronic HBV (linfectivity): + HBsAg, Anti-HBe, IgG anti-HBc, AST/ALT normal.
Recovery: + Anti-HBs, Anti-HBe, IgG Anti-HBc Immunized: +Anti-HBs Tx: Interferon, Lamivudine
Post-exposure Prophylaxis: within <i4days, 0.06 IU/Kg of hepatitis B IG.
HEPATITIS C (HCV): 50% of chronic hepatitis in USA. Cirrhosis at -20 yrs
CA (3% of cirrhotics) at 30 yrs. Other risks: IV drugs, vertical transmission, blood transfusion
before 1989 lx: anti-HCV, confirm w/ HCV-RNA
Tx: REFER - new Tx are able to cure.

HEPATITIS D: Co-infection with HBV only
HEPATITIS E: Only pregnant ? get this. Uncommon in developed countries
ENCEPHALOPATHY:
can be from chronic liver damage/ cirrhosis/hepatitis. Cause:个 ammonia /BUN from bacteria
and liver's inability to process.
/LOC，个 tremors，个 abdo fullness Tx: Need ^ 4 bowel movements/day, get them going
(lactulose best). May use ABx or probiotics. Avoid dehydration.
HYPERLIPIDEMIA
References: Top Alberta docs (2015)
Canadian cardiovascular society Guidelines (2016)
CCS = Canadian cardiovascular society TOP = top Alberta docs
DDx OF HYPERLIPIDEMIA:
EtOH abuse (use CAGE questionnaire), DM, Nephrotic syndrome, Hypothyroidism, Obesity,
Cholestatic liver disease,
Medications (OCP, atypical antipsychotics)
Px: Evidence of atherosclerosis
FHx: premature CAD (<6〇yo in lst-dcgrcc relatives),
hypercholesterolemia, chylomicronemia
SCREENING:
4〇-75yo or younger w/ the following conditions:
DM, HTN, obesity, inflammatory dz (SLE, RA, psoriasis), CKD (eGFR <6o), COPD, $ w/ erectile
dysfunction, HIV infection treated with highly active antiretroviral tx, anyone on antipsychotic
meds, smokers Screen qs yrs.
TOP 2015 reccs: start ? >5〇yo or postmenopausal
Screening lx: Lipid Profile = TG, HDL, LDL (calculated), Total Cholesterol. Can be fasting or not.
Also look at BP, eGFR for risk assessment and consider ALT/CK if initiating Tx
FRAMINGHAM RISK SCORE (FRS):
Provides chance of CAD/CVA in next loyrs Not the only risk calculator - just most common Takes
into account Gender, Age, Total Cholesterol, HDL, BP, DM, smoking status
High risk > 20%, Moderate risk 10-19%, Low risk < 10%
mIf + FHx of young CAD, then DOUBLE the FRS number and Tx accordingly^**
METABOLIC SYNDROME: fCV risk. Consider 个 pt’s FRS category
Dx: Big gut +2 of the following: TG > 1.7, i HDL, BP >130/85, FBG >5.6
TREATMENT & TARGETS:
TOP: LOW risk = don^ treat.

MODERATE risk = consider statins.
HIGH risk = Tx w/ highest tolerated dose of statin. No targets
CCS: LOW risk: TX w/statin if LDL > 5, | LDL >50%. MODERATE risk: Statin if LDL > 3.5 or Non-
HDL > 4.3. Some other modifiers in here. Goal = LDL < 2 (non-HDL <2.6) or |by 50%, whichever
is lower HIGH risk = Tx w/statin, Goal = LDL <2 or I50%, whichever is lower
Always Tx if pt has DM, artherosclerosis, CKD, AAA
NON PHARMACOLOGIC MANAGEMENT PARTS):
1. STOP SMOKING
2. STOP STUFFING YOURSELF
Less fat, less salt, less calories, less booze, more fibre i saturated and trans fats i simple sugars
and refined carbohydrates 个 fruits and vegetables t whole-grain cereals
个 proportion of mono- and polyunsaturated oils, including omega-3 fatty acids
3. GET YOUR ASS ON A TREADMILL
(> i5〇min of mod-vigorous aerobic exercise/week)
PHARMACOLOGIC MANAGEMENT:
STATINS: Prevent the rate-limiting step in cholesterol synthesis in the liver, (also known as Hmg-
CoA reductase inhibitors)
Lowers LDL
not to be used in pregnancy
SE: myositis/rhabdomyolysis (rare) - stop med if muscle pains, follow w/ CK

Myalgias are common, risk vs. benefit discussed if that’s the case
ALT /CK at baseline - depending on your comfort level, then intermittently based on Sx
Example: Atorvastatin io-8〇mg qhs
Cholesterol Absorption Inhibitors (second line)

Also called bile-acid binding resins. Inhibit cholesterol absorption.
Additive effect with Hmg-CoA Reductase Inhibitors (NNT 〜70)
Examples: Ezetimibe lomg daily

SE: nausea, bloating, cramping, and an increase in liver enzymes
Fibrates
Reduce TGs, increase HDL Don't mix with statins Example: Fenofibrate
Make numbers good but don’t do anything for mortality
Niacin
Increases HDL levels.
CAUTION: flushing (give ASA beforehand to reduce likelihood), dry skin, gastritis and worsened
glycemic control DM.
Don’t mix with Statins No effect on mortality
Fish Oils, Omega Fatty acids
Increase TGs, decrease LDL
DON，T MISS:
Starting the following people on statins: DM, metabolic syndrome, CAD, CKD, other vascular
diseases
HYPERTENSION
References: Canadian Task Force on Preventative Health (2012)
Canadian Hypertension Education Program Gudelines (2015, 2016 update)
BACKGROUND:
Epidemiology: 1 in 3 adults approximately Pathophysiology: unknown
SCREENING:
-screen all pts > i8yo yearly
-do further work-up for young pts requiring multiple hypertensive medications, abdominal
bruits, electrolyte abnormalities, or if pts worsen with meds -an abnormal result is considered
greater > 140/90 (or 130/80 in DM, CKD, other signs of vascular dz)
-essential hypertension -hyperaldosteronism -pheochromocytoma -renal artery stenosis -drug
induced -white coat syndrome
-obstructive sleep apnea -hypothyroidism -coarctation of aorta -glomerulonephritis

HISTORY/PHYSICAL:
-for exam purposes, review proper BP measuring techniques
-if hypokalemic or resistance to medications, consider hyperaldosteronism
-if resistant to medications, worsening Cr after starting ACEI, or abdo bruit, consider
renovascular stenosis -if worsened by Beta-blocker, family Hx of genetic disorders, paroxysmal
severe HTN, or symptoms of panic attacks (tachycardia, sweating, etc): consider
pheochromocytoma
HOWTO DIAGNOSE:
-Hypertensive Urgency: diastolic > i3〇mmHg -Hypertensive Emergency: hypertension causing

end organ damage (MI, CVA, renal disease, etc.). May qualify if any acute hypertension related
issue which is life threatening.
Hypertension
=BP > 180/110 at anytime (or hypertensive emergency) =Home BP measurements averages >
135/85 or 24 automated BP measurement average >130/80 =Office BP average > 160/100 over
3 visits, or > 140/90 over 5 visits.
-if BP measured high; f/u measurements should be done within one month
WORKUP:
All new hypertensives should have:
-urinalysis，ACR
-ECG
-lipid profile -fasting glucose/HbAiC -electrolytes and Cr
May also consider:
-hyperaldosteronism^* order aldosterone, renin -renovascular stenosis— order renal imaging
(ie. Doppler sonography)
-pheochromocytoma —biochemical screening tests (urine metanephrines) or imaging -

hyperthyroidism — TSH，T4
-signs of heart decompensation echo/stress test etc.

MANAGEMENT:
-Lifestyle changes:个 exercise (30-60 mins of cardio exercise 4-7 days/ week), |wgt, | sodium,
jfat, I cholesterol (DASH diet =个 folate，I salt，lots of green leafy veggies)， |EtOH (1-2 drinks
or less per day), I stress,
MEDICATIONS
(only first line treatment listed)
-isolated systolic HTN: thiazides, DHP-CCB, ARB -diastolic 土 systolic HTN: thiazides，DHP -
CCB，ARB， ACEI，P- Blockers
-HTN with diabetes: ACEI, ARB, DHP-CCB, thiazide diuretics (if albuminuria use only ACEI, ARB)
-HTN with CAD, previous MI or CHF: ACEI, ARB, p- blocker (if CHF stage 3-4 can use
Spironolactone)
-HTN with past stroke: ACEI & thiazide diuretic combinations
-HTN with non-diabetic CKD: ACEI or ARB
-for overall vascular protection consider pts for low dose ASA and statin (CHEP guidelines). TOP
guidelines suggest ASA only on high risk FRS patients.
-For HTN emergency, use labetalol IV and try to |BP by 20% in 2-8 hrs, donJt go too fast or
they'll stroke out on you and don’t go too slow cause, well you're not doing anyone any good
MED FACTS:
-Chlorthalidone is only drug to have all-cause mortality benefit in HTN
-DHP-CCB such as amlodipine/felodipine make your legs swell
-ACEI supposedly don’t work in black people for isolated HTN (really?)
-don’t use p-Blockers in oldies as they may fall/pass out on you. They also cause sexy time
issues -choose cheap and less times a day if you can
THE BOTTOM LINE:
Screen everyone for HTN.
Multiple BP readings are often required for diagnosis. Treatment should include lifestyle
changes and medical management
IMMIGRANTS
References: CDC
Canadian Thoracic Society: Tuberculosis standards (2013)
Be sensitive to:
磁 IF YOU DON’T KNOW，ASK!!!磁
• Religion
• Cultural tradition- defer decisions to specific family member? Restrictions on ? regarding

6 physicians
• Gender roles- head of household? Decision-maker? Breadwinner?
• Age - blurred age of maturity
• Refugee vs immigrant
• Recent trauma
• LANGUAGE BARRIER: be aware of difficulties if a family member is translating. Always

attempt to set up interpreter services beforehand.
Perform general medical examination:
-Hx&Px +
• Pregnancy = Test prior to vaccines /or Tx considered incompatible with pregnancy. May
need prenatal vitamins and referral for services if +
• Medications = Med list, herbals, OTCs, naturopathic meds, extracts, liquids, spiritual
healers, potions, etc
• Psychosocial = Education level, work/career, Family members, family structure, social

supports, Finances, insurance
Preventive health interventions Immunizations -Record previous vaccines, lab evidence of
immunity, or Hx of disease
-If patient has no documentation, assume he or she is
not vaccinated.
-Give age-appropriate vaccines as indicated
-Laboratory evidence of immunity may be checked
(Hepatitis, rubella, etc.)
-Smoking Cessation - always and forever
Recommended BW for All Refugees (CDC)
► Complete blood count with a white blood cell differential and platelets—> iron
deficiency anemia, inherited anemia (thalassemia, G6PD deficiency), eosinophilia (parasites),
thrombocytopenia (infection).
► Urinalysis (if old enough to provide a clean-catch urine specimen) RO infectious
diseases, kidney disease, diabetes, etc
► Infant metabolic screening in newborn infants, according to state guidelines
► Other Screening for at risk patients- HTN, Lipids, Cervical CA, Breast CA, Colon CA
Mental health screening is encouraged
► Approx. 2/3 of refugees have anxiety or depression
► Exposure to violence, trauma, and upheaval prior to immigration, poverty,
unemployment, social isolation, and language difficulties likely contribute to the increased rate
of psych conditions
When pt presents w/ illness, consider in the
differential，infectious dz acquired before immigration
Disease-specific testing:
► Tuberculosis testing: PPD
► Lead testing: CDC says screen all refugee children 6mo-i6yo. Additional lead test on all
children aged
6mo-6yo within 3-6 mons of placement in a permanent residence, regardless of the results of
the initial lead screen.
► Malaria: Be aware endemic countries (eg Sub-Saharan Africa) Any refugee who has signs
and symptoms of malaria and who originated in a malaria-endemic country should be tested.
► Intestinal Parasites
Sexually transmitted diseases:
History for Sx or the following:
► Syphilis - VDRL if 5~i5yo if sexually active, Hx of sexual abuse, mother who tests or
tested +, exposure in an country endemic for other treponemal subspecies (e.g., yaws, bejal,
pinta), confirmation testing needed
► Chlamydia -Urine NAAT in ? <25 years who are sexually active or those with risk factors
(e.g., new or multiple partners), WBC + on urine sample, ? or children with history of or at risk
for sexual assault, any refugee with Sx
► Gonococcus - Urine NAAT if WBC+ on urine sample, ? or children with Hx of or at risk for
sexual assault, or any refugee with Sx
HIV
► All refugees 13-6470 should be screened for HIV unless they decline
► CDC encourages screening for all ages
► Clear oral and written consent for HIV testing
► Repeat screen in 3-6 mons if recent exposure or 个 risk (high risk countries)
TUBERCULOSIS (Tb):
PPD: induration at site of injection > 5mm in high risk (Hx of (+) contacts, immunosuppression,
(+) CXR findings), >iomm in medium risk (health care workers, immigrants，northern Canada)
or > 15mm in everyone else means the test is positive and require a further workup.
^doesn't matter if you had BCG vaccine in past, these numbers still count**
-Follow (+) result with CXR
If CXR (+), have reactivation/active Tb. Usually found in upper lobes.
-Try to get cultures (bronchoscopy or stomach source) =need sensitivities to drive treatment.
-If active, treat with Isoniazid, Rifampin, Ethambutol, Pyrazinamide (RIPE) for 2 mons, then pick
2 that work for an additional mons (6-9 mons of Tx total)
-If not active, consider risk-benefit of Tx (generally need > 3mons of Tx)
-Risk: Isoniazide = hepatitis, B6 def., feeling weird and off sorts, canJt drink EtOH. Rifampin =
makes you leak orange
IMMUNIZATIONS
References: Canadian Immunization Guidelines (2006) Canadian Pediatric Society Canadian
Public Health Agency
Immunization schedule varies by province cause they are weird crazy that way!!!
Precautions:
Delay giving vaccine if:
-Pt has moderate to severe illness -People treated with blood products should not get a live
vaccine (eg., measles, mumps, rubella, varicella) for > 3 months. Depending on the blood
product and dose received, these vaccines may not work Don’t delay vaccination for:
-minor illness (eg., a cough or cold, with or without fever, rash, aches and pains)
-Mild illness, current antibiotic therapy -Mild/moderate local reaction to previous vaccines.
Contraindications:
-Anaphylactic or other serious allergic reaction after receiving a vaccine (not vmssy local
reactions). Is only a contraindicated to that Vaccine
-If immunocompromised or pregnant can’t have live vaccines
-Guillain-Barre syndrome within 6 wks of vaccine - contraindication to that vaccine
^Clinically severe adverse reactions must be reported to Public Health^
Common Concerns About Vaccinations:
-Autism is frequently linked to certain vaccines in the media, specifically the MMR vaccine all
poppycock -Religious and other conscientious objections -Take concerns about vaccinations
seriously and educate parents/Pts
-Discuss sources of information, risks and benefits ultimately the pt is entitled to make an
informed
decision
-Document the conversation in detail!!
Make Sure You Vaccinate:
-Any patient who is vulnerable to infection or immunocompromised
-HIV patients -Sickle cell patients

-Patients who have family members infected with viral hepatitis
-Cystic fibrosis patients -Patients who travel to 3rd world a lot -Reside on First Nations
reservation
Document ALL Immunizations Given:
-On chart, on immunization card
-Remember to include influenza, H1N1，travel
vaccinations!
Who Needs To “Catch Up” Or Extra:
-Children w/some chronic conditions or who travel outside of North America may require
additional vaccines
-Children new to Canada may not have received vaccines which are routine here
-Children who move within Canada may miss a dose of vaccine because schedules are not
uniform across the country
If a patients presents with a disease you suspect is infectious:
-Consider immune status
-Consider travel history -Consider exposure history!

-Immunization does not guarantee immunity
Disease Effect of disease SE of vaccine
Diphtheria Sor© throat, weakness, CHF, nerve Local redness, pain, sweling
damage. Death in 10% of cases. fever, nodule at ste
Tetanus Painful muscle spasms, seizures As above
Polio Muscle paralysis, death in severe cases As above
Haemophilus Meningtis As above
Pertussis Whooping cough As above
Measles Bronchitis, fever, rash. Death or Fever, rash, encephalitis in
encephalitis n 1 /1000 cases 1 加 ilion, 1/20000 low platelets
Rubella Fever, swollen glands, sever© damage to fetus As above

Mumps Fever, swollen glands, encephalitis in 1/200 cases As above
Pneumococcus MeningKis. death Local redness, pain, swelang, fever, myalgias
Varicella Pneumonia, encephalitis, shingles Rash, local reaction, fever
Hepatitis B Lwer cirrhosis, acute hepatitis Local redness, swelling, headache
Meningococcus Death in 10% of cases , brain damage Local redness, swelling
headache, fevers
Human papilloma virus Ceivical cancerPain and redness/swelling
Influenza The flu, still kills people 1/milion Guillain-Barrer sniffles
Rotavirus Dehydration, diarrhea, death
Me a 沒 es/mumpsAubellaA/a nee Ua vaccine can cause increased seizures than when

admmtstered individually (MMR and VZV seperated)
IN CHILDREN
References: BC Children's Hospital Assessment Canadian Pediatric Society
Medical Conditions that present differently in
Children:
-appendicitis with vague abdominal pain

-general infections (pneumonia, UTI
irritability
etc.) with
OFFICE VISITS: due to infrequent visits, assess and counsel re: the following -unverbalized
problems (e.g., school)
-social well-being (e.g., home, friends)
-modifiable risk factors (exercise, diet)
-risk behaviours (e.g., bike helmets, seatbelts)
Adolescents: use the HEEADSS approach
Home Environment
Education
Employment
Activities
Drugs
Sexuality
Suicide
Pediatric: develop the habit of questioning children on their own about behaviours they may
not wish to discuss in front of parents
-It may be awkward to ask the child if he or she wants the parent to leave the room
-Develop a rapport with pediatric patients, talk to them not their caregivers
-Explain the concept of confidentiality to all your patients!
-use age-appropriate language
-Interview children above the age of eleven years or so on their own for at least part of the
appointment -Remember that young patients may be quite shy when discussing body parts,
sexual questions
Inquire about the development of the child:
school performance? social development? relationships
with friends and peers? bullied, or a bully? Dating? Sexual activity? dietary intake? modifiable
risk behaviour eg. seat belt use, use of bicycle helmets?
INFECTIONS
References: Mosby5s Family Medicine Sourcebook Canadian Anti-infective Guidelines (2013)
Uptodate
Surviving Sepsis Guidelines (2013)
Infections covered in other sections
Otitis media/externa □ covered in "Earache'，
Sinusitis □ covered in "URTI"
Chronic Bronchitis □ covered in “COPD”
Pneumonia □ covered in “Pneumonia” Croup/epiglottitis □ covered in “Croup”
UTI □ Covered in Uuti,j and Udysuria,j Prostatitis □ covered in “prostate”
Vaginitis □ covered in “vaginitis”
Cervicitis/PID/urethritis/Herpes/
Epididymitis/HIV □ covered in sexually transmitted diseases”
Neurological □ EMERGENCY!!!! Covered in “Meningitis”
GI □ covered in “Hepatitis” and “Diarrhea”
Eye □ covered in ’’Red eye”
WHAT TO CULTURE?
Blood for anything serious, urine for UTI, sputum/NP for resp., stool for GI, pus for skin (if able),
vaginal/urethral for STI/ vaginitis, LP for meningitis. CXR helps for pneumonia.
SEPSIS:
ÊMERGENCY! NEED BROAD SPECTRUM IV ABx, DO NOT WAIT FOR CULTURE**
Diagnosis: SIRS criteria =
Temperature >38.5°C or <35°C Heart rate >90 beats/min
Respiratory rate >20 breaths/min or PaC〇2 <32 mmHg
WBC >12,000 cells/mm3 or <4000 cells/mm3, or >10 percent immature (band) forms) +
Infection source.
Severe sepsis = sepsis + organ dysfunction.
Septic shock = sepsis + organ damage + low BP Other things: may
have t BS/lactate/fluid/edema/bilirubin/INR or i plts/urine output
Treatment: ABCs!!! & resuscitation
-Early Goal directed therapy □ FLUIDS to maintain BP(MAP > 65), urine output > o.5ml/kg/hr -
Vasopressors (norepinephrine 1st line) if fluids inadequate
-Broad spectrum ABx (IV P-lactam + IV quinolone or aminoglycoside) ASAP, alter later if/when
Cx is present -Airway management
-Fancy stuff like recombinant protein C, steroids, insulin done by intensivists
BODY
INFECTION CAUSE DIAGNOSIS TREATMENT OTHER
SKIN Impetigo MSSA, MRSA,
Strep. CNnicat - papules that progress to vesicles surrounded by erythema papules progressing
to vesicles uncomplicaled/ regional = Fucidin, Mupiiocin compicated/ spreading *
Cephalexin Walch for post strep
glomerulo¬
nephritis
Folbulitis MSSA. MRSA Clinical pustules around hair follicles Uncomplicated s
warm compress ± Fucidin/ IVlupirocin cream, complicated ■ Cephalexin
Cellulitis & Erysipelas MSSA, MRSA, Strep. erylhenrka. edema and warmth
ur>coniplicated - Cephatexin, severe/on face = IV Cefazolln or Clindamycin, necrotizing
■
IV Cefazolin > Clindamycin. MRSA s Clindamycin or Septra, bites (Pas/uereMa/staph/

anaerobes) ■ Clavulin or IV Ceflriaxone f Metronidazole if complicated diabetic foot (cover
anaerobes + pseudomonas) =Septra + Metronidazole
Shingles VZV erythematous papules, which quickly evolve into grouped vesicles
or bullae along with acute neuritis Famcycloviror Valcyclovir within 72 hrs, complicated
(immunocompromised, pregnancy, eye involvement) » referral for IV Tx Can cause IUGR.
hydrops, hearing/ seeing issues tf pregnant
Necrotizing
fasciitis Strep. MSSA, MRSA Erythema, pain out of proportion of Sx. edema, crepilus.
IV Tazocin, Clindamycin, consider Cipro for Pseudomonas -Broad spectrum
RESP Influenza Virus <type A/6) fever, resp. signs, myalgia. t>eadache. malaise
OseHamivir within 48hrs. 5 days forTx, 10 days for prophylaxis
Acute Viruses productive cough and risk factor modification. RO Laryngitis is
Bronchitis URTI Sx pneumonia treated the
same
TX options:
-pain relief for bad infections.

-refer to appropriate surgeon for bad stuff
BOTTOMLINE:
-consider infection as a Dx in ill-defined problem or unexplained pain
-Do not wait to treat emergency infections
-Tailor therapy to likely cause or when cause is known
in uncomplicated infections.
-Do not treat viral illnesses with ABx.
-Reassess infections to ensure improvement or need for
further therapy
-Be judicious and rational when picking Abx
INFERTILITY
References: Mosby5s Family Medicine Sourcebook Uptodate
SOGC: advanced reproductive age and fertility (2011)
Toronto Notes
Definition:
Inability to conceive after 1 yr of regular unprotected intercourse.
Primary (never had kids) vs secondary (now can't reproduce) infertility.
Epidemiology:
10-15% couples are infertile.
Cause is idiopathic in 10-15% of cases
1/3 ?， 1/3 6 , 1/3 combined issue (assess both
partners)
75% of couples achieve pregnancy in 6 mons, 85% in 1 yr, 90% in 2 yrs
Factors contributing to infertility
AGE!!!!!!!!!!!!!!!
Sexual intercourse frequency
Eggs/ovulation
Sperm
Tubes/peritoneum
History of BOTH partners:

-Name, AGE, relationship for how long, children (current and previous)
-Occupation (risks eg radiation, chemicals)
-Surgeries and injuries (abdo/pelvic/ hernia/testicular/ovarian)
-Vasectomy/Tubal ligation
-PHx (DM, Cystic fibrosis, thyroid, CA, etc),
medications, allergies
-Smoking/EtOH/drugs
-Pregnancy and labour history- Gravida parity status, miscarriages or stillbirth, vaginal/C-
Sections
CAUSES FOR INFERTILITY:
Sexual Intercourse Frequency:
-> 2x/wk!!!!
-Timing in cycle (most fertile 14 days before menses),? completed ejaculation
-Lubricants (some are spermicides), douches, condoms/contraceptives -?stress/psychological
factors
Eggs/Ovulatory dysfunction (1^-20%):
LMP， Menarche， regular q24_35days， flow and duration, dysmenorrhea/menorrhagia

Premenstrual molimina (ovulation)- Headache / mood / water retention/fatigue/breast
tenderness, OCP Hx, Check for PCOS, hypothalamic dysfunction，pituitary (prolactin)，

congenital (Turner’s， etc)，ovarian failure
Sperm- Semen analysis: Need total motile count >20 million.
Specimen 48-72I1 post abstinence.

Volume 2-5ml Motility > 50%
Liquefaction < 30min Morphology > 30%
Concentration > 200 mil/ml WBC < 1 mil/ml
S issues:
varicocele (increased temperature = 30%) testicular tumour, congenital (KleinfelterJs triad:
small firm testes, gynecomastia and azoospermia), cryptorchidism, post-infectious (ex. sexual
infections, mumps),
torsion not corrected within 6 hrs, radiation
Tubes/peritoneal/outflow obstruction:
Sexually transmitted diseases/pelvic surgery/ligation/occlusion (tubal factors 20-30%)
Endometriosis- dysmenorrhea/ dyspareunia/painful defecation/painful urination
Uterine factors- fibroids， congenital, infection, endometrial ablation, etc
Cervical factors- congenital, previous cone bx/laser tx, anti-sperm antibodies, etc
Px - Look for signs of PCOS, thyroid dysfxn, androgenicity
GU exam- pap, swabs, bimanual for uterus and adnexa
Investigations
-O— -Day 3 FSH，LH，TSH，PRL 土 DHEA，free testosterone (if hirsute both S / ?)

-Day 21-23 serum progesterone, consider measuring
basal body temperature Other BW for DM, liver, renal etc -tubal/peritoneal/uterine factors R/0
STIs (urine, swabs, etc)
-imaging - Abdo/pelvic U/S. Testicular U/S if male factors.
When to refer?
<35 yrs: after 1-2 years of trying to conceive 35~4〇yr: after 6 months >4〇yr: immediately
If ++Risk factors (endometriosis, tubal ligation etc), refer early!!!

Referral for:
土 HSG (hysterosalpingogram for tubal patency, inject radio-opaque dye into uterine cavity)
土 Sonohysterogram (ultrasound with saline infusion)
土 Hysteroscopy (endoscopy through cervix)
土 Laparoscopy
± Generic- karyotype both partners if worried about genetic component
Treatment:
• Education- ovulation prediction (-dayi4) and timed intercourse 2-3X that week (can use
calendar or urine ovulation detection kit). Psychological/stress factors
• Medical- ovulation induction (eg clomiphene citrate, metformin in pcos etc)
• Surgical/procedural (ex. lysis of adhesions, tuboplasty, sperm washing, artificial

insemination, IVF, IUI, ICSI, oocyte or sperm donors etc)
BOTTOM LINE:
► 85% of couples become pregnant after 1 year, 90% by 2y. Interview BOTH partners for
RFs
► REFER early according to AGE/risk factors (6mos if >35yo, immediately if >4〇yo)
► Address: Sex frequency, Eggs/ovulation (15-20%), Sperm, Tubes/peritoneum (20-30%)

► BW for ovulatory fxn, hormones/PCOS, thyroid and systemic dx. Do semen analysis.
► MUST test and treat STIs. U/S and HSG for uterine anatomy and tubal patency. Other
investigations as necessary
► Discuss the option of adoption/donation etc.
INSOMNIA
References: Mosb)^s Family Medicine Sourcebook TOP Alberta docs: Management of Adult
Insomnia (2015)
CTS sleep guidelines (2011, driving update 2014)
EPIDEMIOLOGY:
-50% adults experience insomnia any given year. 10- 15% people have chronic insomnia.
Incidence 个 with age, more common in ? and lower SES
ACUTE INSOMNIA:
1 night - few weeks, Generally caused by emotional or physical discomforts.
CHRONIC INSOMNIA:
> 3 nights per week for > 3 month
Usually caused by several factors in conjunction with other health problems

Causes of Insomnia:
-Psych, medical, and neurological D/O (depression and anxiety D/O)
40% if insomnia patients have psychiatric issues -Meds/Substance use (ETOH, caffeine,
stimulants) -Specific sleep D/O:
Restless leg syndrome Periodic limb movement D/O Obstructive sleep apnea
Circadian rhythm sleep D/O (Delayed sleep phase = late to sleep and wake up like teenagers,
Advanced sleep phase = abnormal early to bed early to rise like elderly, jet lag, shift workers)
-Primary or idiopathic insomnia (No identified underlying cause = behavioural and conditioned
causes)
When assessing patients with sleep complaints, obtain a collateral history from the bed
partner, if possible. Âlways screen for mental health/OSA issues^*
MANAGEMENT:
May not require treatment unless it affects daily functioning
Acute insomnia caused by acute stressor: May benefit from counselling (CBT) and short term Rx
(2 wks or so) Chronic Insomnia: Behavioral treatment should be used initially
NONPHARM INTERVENTIONS:
Sleep Hygiene:
AVOID stimulants (coffee, nicotine, alcohol, exercise) in pm.
AVOID clock watching (causes STRESS!)
Promote Comfort, avoid daytime naps
Sleep Consolidation:
Sleep Prescription: # of Hrs of sleep + 3〇min. Adjust sleep time according to FIXED wake up
time.个 by I5min/wk to bed time if >85% of time in bed is spent sleeping. Keep sleep Log
In Bed Stimulus Control:

Eliminate non-sleep activities (i.e. avoid TV) when awake, go to another room, relax, return only
if sleepy. Bed ONLY for SLEEP and SEX
Anxiety Reducing Strategies and Relaxation Techniques:
Stress Management Skills, relaxation therapies, worry Journal, self CBT
CBT
Goal: 1. ID dysfunctional sleep cognition
2. Challenge Validity of those cognitions
3. Replace faulty cognitions with appropriate ones Common Faulty Cognitions:
-Unrealistic Sleep Expectations -Misconceptions about Causes of insomnia -Amplifying
Consequences
-Performance anxiety and loss of control over sleep Pharmacologic Therapy
Always use lowest dose

Prescribe for limited period (<2-4 wks)
Prescribe intermittent doses (2-4 times per week) Discontinue hypnotics gradually
First line treatment Anxiolytics / Hypnotics Zopiclone (Imovane): 3.75-7.5 mg Zolpidem
(Sublinox) 5-iomg Doxepin 3-6mg (for sleep maintenance)
Temazepam (Restoril): 15 - 30 mg ^huge fall ris, also higher addiction than with above**
Trazodone: 25-100 mg
Herbal remedies
Melatonin: 0.3- 5 mg
Valerian: 400 - 900 mg
UTryptophan (Tryptan): 500-2000 mg
Other Non-Prescription drugs used by common folk for sleep (off label and not reccomended):
Diphenhydramine (Benadryl, Nytol, Simply sleep), Dimenhydrinate (Gravol) - not approved in
Canada as a sleep aid, Doxylamine (unisome)
RESTLESS LEG SYNDROME:
Associated with |iron, Parkinson’s, SSRI/TCAs, pregnancy, thyroid dysfunction
Sx: Patient experience urge to move when at rest. Improved with exercise. Worse at
night/evening time. Tx: I caffeine and EtOH lx: sleep study may help
Nonpharm = relaxation techniques, TENS stockings,
iron supplement.
Pharm = Dopamine agonists (ist line, pramipexole), gabapentin/narcotics. Treat associated
symptoms.
OBSTRUCTIVE SLEEP APNEA TOSA^:
Associated w/ obesity, thick necks,个 age，craniofacial abnormalities.
Dx: Excessive daytime sleepiness, snoring, HTN， nocturnal choking/gasping (could also be
GERD) lx: Need sleep study
Tx: Wgt loss, exercise, DC EtOH/nicotine
CPAP definitive Tx, may need surgery if structural
cause.
^check provincial guidelines for duty to report for driving**
ISCHEMIC HEART DISEASE
CCS guidelines for the diagnosis and management of stable ischemic heart disease (2014)
Uptodate Toronto notes Essential evidence plus
BACKGROUND:
This is the leading causes of death.
Includes MI, sudden cardiac death, cardiomyopathy/CHF. Caused by fatty subendothelial
depositions & inflammation.
Major Risk Factors:
Smoking, HTN， DM, dyslipidemia, CKD, FHx， sedentary lifestyle, obesity, poor diet, ethnicity,
males.
DDx. Hx & Px:

See “Chest Pain.” Management of BAD things in Chest Pain section.
***Watch out for atypical presentations, especially in: DM, Elderly, Women***
STABLE ANGINA:
Typical: (l) left sided chest pain (2) provoked by exertion or emotional stress (3) Relieved by NG
or rest. Abnormal vitals - consider ER visit.
WORKUP:
HIGH RISK CHEST PAINS WALKING INTO YOUR CLINIC GET 4 THINGS:
1) an ASA (8img/day)
2) 12 lead EKG (?badness = ST depression, T wave inversion, left ventricular hypertrophy or
strain, and premature ventricular contractions). Consider 15 lead if needed.
3) CXR (r/o copathology)
4) Lipid panel, DM screen，Hgb，Cr, LFTs 土 TSH if not done so recently
Next Step:
Group 1) <1 of 3 typical Sx as above + no risk factors + <4〇y〇 + normal ECG = look for other
causes (chance of CAD <5%).
Group 2) <1 of 3 typical Sx + risk factors OR $ >4〇y〇 OR ? > 6〇yo OR abnormal lx =send for
further cardiac testing
Group 3) (the “Oh $&#%!” category)
>2 of 3 typical Sx OR heavy risk factors OR elderly = send for further cardiac testing OR to ER for
assessment based on Sx
Âlmost NEVER do stress tests on asymptomatic people**
Cardiac Testing: Based on local availabilities and abilities:
Low risk + normal ECG + can exercise = go for exercise stress test
High risk OR abnormal ECG + can exercise = exercise echocardiography OR exercise
radionucleotide myocardial perfusion imaging (SESTAMIBI)
If unable to exercise = vasodilator or dobutamine echocardiography
if LBBB on ECG or pacemaker = vasodilator (persantine) SESTAMIBI
IF THE ABOVE TEST SHOWS HIGH RISK FEATURES or ABNORMAL or + TROPONINS = Need
Cardiologist for Angiography (may already be seeing cardiology to get above tests)
NON-PHARMACOLOGIC MANAGEMENT:
STOP Smoking!!!
Moderate EtOH
Chest pain action plan (ASA, NTG x l, seek help, either office or ER)
Exercise, Cardiac rehab program DASH diet, Weight loss
EVERYONE WITH ISCHEMIC HEART DISEASE
SHOULD BE ON THESE DRUGS:
ASA 8img daily indefinitely (clopidogrel if true allergy) PBlockers (First line - keep HR 55-60)
Statin - per hyperlipidemia section
ACEI (if post-MI, CHF, CKD, DM, EF <40%, or if feel
like it, ARB if unable to tolerate)
2nd lines:
Calcium channel blockers (DHP; NOT
Verapamil/Diltiazem - can cause blocks/arrhythmias with PBlockers) - helps with chest pain
NilTRATES (Never in right sided CAD, NG 〇4mg patch, off qhs) spray also an option
Others:
AVOID that chelation or Chinese herbal crap
Plavix only for the length of time needed (varying
evidence on benefit afterwards)
ACUTE MANAGEMENT
ASA for anyone w/ suspected or confirmed CAD (secondary prevention)
Management of Angina: based on Sx
pattern/ compliance (NTG spray qsmin), activity limitation vs exercise need, evaluation of
copathology (PVD, CVA, etc.)
Unstable Angina: urgent output, referral to cardiology vs. ER visit
Emergencies: Pulmonary Edema/CHF/
NSTEMI/STEMI See "Chest pain" & MACLSM Medications: ASA 75~325mg daily (Avoid if GI
bleed or hypersensitivity). NTG 〇.4mg si qsmin X 3 (Call EMS if not responding. Caution w/
dizziness & headache, NO Viagra on board!!). See ’’Hypertension'’/ "Chest pain'’/
"Hyperlipidemia"
CHRONIC MANAGEMENT:
Follow-up pts regularly, assess Sx control, meds compliance, impact on daily activities, lifestyle
modification, Sx of complications THE BOTTOM LINE:
-manage risk factors for CAD.
-Recognize a presentation of CAD (Watch out for Atypical Presenters)
-Know the work-up.
ASA for everyone!!
JOINT DISORDER
References: BC Guidelines: Rheumatoid Arthritis (2012)
BC Guidelines: Osteoarthritis in Peripheral Joints - Diagnosis and Treatment (2009)
Uptodate
Mosby’s Family Medicine Sourcebook Essential evidence plus
Differential Diagnosis of Joint Pain
Articular
Monoarticular Infectious (Sepsis, Transient synovitisi Inflammatory (Seropositê, Seronegatê)
Hemarthosis Degenerative (Osteoarthriis) Crystal-Induced (Gout, Pseudogout)
Pofyartici/far Infectious (Bacterial Endocardiis, Gonoccocus, Lyme disease)
(Seropositive, Seronegative) Degenerative Osteoarthritis Post-lnfe ctious (Rheumatic Fever,

Reactive Arthritis)
Non-Artcular
MSK ■ Other
Localized Referred Pain

(Tendon lis, Bursitis, Capsulitis, Muscle Sprain) Generalized (Fibromyalgia PMR)
Angina (refers from shoulder)
SCFE (refers to knee from hip) Neurological (Spinal Stenosis) Vascular Neurogenic Claudication
Vasculitis
Differential Diagnosis of Seronegative Joint D/Os: Often have extraarticular symptoms including
Rash, Mucosal lesions, Eye Sx, and Urethritis
Ankylosing
Spondylitis Psoriatic Arthritis Reactive Arthritis (Reiter's) Inflammatory bowel disease
Hx Lower back stiffness, mostly? 10% of pt with psoriasis, most commonly oligoarticular
Occurs =4mons post infection Associated with Sx of IBD (Crohns > Ulcerative
coliis)
Px + Schober, + Faber (sacroilitisX ^ spine ROM Psoriatic rash "Can*t see, cant pee, can't
climb a tree" Erythema Nodosum,
Pyoderma
Gar>gemosum
Differential Diagnosis of Ser〇D〇sitive Joint
D/Os
Rheumatoid Lupus Sderoderma Dermatomyositis
Hx AM stiffness =1 hr Malar Rash, Discoid Rash, Serositis, Oral Ulcer, Photosensitivity,
Blood dx (Anemia), 1 Localized vs.
Generalized 1 (CREST) Proximal musde weakness & rash, linked to underlying CA
Px Active Joints, joint deformity, rtieumatoid nodules Renal dx, Arthritis, Immune (as
below), Neurologic (Seizures or Psychosis). Sderoderma,
sclerodactyly Proximal muscle weakness
lx ESRtRFfAnth cyclic ciruUmated protein Ab ESR.Â/zA, anti-double stranded DNAf anth
Smooth muscle Ab ESR, yAA/A, Anti- centromere, Anti- topoisom eraseESR, ANA, anti-Mi,
anti-Jo, Muscle Bxt CK
DDx of Vasculitidies
Small Vessel Medium Vessel Larae Vessel
Non ANCA Henoch-Sconlein Purpura Kawasakfs
Polyarteritis Giant Cell Arte ritis, Takeyasu.s (Pulseless Dz)
ANCA (Ch Granomulatosis wih polyangitis WANCA = antinei itrophi
ANCA, p- ANCA) (Wegeners), Allergic granolumatosis (Chugg-St ran ss)，Microscopic

Polyangtis cytoplasmic Ab, C =perinudear*** =cytoplasmic, P
DDx of Common Pediatric Joint Dz: CRP = c
reactive protein. JRA = juvenile rheumatoid arthritis. IVIG = IV immunoglobin. DMARDs =
disease modifying antirheumatic drugs. AVN = avascular necrosis. CREAM = conjunctivitis, rash,
erythema, adenopathy, mucus membranes involved
Transient
Synovitis JRA Kawasaki's SCFE Legg
Calves
Perthes Growing
Pains
Info Preceded stirs, Fever, Obese AVN of Poorly
byURI, dx Oligoarticular, CREAM, adolescent femoral localized
of Polyarticular, suspect if males at head in 5- bilateral leg
exclusion, Enthesitis- fever >5 growth spurt, 10 y〇 ? pain，worse

in
most Related, days, no Tx limp with birth wgt, PM, better in
common Psoriatic, leads to groin/ hip/ short AM, age 2-
reason for hip pain/ bmp in 3- 8yo Screen for anterior uveitis coronary
artery
aneurysm knee pain, leads to AVN stature, painful or painless limp that can radiate to
knee 12yo
lx CBC &
ESR
normal, US CRP, ESR, ANA, RF ESR. Echo Hip x-rays^ CT, MRI Hip x-rays, CT.MRI
Not required
Tx Rest， NSAIDS, ? dose ASA, Ortho Ortho Reassurance,
NSAIDS DMARDS, OT/PT & specialists IVIG referral, (Traction f surgery)

referral resolves w/ age.
analgesia
Housework,
preparation,
Hx Taking:
Functional (ADLs, IADLS): Shopping,
Accounting, Hygiene, Food
Transportation/Taking meds, Dressing, Eating,
Ambulating, Toileting
Inflammatory /Infectious: Pain, erythema, swelling, morning stiffness (>30 min), better w/ use,
constitutional Sxs (fever), # joints involved Degenerative: Trauma, pain 个 w/ use &| w/ rest,
crepitus, locking, instability, swelling Extra-Articular: Rash, mucosal lesions, eye Sxs, dysuria,
sexual Hx?
1 JOINT
septic arthritis,
gout pseudogout
NO
Degenerative:
Morning stiffness
<30min, pain worst
at end of day.
improved with rest
Osteoarthritis
trauma.. AVN
NO
Migratory:
gonococcal,
rheumatic
fever
24 JOINTS
Gout, pseudogout.
Seronegative
spondyloarthropathies
S5 JOINTS
-Rheumatoid arthritis, lupus
-Vasculitis: Wegner's. Churg-
strauss, polyarteritis nodosa, viral
hepatitis, giant cell arteritis
Osteoarthritis (OA^:
Risk Factors: Age, FHx, Trauma, Obesity, Physical wear and Tear. It's a Clinical Dx
Ixs: X-ray of affected joint (AP, lateral, skyline) = |joint space, cyst formation/
subchondral sclerosis,
osteophytes
Tx: The Arthritis Society (education), smoking/EtOH cessation, exercise/rehab (PT/OT), ortho
referral when medical TX fails for joint replacement, Acetaminophen (max 4g/day),
topicals (NS AIDS, Capsaicin),
NSAIDS/COX-2 inhibitors (Lots of SE)
Steroid/viscosupplementation injections, controversy for Glucosamine/Chondroitin sulphate.

Opioids (3rd line, try to avoid!)
FU: q6-i2mons. Check Hgb, BP, SE of meds. Gait aids when needed.
Rheumatoid Arthritis (RA):
Chronic dz w/ flares leading to J, function. Possible autoimmune inflammatory response, may
be triggered by infectious process.
Dx: BC guideline = inflammatory arthritis, >4 wks, >3 joints, morning stiffness >3〇min,
symmetric. Clinical Dx.
Ixs: CBC, LFTs, CRP, ESR, RF (sensitive), anti-CCP (specific), X-ray (erosions) of affected joints, US
(inflammation), Consider early lipid and BMD screening
Tx: Rheumatology referral, pt education, exercise, multidisciplinary team. Can use meds similar
to OA: NSAIDS (non disease modifying), steroids (may modify disease).
Disease Modifying Antirheumatic Drugs (DMARDS) are 1st line Tx. Start as soon as possible.
Require frequent BW & FU.
-MTX (cheapest, effective, need to take folate), Sulfasalazine, Infliximab (TNFinhibtor,
expensive) -Biologies Rx by rheumatologists.
Gout:
Usually involves the lower extremities. Usually monoarticular. Exacerbations caused by 个 urate
levels due to i Excretion (90%) or f Production (10%)- Causes: Renal Dz, meds, HTN, EtOH, f
cholesterol,
obesity, purine rich foods

Dx: Serum uric acid may be |w/ acute exacerbation. Arthrocentesis to dx and r/o septic arthritis
or pseudogout. Test for cell count, crystals and Cx (Gram stain)
Tx: Trigger Identification/avoidance, dietitian for purine poor diet, stop EtOH
Meds: Acute =NSAIDS (Indomethacin), Colchicine (Antigout Agent), Steroids (avoid unless sure
not septic arthritis. Can give systemic or injected)
Chronic = Allopurinol/Febuxostat (Xhanthine Oxidase inhibitors). Never give acutely. Consider in
patients w/ >3 attacks/yr or no response to acute Tx. Probenecid (Antigout agent) 2nd line if
not controlled on Allopurinol
Septic Arthritis: Medical Emergency!! Triad of Fever, Pain & |ROM of affected joint.
Causes: Staph most common cause. N. Gonorrhea most common in younger, sexually active
people Tx: Admit to hospital. At risk for STD: IV Ceftriaxone. Not at Risk for STD: Vancomycin ±
others. Consult Ortho for surgical Tx/ therapeutic aspiration/joint irrigation. If Prosthetic Joint:
PANIC = call ortho, ID, whomever will listen!!
LACERATION
References: Mosby^ Family Medicine Sourcebook
Uptodate
Identify Difficult Lacerations:

Perineal Tears: Can be 1st, 2nd or 3rd degree. Find the right parts and sew them back together.
Lip Lacerations: Local infiltration of anesthetic can cause swelling and distortion of landmarks
(consider blocks) Teeth must be inspected for damage.
Eye Lid Lacerations: Protrusion of fat through laceration t suspicion for injury to the orbital
septum. Complex lid lacerations = emergency referral to an ophthalmologist.
Arterial Lacerations: Actively bleeding wounds require hemostasis before repair.
Tendon Lacerations: Tendon should be assessed for tendon function/ injury if wound is
overlying.
Open Fractures: orthopaedic emergency Bites: usually polymicrobial (aerobic and anaerobic).
Human bites > cat bites > dog bites for infection risk. Tx with Clavulin
Puncture Wounds: f rate of infection in a puncture wound. Staph and Strep species.
^Don't close contaminated wounds^*
Neurovascular Injury see,J fracture,J
Foreign Body (FB): Explore wounds. Vegetative FBs > Metal, glass and plastic for inflammatory
response. Xrays find 80-90% of FBs. US = variation in sensitivity. Try to remove FB if possible.
Prophylactic Abx for dirty wounds, particularly if tendon, joint or bone is involved.
Irrigation: Isotonic NS or tap water can be used. Most important means of i incidence of wound
infection.
Debridement: Remove devitalized tissue which impairs the wound’s ability to heal
Tetanus : Neuro DO by C. Tetani. Primary immunization in childhood. Booster dose (Td) given
qioyrs. Consider sooner if dirty wounds (ie. qsyrs). Tetanus Immune Globulin (Tig) given in dirty
wounds or immunodeficiency.
Bottom Line: ensure appropriate analgesia /or sedation. Allow adequate time to use techniques
that will achieve good cosmetic results
LEARNING
References: Royal College of Physicians and Surgeons Mosby’s Family Medicine Sourcebook
Nelsons Pediatric Guide
Prevention of learning difficulties
-promoting literacy, emphasizes exposing children to books daily from birth, early childhood
education all the buzz. Family to get involved.
Screening for learning difficulties
1. Ask about literacy and vocabulary
2. difficulties at school or at home
If there is a positive screen:
-try to determine which domain(s) the child has trouble with (LD types)
-Denver II developmental screen breaks it up by age and dev domain (gross motor, fine motor,
social, language)
-Assess for secondary cause: genetic or congenital syndrome (if suspected can refer)
-screen for ADHD
-T-caps and SNAP-IV screening tools are widely used. T-caps is a screen for all types of
child/adol psych
-screen for vision problems (age 3 snellen shapes chart if able, and q3-6 months from there
until able to use normal snellen
-screen for hearing problems (examine for cerumen, check for hx of frequent AOM5s, -
audiology if in doubt- age 4 earliest)
Primary care of a family with a child w/ a Learning disability
-Ask the parents what their understanding is of the situation once a diagnosis is made -Allow
the parents to vent, facilitate clarification of any issues, support problem solving, suggest
environmental changes/ OT home assessments, facilitate referrals, interpret specialist visits.
Help encourage individual education plan in the classroom. Also can write a request to the
school for psychoeducational testing
Know that this child is at higher risk of abuse, and you should be watching very carefully for
signs
Inform family about resources available to every community:
1. Early years centres-drop in centre for parents and
children to promote engaging activities before school begins.

2. Promotes literacy and socialization.
3. http://www.ldac-acta.ca/
The 4 principles of FM:
1. The FP is a skilled clinician
2. FM is a community based discipline
3. The FP is a resource to a defined practice population
4. The patient-physician relationship is central to the role of the FP
Physicians Self-Directed Learning
-Continuously assess your learning needs.
-Effectively address your learning needs.
-Incorporate your new knowledge into your practice
CANMEDS ROLES:
Communicator
Professional
Collaborator
MiEDICAL
EXPERT
Scholar
Manager
Health Advocate
Medical Experts, physicians integrate all of the
CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their
provision of patient-centered care.
Communicators, physicians effectively facilitate the doctor-patient relationship and the
dynamic exchanges that occur before, during, and after the medical encounter.
Collaborators, physicians effectively work within a healthcare team to achieve optimal patient
care.
Managers, physicians are integral participants in healthcare organizations, organizing
sustainable practices, making decisions about allocating resources, and contributing to the
effectiveness of the healthcare system.
Health Advocates, physicians responsibly use their expertise and influence to advance the
health and well-being of individual patients, communities, and populations.
Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the
creation, dissemination, application and translation of medical knowledge.
Professionals, physicians are committed to the health and well-being of individuals and society
through ethical practice, profession-led regulation, and high personal standards of behaviour.
LIFESTYLE
Âlways keep asking about lifestyle**
Review stage of change: pre-contemplation, contemplation, preparation, action, maintenance -
how you approach will determine where the patient is
Lifestyle things to help Health
Diet = refer to Canada’s food guide. All diets the same generally. Mediterranean diet slightly
better. Basically reduce calories. Weight watchers works best due to communal effort. Physical
activity = 3〇_4〇min @ moderate exercise 3-5X a week □ 3〇min everyday Substance use =
should be NONE Smoking = should be NONE Alcohol = <14 drinks/week for males, < 9 for
females, < 2 any given day. NONE for pregnant people
Safe Sex = barrier protection always, especially new partners
Safety = always helmets with bicycles, pads for roller blading, no guns in house, seatbelts and
car seats for < 8olbs.
Hot water scalds = set water temp to <49 C
Bottom-line:
-Explore a person’s context (e.g., poverty) before making recommendations about lifestyle
modification
(e.g., healthy eating choices, exercise suggestions) so as to avoid making recommendations

incompatible with the patient’s context.
-In the ongoing care of patients, periodically review their behaviours, recognizing that these
may change.
-In the ongoing care of a patient, regularly reinforce advice about lifestyle modification,
whether or not the patient has instituted a change in behaviour
Loss OF CONSCIOUSNESS
References: Essential Evidence Plus: EBMJ guidelines (2010),
Parachutecanada.org
CM A driver’s Guide (2012)
Guidelines for diagnosing and managing pediatric concussion: Neurotrauma Foundation (2014)
Clinical practice guidelines for mild traumatic brain injury and persistent symptoms (2012)
ETIOLOGY:
Pressure low, Arrhythmia, Seizures, Sugars, Output, Unusual, TIA
Stroke, Vasovagal, Neurogenic, Cardiac, Orthostatic, Psychiatric, Extras
LIFE THREATENING CAUSES OF SYNCOPE
Arrhythmia
• Ventricular tachycardia. Long QT syndrome, Brngada syndrome. Bradycardia (2nd/3rd degree

heart block), Sinus pauses
Ischemia
Cardiac
Structural
abnormalities
♦ Acute coronary syndrome, STEMI/NSTEMI
• Aortic stenosis, mitral stenosis. Cardiomyopathy, Atrial myxoma. Cardiac tamponade. Aortic
dissection
Hemorrhage
Trauma, Gl bleed, Tissue rupture (spleen, aorta, ovarian cyst, ectopic pregnancy), Subarachnoid
hemorrhage
Pulmonary
embolism
Saddle embolus resulting in outflow tract obstruction
Infection
• Sepsis, meningitis, encephalitis

Hx &Px:
-obtain Hx from pt or witnesses: duration, trauma,
PHx, drugs, toxins, meds and seizure activity
-Px to find localizing and diagnostic signs (GCS,
neuro/cardiac exam, smell the pt)•个 RISK FOR
BADNESS:
C) ardiac disease H) ematocrit <30 or HgB low E) CG abnormal S) ystolic BP <90
S) hortness of breath
Tx for Acute LOC
ABCs □ ACLS if needed □ Specific Meds:
• Oxygen ± Intubation for resp failure
• If | sugars, D50 IV 1-2 amps. Glucagon if persistent.
• If EtOH/| nutrition, IV Thiamine loomg
• Hyperglycemia: Fluids + Insulin
• IV NS for SHOCK— ACLS，vasopressors
• Rewarm if Hypothermic
• OPIATE overdose: Naloxone 0.8-2 mg /IV
• Mannitol 1 gm/kg if 个 cranial pressure
• Sepsis covered in infections section
lx: BW (sugar, prolactin for seizures, electrolytes, CBC, LFTS, blood Cx, troponin), ECG, Head CT,
drug screen, urine Cx. Holter/EEG/CSF if applicable. Pursue others if no obvious cause found.
IF TRAUMA = need to RO head bleed
CT HEAD RULES f>l6yo):
-GCS <15 two hours after injury
-Suspected open or depressed skull fracture
-Any sign of basilar skull fracture: hemotympanum,
raccoon eyes (infraorbital bruising), Battle’s sign
(retroauricular bruising), or cerebrospinal fluid leak
(oto/rhinorrhea)
->2 episodes of vomiting -> 65 yo
-Amnesia before impact > 30 minutes
-Dangerous mechanism (pedestrian struck by motor
vehicle, occupant ejected from motor vehicle, fall from
>3 feet / >5 stairs)

-New seizures, neurological defect or on anticoagulants =AUTOMATIC CT SCAN
CATCH RULE f<l6yo):
High risk (get CT and Surg consult) -Failure to reach a GCS of 15 in <2 hours -Suspected open or
depressed skull fracture -History of worsening headache
Medium risk (CT only)

-Any sign of basal skull fracture -Large, boggy hematoma of the scalp -Dangerous mechanism of
injury (eg, motor vehicle crash, fall from elevation > 3 feet/5 stairs, fall from bicycle with no
helmet
CONCUSSION: Head or neck injury with some sort of neuro sequela (functional not structural):
SCAT2 or another tool to assess
Signs & Sxs: Presence of any suggest concussion
?LOC, Amnesia, Headache, Neck pain, Nausea, Feeling slowed down or in a fog, Difficulty
Vomiting, Dizziness, Blurred vision, Balance concentrating or remembering, Fatigue, Low
problems, Sensitivly to light or noise, Seeing energy, Confusion, Drowsiness, More stars,
Tinnitus emotional, IrrtabHy, Anxiety, Depression
Monitor for >24hrs while awake for:
-Inability to awaken the patient (don’t wake if supposed to be sleeping)
-Severe or | headaches -Somnolence or confusion -Restlessness, unsteadiness, or seizures -
Difficulties with vision -Vomiting, fever, or stiff neck -Urinary or bowel incontinence
-Weakness or numbness involving any part of the body Concerning scenarios: Prolonged Sx,
neuropsych issues after Sx resolve and repeat concussions.
Tx: Graduated return to play protocol (must be Sx free for 24hr before going to next step, if not,
go back to previous step) = no activity/stimulation—light aerobic exercise— sport specific
exercise —non-contact drills— contact practice— game time
DRIVING:
LOC: Single episode, etiology explained, unlikely to recur, can safely observe
Recurrent LOC: cannot drive until etiology determined Seizure: Single episode & Private vehicle:
3 mons seizure free if negative lx. Commercial vehicle: i2mons if no epilepsy
Epilepsy = Private vehicle: 6mons w/ meds, or i2mons seizure free. Commercial vehicle: 5 yrs
Reasons to revoke License: EtOH or drug dependence, seizures, heart dz w/ syncope or
arrhythmias, blackouts or LOC, stroke/TIA, head injury with deficits, |visual field or acuity,
uncontrolled DM causing | BS, dementia, uncontrolled OSA, narcolepsy, motor function
impairment, anything that may cause a driver to be dangerous to others on the road
Loss OF WEIGHT
The toddler who is falling off the growth chart: CPS (2015)
OVERVIEW:
5% loss over 6 months is significant.
âlways think cancer badness**
DIFFERENTIAL
CANCER anywhere (badness!!)
ENDOCRINE = DM, thyroid DO
HEAD = Psych (eating disorders, depression, psychosis), neurologic (brain tumour, multiple
sclerosis, Parkinson's)
CHEST = Lung DO (cancer, COPD, fibrosis),
Heart DO (valvular lesion, infection, CHF)
GUT = Malabsorption (celiac, short gut), cancer, liver
dz/cirrhosis
ID = HIV, hepatitis, TB
DRUGS = Legal (Ritalin, Metformin, SSRIs), fun ones (all of them except weed).
Hx for WEIGHT LOSS
Constitutional Sx, Psych screener Eating habits, Risk factors for infection (sexual, blood, travel),
Drugs (legal and illegal, the heroin diet), Social History (money, abuse, travel), Full GI Hx.
Px for WEIGHT LOSS
Thyroid exam!! Serial weights Remainder as directed by Hx.
MINIMUM WORK-UP for Weight Loss
CBC, lytes, extended lytes, glucose, Creatinine, LFTs, TSH, Imaging as indicated.
MANAGEMENT
Add calories only if pt is less than normal weight, rapid loss, chronic disease. Close follow-up!!!
with serial weights.
FAILURE TO THRIVE (FTT^:
Dropping 2 percentile categories on WHO growth chart considered abnormal (-25% of children
change 2 categories on CDC growth chart). No percentile changes after 3yo until puberty.
HISTORY (Failure to Thrive)
All the usual: Prenatal, Delivery, FHx, Postnatal/PHx, Developmental screener,
Specific to FTT: feeding behaviours, breast or formula, social situation.
DDx of Failure to Thrive
NON-Organic = Careful Hx, most common cause of FTT: parental ignorance, poverty, mental
illness, misreading feeding queues INTAKE Problem = Dysphagia/neurologic, GERD
MALABSORPTION = Cystic fibrosis, celiac 个 LOSSES = Chronic diarrhea，renal dz INEFFICIENCY
= Thyroid DO, growth hormone dysfunction, chromosomal, prenatal insults (TORCH organisms)
INCREASED REQUIREMENTS = Lung DO, heart DO, malignancies
EXCLUDE = Familial short stature, constitutional delay (late bloomers)
WORK-UP OF FTT: Growth charts and accurate
measurements, observed feeding session.
BW: CBC, ESR, lytes, BS, Cr, BUN, protein levels, iron studies, liver enzymes, TSH, urinaylysis
MANAGEMENT: Counsel for proper feeds.
Referral to outpatient services Follow-up!! Repeated weights. CAS as indicated.
^GROWTH CHARTS (if Head is affected, bad sign)
Referal to pediatrics for assessment if anything serious or unexplained
Cyproheptadine is an appetite stimulant. Use with discretion.
Low BACK PAIN
References: TOP Alberta doc guidelines (2015)
Uptodate
Mosby’s Family Medicine Sourcebook Essential Evidence Plus
Definition:
Acute <6 weeks Subacute 6-12 weeks Chronic > 12 weeks
Life time prevalence of 80%. Most common location is at the L4-L5 & L5-S1 levels of the spine
Prognosis: 70% improve in < 2wks, 90% - 95% in 8wks. 5-10% will become chronic.
History
Pain Hx, RED FLAGS: BACCPAIN bladder retention, Bowel incontinence (cauda equina) Age >5〇
yo (Cancer, Compression fracture) Constitutional symptoms (infection)
Cancer Hx (metastatic disease)
Pain at night or at rest (Cancer, Infection) Arthropathies/Stiffness (Think ankylosing spondylitis)
/ V drug use (Infection)/ Immunocompromise iVeurological symptoms (sciatica, cauda equina)
Yellow Flags: These are psychological barriers to recovery that may increase the risk of long
term disability.
Affect/ Mood disorder (depression)
Behaviour (Withdrawal from activities)
Belief that pain and activity are harmful. Belief that pain needs to be completely eliminated
before going back to work
Work (Compensation claims, poor job satisfaction)
SCIATICA: Remember that sciatica is a symptom usually caused by a herniated disc, piriformis
syndrome, or even cancer. It is not a diagnosis!
3Ps: Pain Below the knee, Parasthesias Positive SLR/Bowstring tests
Physical:
-Inspection (Deformities like kyphosis and scoliosis), wounds around spine, drug use
-Palpation (Palpate/percuss vertebrae for pinpoint pain (fracture)/ step off deformity
(spondylolisthesis), palpate paravertebral muscles for pain -ROM (Flexion/ Shrober’s test
(limited in Ankylosing Spondylitis), Extension (+++ pain in spinal stenosis), Side
flexion/extension, rotation)
Motor = Squat and stand up or knee extension (L4), Walk on heels or dorsiflexion (L5), Walk on
toes or plantarflexion (L6)
Sensory Fx: Medial foot (L4), Dorsal Foot (L5), Lateral Foot (Si)
Reflex:Knee (L4), Ankle (Si), Babinski Straight leg raises Faber (for SI pathology)
Anal tone
L3-L4 L4-L5 L5-S1

Nerve L4 L5 S1
Sensory Medial Foot Dorsal Foot Lateral Foot
Motor oxtGnsio 门 Ankle dors 卜 flex ion Ankle plantar-flexion
Exarn^^^ ^Squa^îse^ Heel walk walk

Reflex PateJIar N/A Achilles
Investigations: Only investigate if there are RED FLAGS or pain has become chronic in nature.
Labs: CBC, ESR, CRP, PSA (CA Hx)
X-ray (AP and lateral)
MRI (ist line if you suspect infection or cauda equina syndrome)
DEXA scan for bone mineral density Bone scan (tumors, inflammatory D/Os)
Treatment for Acute/Subacute Low Back
Ice and/or Heat regularly (i5_2〇min at a time directly on skin)
Pain: 4MJS = Mild Analgesia (Pharm Tx):
1st line Acetaminophen/2nd line NS AIDS 土 muscle relaxant (Cyclobenzaprine, SE = sedating

[good if pt. having sleeping issues], dizzy). Avoid Opioids (4th line) Maintain activity (Non
Pharm): Stay active within limits permitted by pain, early return to work.
Medical Reassurance (Non Pharm): Tell them that acute pain will often resolve
Multidisciplinary referrals (Non Pharm): interventions as best for acute low back pain: Spinal
Manipulation, Sports Medicine, Physiotherapy, Osteopath
Treatment for Chronic Back Pain
Non Pharm: Exercises (like core strengthening), Spinal Manipulation, Sports Medicine, PT,
Osteopathy, Pain Clinics, Massage, Acupuncture, TENS Tx, Joint
injections/Surgery if warranted Pharm:
1st line: Acetaminophen ，
2nd line: NSAIDs 土 PPI，
3rd line: Codeine, TCA, Tramadol 4th line: Heavier opiates

Neuropathic pain: Gabapentin (anticonvulsant), TCAs Sleep issues: TCAs, Trazadone
Some herbal things: Devil's claw, purple willow, Capsicum (watch for SE)
MENINGITIS
References: CMAJ treatment for Meningitis (2012)
CPS society Guidelines (2014)
Mosby’s Family Medicine Sourcebook Essential evidence plus
ETIOLOGY:
septic (bacterial) aseptic (viral)
Tuberculosis
(fungal is also possible although often only in immune compromised individuals)
Acute meningitis is a medical emergency due to high rates of morbidity and mortality. Bacterial
meningitis is more lethal. Death rate is about 20-25%
Risk factors:
-immuno-compromised individuals
-alcoholism -recent neurosurgery -head injury

-recent abdominal surgery -neonates -aboriginal groups -students living in residence -asplenia
-foreigner/military
=2 of Fever, neck stiffness, altered mental status, headache 95%
CSF WBC > 100 93%
Headache 87%
Neck stiffness 83%
Fever 77%
Nausea 74%
GCS <14 69%
Positive Blood culture 66%
All 3. fever. n©ck stiffness, altered mental status 44%
Focal neurologic signs 33%
Seizure 5%
Papitedema 3%
Note: neonates are more likely to present with atypical findings such as fever, vomiting,
lethargy, irritability and poor feeding. In elderly, there may be no fever or variable meningeal
signs
Special tests on physical exam:
-Kernig’s and Brudzinski’s (poor sensitivity; good specificity), Jolt accentuation of headache
Investigations:
-CBC with differential, blood culture, electrolytes (for SIADH)
-X-rays may indicate primary site of spread (CXR, sinuses, mastoid bone)
-Lumbar puncture (LP) for CSF (protein glucose, cell count and diff., gram stain, culture, PCR for
viruses mALL CASES OF SUSPECTED MENINGITIS SHOULD HAVE AN LP 磁
A CT scan should be performed before LP (to decrease

risk of herniation) in all of the following situations:
-papilledema on exam
-abnormal level of consciousness
-focal neurologic deficit
-new onset seizure
-Hx of CNS disease
-immune compromised state
LUMBAR PUNCTURE EVALUATION: Hook for cryptococcus, TB and other weird things in HIV
patients)
Condition Appearance Pressure WBC Glucose Total Gram
(cm) proteinStain
Normal Clear 9-18 0-5 2.8-4.2 15-40 Negative
Bacterial Cloudy 18-30 100-10.000. Neut (80%) 2.5 100-
1000 Positive
Aseptic/
Viral Clear 9-18 <300 2.8-5.6 50-100 Negative
In the differentiation between viral and bacterial meningitis, adjust the interpretation of the
data in light of recent antibiotic use.
Treatment:
mTX SHOULD BE STARTED PROMPTLY & SHOULD
NOT BE DELAYED 磁
-Normal Adult: Ceftriaxone + Vancomycin
-Add Ampicillin for Listeria coverage
-Immunocompromised: Ampicillin + Ceftazidime +
Vancomycin + Acyclovir (for herpes)
-CSF Shunts: Vancomycin + Ceftazidime/Cefipime
Steroids: Dexamethasone can be started before or with the first dose of abx. Dexamethasone
should only be continued if the CSF Gram stain and/or the CSF or blood cultures reveal S.
pneumoniae or H. Influenza.
POPULATION PATHOGENS EMPIRIC THERAPY
slmo Group B Strep, Listeria, E.Coli, gram negative bacilli Ampicillin + Cefotaxime
^23mo S. Pneumo, N. Meningitidis, Group B Strep, E. Colir H. Flu Vancomycin + Ceftriaxone
Children/Adults N. Meningitidis, S. Pneumo, (Listeria for immunocompromized or t50yo)
Vancomycin + Ceftriaxone ± Ampicillin (for Listeria coverage)
Trauma, Post neurosurgery, shunt S. Pneumo, N. Meningitidis, Group A Strep, Pseudomonas,
H. Flu, S.Aureus Vancomycin +
Cefipime
(Ceftazidine)
If unable to perform LP without delay, ensure blood culture is obtained and then start empirical
IV Abx treatment
PROPHYLAXIS FOR MENINGITIS CONTACTS:
N. Meningitidis Close contact >8hrs or contact wtoral secretions Rifampin or
Ciprofloxacin or Ceftriaxone
H. Flu Household contact if
unimmunizedlncomplete immunized people Rifampin
Group B Strep If Group B positive 35-37wks gestation Penicillin or Clindamycin or Cefazolin
Contact public health to do contact tracing
MENOPAUSE
References: Mosby5s Family Medicine Sourcebook Managing Menopause: SOGC (2014)
TIMELINE OF “THE CHANGE OF LIFE”

1. Menopausal transition/Perimenopause
Early = Variation in period length (土 7 days from normal), not heavier
Late = skipped cycles + amenorrhea 2 6odays 土 hot flashes
2. MENOPAUSE = 12 MONTHS of AMENORRHEA (average time 47-55yo)

3. Post menopause
Early < 5 years post menopause (hot flashes persist)
Late = 6 years to death
If in the timeframe, ask about Sx.
PREMATURE OVARIAN FAILURE:
Menopause < 4〇_45yo (depending on who you ask). Softer risk factors for early menopause:
Barren from children, smokes like a chimney, FHx, Black, Hispanic (Asians and Whites are later).
DDx:
Genetic = Turner XO, Fragile X.
Chemotherapy
Autoimmune/idiopathic
Viruses
If a 45+ year-old woman walks into your clinic, remarking on amenorrhea of 1 year. NO WORK-
UP NEEDED!!! if she’s younger or perimenopausal (irregularity, menorrhagia, Sx of menopause)
then investigate.
Hx:
Menarche. Gyne Hx (Paps, STIs)
Menstrual history (cycle length, regularity, period length and duration/flow).

FHx (Lady Cancers, age of onset).
Herbal supplements.
Px:
Thyroid exam (this is top of your differential).Pelvic and speculum (assess for fibroids,
pregnancy, lady cancer mass, vaginal atrophy).
LABS: Pregnancy test!! TSH, Prolactin, HgB, FSH (watch out! Fluctuates wildly in early
perimenopause. May need to be trended).
IMAGING:
Transvaginal US (if menorrhagia or red flags, RO fibroids/CA).
Start Mammogram screening if risk factors or >5〇yo.
Just cause test results may not support the dx, does not mean you eliminate the possibility of
menopause.
HEAD TO TOE Tx OF MENOPAUSE: Keep in mind menopause is NORMAL!!
DEPRESSION. Very common
Use an SNRI (Venlafaxine) if concomitant hot flashes. Otherwise Tx w/ your favorite
antidepressant. HRT may be beneficial in refractory cases.
HOT FLASHES (A.K.A. vasomotor Sxs). Usually last < 7 years. Maybe >15 years.
DDX: Hyperthyroidism, Panic DO, CA
Tx: nonpharm = |Wgt,个 Exercise， Stop smoking, | EtOH, Hot drinks, wear layers
Pharm = OCPs (in perimenopausal period), Venlafaxine, Gabapentin, Clonidine, HRT.

DRY VAGINA: Desiccation, atrophy, loss of clitoral hood, l local fat. Causes dryness, pruritus,
pain, dyspareunia, discharge, dysuria, recurrent UTI.
Tx: nonpharm = Better undergarments, Lubricants, Sex (yes, it prevents loss of vaginal wall and
vault elasticity)
Pharm = Steroids topically (see “Vaginitis” notes).
HRT: suppositories/creams.
URINARY INCONTINENCE & PROLAPSE: Atrophy of urethral epithelium. 10% of ? by 5〇yo.
Tx: nonpharm = ^Weight, Exercise (Kegels), Vaginal cones, Pelvic floor physio (土
biofeedback)，Pessaries (gallhorn, ring, ring w/support)
Pharm =HRT may make incontinence worse!!! Can use for urge incontinence. Also
antimuscarinic agents (Oxybutynin).
BONE LOSS (See “Osteoporosis” notes)
OTHER HORRIBLE PROBLEMS RELATED TO MENOPAUSE:
Dementia, breast pain, menstrual migraines, skin changes, joint pain, poor balance, SEXUAL
DYSFUNCTION. Remember to do your usual preventative health stuff.
HRT
Not as scary as the WHI makes it out to be.
BAD HOT FLASHES ARE THE ONLY INDICATION FOR USING SYSTEMIC HRT IN FAMILY
PRACTICE!!! Tx: Short term < 5yrs ONLY FOR HOT FLASHES!! Use lowest effective dose.
Avoid systemic use (prefer vaginal suppositories for local issues). If she has a UTERUS, ALWAYS
use PROGESTERONE!!!
Contraindications: Active CVA/CAD, *Active Breast CA*, PE/DVT, Undiagnosed liver disease.
Basically the same as OCP.
PREPARATIONS:
Oral: Premarin (conjugated estrogen)
Transdermal: Climera
Vaginal Suppository: Vagifem 25i|g (ltab daily for 2 weeks then 2/week)
Vaginal Cream: Premarin
Uterine Prolapse: Use pessaries to relieve constipation. May need surgery.
Fibroids: AKA leiomyomata. Goal directed therapy, surgery or medical management (pain relief)
based on preferences/Sx.
HERBAL PRODUCTS: Health Canada has approved a few things. Warn that few things work. St
John’s wort best (improved quality of life/sleep, not hot flashes, from single study).
MENTAL COMPETENCY
References: Substitute Decision Act
CPSO policy statement
ACE aid to Capacity Evaluation form
Guidelines for Conducting Assessments of Capacity: Ontario Ministry of Attorney General
(2005)
Assessing Capacity
-HCCA (Health Care Consent Act 1996) requires MD to assess pfs ability to consent (decision
making capacity) -Formal capacity assessment is not necessary - in most cases capacity can be
presumed unless there are reasonable grounds to believe the person is incapable
1. Understand the information relevant to a treatment decision

2. Appreciate the reasonably foreseeable consequences of or lack of decision
Capacity is specific for each decision (e.g. person may be capable to consent to a CXR, but not
for a bronchoscopy)
Capacity can change over time (e.g. temporary incapacity due to delirium)
Clinical capacity assessment may include:
1. Specific capacity assessment
-Effective disclosure of information and evaluation of pt's reason for decision
-Assessment of understanding & appreciation
2. Assessment of cognitive function
3. General impressions
4. Should screen for Psych issues
“Aid to Capacity Evaluation”
1. Ability to understand the medical problem

2. Ability to understand the proposed Tx
3. Ability to understand the alternatives (if any) to the proposed Tx
4. Ability to understand the option of refusing Tx or it being withheld or withdrawn
5. Ability to understand the foreseeable consequences of accepting the proposed
treatment
6. Ability to understand the foreseeable consequences of refusing the proposed Tx
7. Ability to make a decision that is not mostly based on delusions or depression
Incapacity decision may warrant further assessment -psychiatry, legal review boards, such as
the courts or, in Ontario，the Consent and Capacity Review Board
Ethical principles underlying capacity

-Pt autonomy and respect for persons
-Beneficence requires that incapable pts be protected
from making harmful decisions
-Pts allowed to make their own informed decision, or appoint their own substitute decision
maker Agreement or disagreement does not equal capacity. Just cause someone has a Dx which
affects their mind, doesn't mean they are incapable.
Age of medical treatment in Canada
-Some provinces have a specific age of consent (PEI, NB, QC, SK, BC), but despite these
regulation, common law and case law could allow under age “capable persons” the right to
make their own choice, ie. a
person of any age (including legal ‘minors’）may consent for treatment if he or she is
deemed capable
Capacity is an essential component of valid consent, and obtaining valid consent
Hierarchy for substitute decision makers:
-legally appointed guardian/attorney
-Representative appointed by the Consent and Capacity
Board
-Spouse or partner
-Child or parent (unless the parent has only a right of
access)
-Parent with only a right of access -Sibling
-Other relative(s)
-Public guardian and trustee
MULTIPLE MEDICAL PROBLEMS
Bottom lines:
- Review what patient is bringing to table and PRIORITIZE
-FIFE EVERYONE
-Screen for depression or other psych illnesses and abuse (but remember to look for organic
issues too!)
-Avoid polypharmacy (dementia/elderly)
- Figure out WHY ARE THEY HERE (take appropriate Hx)
-Set limits with patients DON}T LET THEM MONOPOLIZE YOUR TIME
-Pt's with multiple visits/issues need routine review to update on current guidelines and
practices
NECK PAIN
References: BM J neck assessment Canadian C-spine rules,
DIFFERENTIAL:
BROAD!!! Don’t attribute just to “Muscles” --- must R/0 BAD THINGS
Degenerative: Osteoarthritis, degenerative disc disease (DDD, most common)
Rheumatologic: PMR, Giant Cell Arteritis, fibromyalgia
Infection: Meningitis, pharyngeal abscess, other
infectious causes of lymphadenopathy
Neoplastic: Lymphoma= pain due to lymphadenopathy,
neuro compression, bony mets, other
Myelopathy, Radiculopathy, Trauma
Neuropathy: Diabetic, Herpes Zoster, radiculopathy
Cardiologic: referred from MI, anginal pain
Muscular: referred from shoulder pain, cervical muscle
strain/whiplash
Vascular: vertebral or carotid artery dissection
FEVER + NECK PAIN = infectious until proven otherwise (nuchal rigidity = meningitis, bacteremia
= cervical osteomyelitis/epidural abscesses CANCER HX + NECK PAIN = due to tumour until
proven otherwise! (unremitting pain，worse at night)
Nerve root compression (radiculopathy):
Cy (50% -7〇%), C6 (>20%), C8 (10%), and C5 (<10%). Multimodal Tx, 95% improve
spontaneously in 4-8wks Sx = Pain radiating from the neck to arm in nerve root pattern (pain
worse in extremities),
Numbness/weakness/ paralysis in arm, loss of co¬ordination

Changes in gait or bowel or bladder function: BAD SIGNS indicative of cord compression
(myelopathy)
Physical
Neurologic exam + reflexes
Neck and shoulder range of motion
Jolt accentuation for meningitis = better
sensitivity/specificity than nuchal rigidity (Kernig and
Brudzinski)
Spurling test (pain radiating to the limb on the side that the head is rotated to, DO NOT do if
trauma/cancer/ infection suspected). Sensitivity 30%, specificity 93% for cervical radiculopathy
Palpate paraspinals
Work-up
X-rays (non-trauma) if radicular symptoms, not responding to conservative care after 4-6 weeks
or >5〇yo with new or constitutional Sx. Anterior- posterior, lateral, and open mouth views.
Oblique views may be requested if there is concern for radiculopathy. Ensure C7/odontoid is
visualized!!!! If trauma, see c- spine rules.
CT or MRI if neuro findings, persistent Sx despite conservative care, suspicion of infection or
malignancy CT better for: facet arthritis or other bony changes MRI better for: disc herniations,
foraminal stenosis, tumour
EMG if suspect radiculopathy, especially if more prominent pain in extremities than neck Bone
scan if suspect mets
Whiplash-
soft tissue injury following strain beyond normal range of motion (eg car accident)
-Ensure no red flags present!! Typically stiffer/more tender the day after injury. Neurologically
intact.
-Tx: NSAIDs, Acetaminophen, ice pack, decrease repetitive strain, gentle exercise to prevent
stiffness/physiotherapy 土 muscle relaxant for spasmodic pain (eg. Cyclobenzaprine)
-Imaging if red flags or no improvement

TRAUMA PATIENT = C SPINE IMMOBILIZATION until cleared or imaged!!! NEXUS criteria (blunt
trauma) - must meet all 5 to be considered low risk!!!!
• No tenderness at the posterior midline of the cervical spine
• No focal neurological deficit
• Normal level of alertness
• No evidence of intoxication
• No clinically apparent, painful injury that might distract from c-spine pain
CANADIAN C-SPINE RULES
ANY HIGH RISK FACTOR：
Age ^65yo OR Dangerous

mechanism OR Paresthesias on
extremities
YES
R
A
D
G
R
A
P
H
Y
Bottom line
• Broad DDx- R/O scary things like, ACS, meningitis, neoplasm, artery dissection, giant cell
arteritis
• Nerve compression/radiculopathy if neuro deficits and pain worse in extremities! Get

CT/MRI/EMG.
Vast majority spontaneously improve
• In chronic neck pain, use multimodal tx (eg physiotherapy /chiropractor/

acupuncture/analgesia)
• Trauma patient = C-SPINE collar until cleared!!!! Follow NEXUS, C-spine rules.
• Xrays- image to C7 and don’t forget odontoid
NEWBORN
References: Uptodate,
GBS CDC Guidelines (2010)
AHA Neonatal Resuscitation Guidelines (2015)
Management of increased risk of Sepsis: CPS (2007)
Guidelines for Hypebilrubinemia in Late preterm/Term infants: CPS (2007)
DEFINITIONS:
Term Newborn 237 wks, Late Preterm: 34_36wks +6 days
PHYSICAL EXAM: head to toe exam
HEAD - Fontanelles patent, nol bulging, at 30 degrees angulation. CapiJt succedaneum {cone
bead). Cephalhematoma; does not cross suture lines (can cause jaundice). Subgaleai
hematoma: crosses suture line, may have significant bteed (jaundce risk) fiACE = Look
for asymmetries, deformities. Asymmetric crying facies: associated vAh congenital heart
disease.
NOSE ■ Asymmetry and cletts. Asymmetric nares/deviated septum from birth injury.
NECK =Tortko»lis. Cyslic hygroma, tfirogkjssal duct cysf <ctntra»y tocatwl).
branchial cleft cyst (on sid«), hematomas, webbing/redundanl skin. MOUTH - Micrognathia.
AsyrKlilism (one sided jaw) may resotve as related loutdtin^ posMion. Con&lddr ElOH baby if
flat/long ptilttrum. Look for cl*fls. ankylogiossla |tongu« tl«).
EYES = Hypertelorism, palpebral fissures, movement. RED REFLEX EAR* Low set ear. helix to
lateral canthus. Isolated pits and tags not indication for renal U^S. Hearing assessment on
discharge from hospital. CHEST WALL^ look for malformations, observe movement
for flail segment. Check clavicle. Discharge nofmarWitch s milk”.
Nipple distance ^25% of chest circumference
LUNGS^ Observe for granting/secretions. Rales maybe normal after a few hours
CARDiOVASCULAR * FtMurts assoclMed with innocent munnurs: Murmur intensity <
grad« 2, h«ard at left «t«rnal border, normal 2nd h«art »ound. no audible clicks, normal pul 丨
no oth«r abr>onnaHties.
Signs uiflgtst congenital h«art dz Murmur intensity 2 grade 3, harsh quality, pansystolic
duration, loudest at upper kft stemul border, abnormal 2r>d hedrt sound sbsenit or , femoral
puls«s.
ABDOMEN = Palpate for
mass, gastroschisis,
omphalocoele. Umbilicus:
Single artery in isolation not
indication for renal u/s:
observe for
infection/discharge, quality
and size of cord
TRUNK S SPiNE =Look for
def«ctsAnasses. Hemangioma, tuft of
tialr. Sacral dimple ^0.5cm,
from anaJ verge, hypertrichosis,
discoloration - wofrisome.
HIPS s Barlow and Orlolani maneuvers
EXTREMITIES: Obs«rv« for
movwn^nl/ bfacWal ptexus injury. # of
ifitoris
nd
GENITALIA => Labia min
usuaRy larger than majora a
reverses as they age. Vaginal tags
normal. Observe for imperforate
hymen or hypospadias. Testicles
descended by 6 mons. beware of
retractile testicles & torsion. Be
aware of ambiguous genitalia and
check for imperforate anus.
SKIN = Benign: Milia, transient
pustular melanosis, erythsma
toxicum, Mongolian spots.
Nevus Simplex (stork Bite),
congenital nevi. Not benign:
Port wine stain/Nevus
flammeus.
NEURO- Observe for tone and movement Moro reflex:
disappears by 3-6mo. Stepping reflex disappears by 1-
2mo..Gra$p reflexes {palmar and plantar) disappear by 3mo.
Absence of plantar grasp reflex in term newborn reported to be
associated with * risk of developing cerebral palsy. Asymmetrical
tonic neck reflex/fencing appears at 35 wks gestation and
disappears by 3-6 Mo. Also Galant reflex and Rooting reflex.
Normal Neonatal Vitals:
-Axillary temp of 36.1 - 37°C (97 - 98.6°F) in an open crib
-Respiratory rate of 40 - 60
-Heart rate of 120 -160； may | to 85 - 90
-Use a neonatal size blood pressure cuff.

APGAR 2 1 0
Appearance Pink Blue Limbs All blue
Pulse >100 <100 0
I Grimace Cough well Depressed Nil
Activity Active Limb Flexion Nil
Respiration Strong Inreg Nil
NRP = see "advanced cardiac life support" Neonatal Routine Care:
If DC <48hrs = see MD in <48hrs. If DC >48hrs = see MD in <1 week. Prophylactic eye care to
prevent neonatal gonococcal ophthalmia. Vitamin K to | deficient bleeding. HBV vaccination if
at risk. Umbilical cord care to | infection. Monitoring for 个 bilirubin & | sugars，Metabolic
screen，Hearing test. Support bottle feeding in those who choose to.
Periodic exam in periodic health exam section. Advise of serious or impending illness red flags.
JAUNDICE:
Bad if <24hrs or >7days
Causes: Sepsis, fever, FHx, ABO incompatibility, genetic def” prematurity, feeding issues,
biliary atresia/PKU (if >7days).Severe > 340 ijmol/L， critical > 425i|mol/L.
Sx: weight loss >10% birth weight, bulging fontanelles, lethargy, seizures/coma when bad.
Ix: All infants get bilirubin checked. Graph on curve. FU or Tx based on risk levels.
Tx: Improve feeding and prevent dehydration, phototherapy, transfusion.
Risk factors for sepsis:
Mother with GBS infection. Pen-G / Cefazolin/ Vancomycin / Clinda given <4 hrs pre-delivery.
Intrapartum temp > 38°C (I〇〇.40F). Membrane rupture > 18 hours. Delivery at <37 weeks
gestation, chorioamnionitis.
Ix: CBC, BS. If WBC < 5 concerning. Serial exams when concerns. Full septic workup (see
fever/infection sections)
Tx: If infant unwell - see NRP section. Full septic work
up. Ampicillin/Gentamicin ( > 2days)

If infant well, no risk factors or mother Tx w/ABx > 4hrs before birth = no Tx needed If infant
well but: risk factors, not enough ABx in mother = observe, WBC < 5 = septic workup (Tx if
septic)
Look for sepsis. They don't present the same. Make provisional Dx if needed.
DOWNS:
Trisomy 21,1/1000 births.
Sx: I tone, epicanthal folds, | palpebral fissures, flat nasal bridge, cushing heart DO,个 web
space, simian crease. Developmental delays.
OBESITY
References: CMAJ BC Guidelines (2011)
Canadian Task Force on Preventative Help Guidelines (2015) EPIDEMIOLOGY:
-1/3 of adults in US are obese and 2/3 are overweight/obese. Rate of pediatric obesity is
climbing.
Hx:
Do you eat a nutritionally balanced breakfast soon after awakening? Do you eat fast food (e.g.,
hamburgers, fries) more than once per week? Do you consume >1 serving of sweet beverages
per day? Do you engage in at >3〇-6〇mins of physical activity per day? Do you
reward yourself with food? Do you eat your meal around the table or in front of TV? (note:
average child watches 4 hrs of TV daily)
LOOK FOR COMORBIDITIES: HTN, OSA, arthritis, DM or CAD. If they donJt have it already, they
will!!!
LABS:
Check blood pressure, sugars, and cholesterol levels. TSH may be needed. AVOID LOOKING FOR
THYROID ISSUES IF ALREADY CHECKED AND NEGATIVE
DEFINITIONS: RISK OF DISEASE
Type BMI Obesity Class Waist Circumference ? =102cmt ? =88cw
Circumference ? >102cm, ^ >88cm
Under-weight <185
Normal Ove「-weight 18.5-24 9 25-29 9 + ♦♦
Obesity 30-39.9 BMI <35 =1, ++/+++ BMI >35 =2

Extreme Obesity =40 3 ++++ ++++
PHARM Tx: START W/NON-PHARM Tx = exercise, dietary control and support!!
• Orlistat (Xenical) and Liraglutide
(Saxenda/Victoza) only medications currently approved for the long-term treatment of obesity.
Orlistat decreases fat absorption/Liraglutide is GLP-i antagonist. Orlistat can be used in
people >i2yo, Liraglutide >i8yo
• try to avoid use of medications that cause weight gain if possible (TCAs, antipsychotics,
P Blockers, valproic acid, diabetes medications, prednisone)
• Surgical interventions: gastric banding, vertical sleeve
• gastrectomy (newer procedure), roux-en-y
gastric bypass
COUNSELLING:
-Counselling should involved multi-disciplinary approach: dietician, YMCA, motivational
interviewing, others
-Focus counselling based on stage of change level -help pt to make realistic attainable goals to
help boost confidence
-Childhood obesity also may involve counselling with parents (consider school breakfast clubs,
athletic teams/clubs to increase physical fitness)
-Counsel around social stigma of obesity (self-esteem). See how it is effecting their life
-Interventions may be need to be family wide. Focus on change, don’t berate
***PVgt loss of 5-10% is worthwhile(eg. can / DM by 50%), long term goal should be wgt
maintenance and wgt gain prevention***
Overweight or Obese adult:
measure BMI/waist circumference 峰 If High BMI or waist circumference: Assess

comorbid conditions (HTN. lipids. DM) • Screen for Depression and Mood DO
Devise goals and programs for wgt loss and risk factors . Assess readiness to change
behaviours (assess barriers to change) Treat comorbid and health risks
Health team to advise program
(Wgt loss goal 5-10%, 1-2lbs/wk for 6mons) 峰 PROGRAM:
Nutrition reduce intake by 500-1000kcal/day Exercise: >30min 3- 5/Wk 峰 SUCCESS?
NO: Bariatric Surgery BMI > 40 <or 35 w/risk factors) - all other attempts fail, need lifelong
monitoring • NO: Pharmacotherapy BMI>30 (or 27 wi/risk factors) YES:
regular monitoring, wgt maintenance & prevention of gain
OSTEOPOROSIS
References: Canadian Task Force on Preventative Health Guidelines (2015),
Osteoporosis Guidelines: Osteoporosis, ca (2011)
TOP Alberta doc: Guidelines (2016)
BCGuidelines (2012)
Epidemiology:
->5〇yo, 1 in 4 women, 1 in 8 men
-Causes 〜8〇% of fractures in people >6〇yo -Implications: 23% of pts w/hip fractures die in
<iyr
Etiology:
Primary: age, FHx, inadequate calcium Secondary:
Conditions: Primary hyperparathyroidism，Cushing’s， hypogonadism, premature

menopause, DM, Malabsorption syndromes, rheumatoid arthritis (RA), other inflammatory
conditions,
Medications: Glucocorticoids (>3mons), Aromatase inhibitors (for breast CA), Anticonvulsants,
GnRH analogues, anticoagulants, thiazolidinediones for DM (pioglitazone/ACTOS), proton pump
inhibitors
Diagnosis
BMD >2.5 standard deviations below peak bone mass for young adults (ie: T-score < -2.5)
Identification:
History: Screen for risk in everyone >5〇yo -Prior fragility or Parental hip fractures,
glucocorticoid use (> 3 consecutive mons in past year), RA, Smoking (current), EtOH 23/day，
Falls in past 12 months Physical: Weight (loss > 10% since age 25 or 57kg total), Vertebral
fracture screen (annual height > 2cm loss, or > 6cm historical loss, rib to pelvic distance
<fingers), Kyphosis (occiput to wall >5cm), Fall Risk (get up and go test (<2〇seconds)
Screening - Indications for BMD:

-65 years and older = Everyone(TOP states 6 w/ risk factors)
-50-64 years old + risk factors, or + physical exam (as in identification)

TOP suggests: if wgt - age <10 should be screened -<50 years old = Previous fragility fracture, +
risk for secondary Osteoporosis (conditions, & medications as above)
Work-up: BMD + Labs
Calcium corrected for albumin, CBC, Creatinine, ALP, TSH, Serum protein electrophoresis (only if
vertebral fracture present), 25-Hydroxyvitamin D 2-4 mo after supplementation (don’t repeat if
value >75 nmol/L)
Treatment:
Prevention/Lifestyle
-Everyone: weight bearing exercise, fall prevention, Calcium i2〇omg/day (all sources), Vitamin
D 800- 2000 IU/day in >5〇yo or 400-1000 IU/day in <5〇yo, reduce EtOH, smoking cessation,
hip protectors -Don't prescribe meds that could cause falls and fractures
Preventative Pharmacotherapy -Dependant on loyr fracture Risk (Using CAROC or FRAX risk
assessment tools):
High Risk (>20%) = Good evidence for
pharmacotherapy
Low Risk (<10%) = reassess in 5 yr
Moderate Risk (10-20%) = Depends on other risk
factors, secondary causes, patient preference
Tools to help in moderate risk: T4-L4 radiograph -
identify undiagnosed fractures
-Hx of wrist fractures
-rapid bone loss of subsequent BMD

-medications/conditions causing secondary
osteoporosis
-frequent falls
-monitor BMD qi-3yr if no Tx
***if pt has vertebral, hip or fragility fractures, pt is considered to have osteoporosis. Once they
have the disease, should consider initiation ofTx^**
Medications:
-reduce vertebral fracture risk 30-70%, may also have mortality benefit
-Use only 1 antiresorptive Tx at a time (bisphosphonates, SERMs)
Bisphosphonates -antiresorptive (inhibits osteoclasts) Alendronate (Fosamax) - lomg/day or 7〇

mg/wk Risendronate (Actonel) - smg/day or 35mg/wk or i5〇mg/mo
Zoledronic Acid - smg IV infusion/year Risks: Osteonecrosis of Jaw -remote risk, atypical fracture
of femur, esophageal CA. Does not work without optimal Vitamin D levels
SERM - weak antiresorptive
Raloxifen (Evista) 4〇omg xi4days, then Elemental Calcium 5〇omg (Carbonate i25〇mg) x 76
days，then repeat cycle
Calcitonin- 2〇oIU intranasally -alternate nostrils daily. Good for PAIN form acute vertebral
compression fractures
PTH Teriparatide (Forteo)

use if prior fragility fractures and very low BMD (-3 or more) or recurrent fracture on Tx. very
very expensive
Hormone Therapy -postmenopausal ?
RANKL inhibitor - Prolia, expensive, risk of serious infections
Monitoring Therapy
repeat BMD qi-3yearsif moderate risk, q > 5yr if initiating meds.
response = unchanged or improved BMD When to Refer
-fracture or ongoing BMD decrease while on first-line therapy
-intolerance to 1st or 2nd line therapy -any secondary cause of osteoporosis -outside expertise -
extremely low BMD
Treatment of Acute fracture Pain:
Calcitonin, Tylenol, opiates, NSAIDs
STOPPING THERAPY:
If patient has disease state of osteoporosis (some type of fracture), consider treatment for >i〇
yrs.
If using medication for prevention, consider treatment for 5 years. Worsening or improved
BMD post removal of pharmacotherapy will determine whether Tx should be continued.
Calcium:
Need adequate Vitamin D to Tx osteoporosis (>75). However Calcium is controversial. There
may or may not be evidence that calcium causes CAD/ACS. Must weigh out risks and benefits
per pt.
PALLIATIVE CARE
References: 2007 Palliative Care pain and Symptom Management Reference
BC Guidelines: Palliative Care with patient with Cancer or Advanced Disease (2011)
DEFINITION:
An approach to care for people who are living with a life-threatening illness, regardless of age.
The focus of care is on achieving comfort & ensuring respect for the person nearing death,
maximizing quality of life for the patient, family and loved ones.
When to initiate palliative care?
Therapy to cure/ control Disease

Palliative care approach
ILLNESS TRAJECTORY——
Goals:
-managing pain and other Sxs
-providing social, psychological, cultural, emotional, spiritual and practical support -supporting
caregivers -providing support for bereavement
DEATH
DIAGNOSIS
Essential Components of Palliative Care:

Sx control, effective communication, rehabilitation, continuity of care, terminal care, support in
bereavement
Communication: see breaking bad news section.
Care Team: usually consists of GP, nurse, SW, Palliative home care, family members, spiritual
services, religious advisors,
-Ensure care is coordinated & appropriate referrals are made, ie. CCAC, hospice
- know community resources and volunteer organizations in your area
Emotional and Spiritual Issues
Depression assessment, Fear and Bereavement, Grief (see objectives)
Social Issues:
Finances, decision maker
Advance Directives (2 parts) — instruction directives (also known as living wills) and proxy
directives (power of attorney [POA] for health care). Living wills contain wishes concerning care
when person is incompetent. Discuss living will, POA, substitute decision making for finances &
health-care. CONSTANTLY RE-EVALUATE TX GOALS: DNR doesn’t mean no Tx.
Capacity: See section
Tx of Physical Issues
1. Nausea/Vomiting Opioid-induced = Haldol, Stemetil Gastroparesis/dysmotility =
Metoclopramide, Domperidone
Vestibular/vertiginous = Gravol, Meclizine Alternatives: Nabilone, Ondansetron (chemotherapy-
related), Dexamethasone,
2. Constipation - hydration, diet change, Sennosides, Milk of Magnesia, Docusate,
Lactulose, Phosphate enema, manual disimpaction, bowel preps RO bowel obstruction with
AXR
3. Dyspnea - fans, oxygen, opioids, benzos, puffers (treat cause)
4. Respiratory Secretions - , suction, swallowing, atropine or glycopyrolate drops
5. Delirium - i causative meds, Haldoperidol, Midazolam, find and avoid triggers
6. Sedation opioid, Methyphenidate
7. Myoclonus - | opioid, Benzo, hydration
8. Seizure control - Benzo, Midalozam, Phenobarbitol
9. Intractable Hiccups - Haloperidol, Metoclopramide
10. Anorexia - Dexamethasone, Domperidone, cannabinoid
11. Hypercalcemia - hydration, Pamidronate,
12. Mouth /Skin Care: thrush = Nystatin ulceration = Lidocaine Debris/Crust = H202
Pruritis = topical Camphor/Menthol, antihistamine
cream, topical steroids
Jaundice = Cholestyramine
Wound pain = Lidocaine
Malodour = Metronidazole gel
15. Bowel Obstruction - AXR, treat reversible causes metabolic and stool impaction or
dysmotility (prokinetic) Metoclopramide, steroid, Haloperidol
16. Malignant Ascites - Furosemide, indwelling peritoneal catheter
17. End stage restlessness - Haloperidol, benzo, Midazolam
Pain Control:
Assess pain & Sxs effectively via a pain Hx, appropriate Px and relevant lx. (Use WHO pain
ladder) -monitor for S/E and efficacy
-Prescribe opioids effectively including initiating dosage, titration, breakthrough dosing and
prevention of side effects.
PO ? IV/SQ MorDhine:〇Diate Oral dose ratio
Codeine 2:1 110 about

Morphine 2:1 1:1
Oxycodone N/A 2:1
Hydromorphone 2:1 5:1
-Prescribe adjuvant modalities and medications for pain.
Nociceptive Pain
Bone Pain - NS AIDS, Tylenol, steroids,
bisphosphonates, radiation Inflammatory Pain - NS AIDS, steroids, Tylenol Visceral Pain -

steroids, anti-spasmodic meds Raised cranial pressure - steroids, NSAIDs, radiation Muscle
Spasm - Baclofen, benzo, Buscopan, Dantrolene Neuropathic Pain - steroids, radiation, TCAs,
Anticonvulsants, cannabinoids, Lidocaine
PARKINSONISM
References: Essential Evidence Plus
Canadian Guidelines on Parkinson's Disease (2012)
TREMOR DIFFERENTIAL
Resting (hand at Non Resting Postural (outstretched hands)
rest while distracted)
Parkinsonism, Metabolic Essential (better w/ Drugs Intentional (finaer
Parkinson’s Hyperthyroidism EtOH) Autosomal Overdose to nose, worse
Hyperglycemia dominant. Can Caffeine, with EtOH) = Any
Hypoglycemia treat with 3-blocker amphet¬ Cerebellar DO
Pheo- (Propanolol) or amines, (Wilson s disease,
chromocytoma benzos (2nd line) or anticonvulsants SABA
Withdrawal
EtOH,
Benzos stroke)
In people <45 years consider doing a TSH, Glucose, serum ceruloplasmin, and or CT/MRI
DDx of Parkinsonism (All present with TRAP)
Diagnosis Signs/Symptoms Imaging (CT/MRI}

Idiopathic
Parkinson^ TRAP (tremor, rigidity, akinesia, postural instability) Normal findings
Drug Induced Caused by drugs as metoclopramide, antipsychotics Normal findings
Vascular Fixed deficts Lesions in basal ganglia
Normal Pressure Hydrocephalus Ataxia, dementia, uhnary incontinence CT^MRIs both
wilshow hydrocephalus
Lewy body dementia Cognitê impairment, hallucinations, fluctuating course, poor response to
Parkinsonian drugs Usually normal, PET scan abnormal
Multiple System Atrophy Autonomic dysfunction (Orthostatic changes, urinary sx) MRI
abnormal
Progressive Supranuclear Palsy Vertical gaze paralysis, Postural instability MRI abnormal
Corticobasilar
degeneration Asymmetrical parkinsonism, abnormal movements MRI shows corticobasliar
atrophy
Idiormthic Parkinson’s disease
Diagnosis
Difficult to diagnose in early stages, diagnosis is often delayed. Diagnosis is mostly clinical.
Formally one can use Queen Square criteria:
Tremor
Rigidity
Akithesia/Bradkinesia Postural instability
Bardkinesia with at least one of the other three is diagnostic of Parkinson’s. Response to
Levodopa can also be used to help with diagnosis
History
Neurological screening questions: Weakness,
numbness, parasthesias, visual symptoms, ataxia, aphasia (slurred speech), syncope,
presyncope, history of cerebrovascular disease
Rule out NPH = Ask about ataxia, cognitive decline, and urinary incontinence
Rule out Lewy Body = Ask about fluctuating cognitive decline, hallucinations,
Tremor: Ask about resting tremor Rigidity: Ask about feelings of rigidity, difficulty opening jars,
difficulty turning in bed, difficulty rising from chairs
Akithesia/Bradkinesia: Ask about sluggishness,
shuffling gait, micrographia
Postural instability: Ask about falls, orthostatic changes, shuffling gait
Functional Inquiry (death, shaft)
ADL: Dressing, Eating, Ambulating (how?
cane/walker), Toilet, Hygiene
IADL: Shopping, Houskeeping, Accounting, Food Prep, Transport/Driving licence, Taking meds
DonJt forget your Geriatric Giants: Falls, Incontinence, Polypharamcy, Confusion/Cognition
Physical
Ortho Vitals Screening Neuro Exam Tremor: Test for Resting Tremor Rigidity: lead pipe, cog
wheel
Akathisia/ Br adykinesia: Micrographia, pincer
grasping, heel tapping, globellar tap Postural Instability: Get up and go test, shuffling gait,
festinating gait, difficulty turning, not swinging arms Olfactory dysfunction: can't smell coffee or
peppermint
Investigations
<45 yo need to r/o Wilson’s disease: Liver Enzymes, Plasma copper and ceruloplasmin levels,
士 TSH. If suspect NPH, need to order urgent CT/LP, If you suspect Vascular, need to order
imaging as well
Treatment
Non Pharmacological: Patient and Family education, Multidisciplinary team,
Diet (patients with parkinsonism are at an increased risk for poor nutrition and difficulty
swallowing) Exercise (good evidence for Tai Chi, but all other forms of exercise also good)
Smoking Cessation
Weight Loss
Assess ability to DRIVE
Referral: Neurology (Early referral), Geriatrics, PT/OT, Falls program
Pharmacological: Dopamine Precursors First Line in older people = Levodopa/Carbidopa: S/E =
Nausea, hallucinations/nightmares/psychosis,
orthostatic hypotension, dyskinesia, wearing off effect Dopamine Agonists = Can use as
adjuvant to Dopamine Precursors, 1st line in younger people since they cause less dyskinesia
but more S/E. Bromocriptine (only safe drug in pregnancy, category B)/Pramipexole (Mirapex,
can use in restless legs, category C)=S/E: Nausea, Hallucinations/nightmares /psychosis,
orthostatic hypotension, dyskinesia
Anticholinergics = Useful for tremor, but avoid in elderly due to S/E profile
Benztropine = S/E: dry mouth, blurry vision，rash， confusion, const/retention,

tachycardia. COMT
(encaptone) and MAOI (selegeline) can be used as well.
Common Co-morbid Conditions: Dementia, Depression, Hallucinations/Delirium, Sleep
Disturbance, Urinary Incontinence, Dysphagia,
Constipation, Orthostatic hypotension, Falls

PERIODIC HEALTH ASSESSMENT/SCREENING
References: Canadian Task Force on Preventative Health CCFP preventative Health Guide (2015)
Canadian Pediatric Society Position Statements Rourke baby record (2014)
WHAT YOU MUST DO! (grade A evidence)
^^periodically check healthyy = take any opportunity presented to fulfill screening and
preventative healthm
EDUCATION:
Folic Acid = ? of child bearing age before and after conception (0.4-img low risk, 4~5mg high
risk), reduces neural tube issues.
Smoking Cessation = No one should smoke, you know why
Oral Care = Brush your teeth with fluoride, prevents dental caries
Hearing protection = If in that line of work FUNCTION:
Cognitive decline = MOCHA/MMSE screens when pts/families bring concerns
Falls = assess post falls in elderly, no need to counsel if not at risk
PHYSICAL:
Blood pressure = HTN is very prevalent
INVESTIGATIONS
Mammo = 5〇-74yo, q2-3 yrs, prevents Breast Cancers. More if risk factors
FOBT = >5〇y〇, q2-3 years, prevents colon cancer I guess. Colonoscopy for risk factors STDs =
check if high risk
IMMUNIZATIONS:
Tetanus = q 10 years after primary series Pneumovax = q5-i〇yrs if high risk, l x if > 65 yo,
Flu vaccine = q yearly

^îvhenever something is not indicated or
controversial, provide patients with pros/cons and consequences so they can make an informed
decision^*
WHAT YOU COULD DO! (good evidence)
EDUCATION:
Nutrition: | fats/sugars/salts，anything that tastes good, prevents lots of stuff
Exercise = Helps every disease state that kills you.

Moderate amount most days of week
Safe Sex = Prevents spread of disease
Sun exposure = cover up, no one wants to see that!!
EtOH = case finding, counsel your problem drinkers
Professional Teeth cleaning = go to the dentist, donJt
get the evil gingivitis
Household safety = poison control numbers, smoke detectors, lower hot water settings
PHYSICAL:
Elderly vision/hearing = cause they may lose these abilities over time
PAP = to prevent the CA. See "Cancer" section.
INVESTIGATIONS:
BMD = 65yo or sooner for risk factors, detects osteoporosis
Fasting sugars/Lipids = according to guidelines
MEH! (Poor evidence)
PHYSICAL:
BMIs □ fat is fat, can you tell?
Breast/rectals □ controversial
INVESTIGATIONS:
PSA and pretty much everything else Calcium/vitamin D intake ok? mental illness present?
IMMUNIZATIONS:
Pertussis, VZV, meningitis, HPV, MMR
ADOLESCENT PREVENTATIVE HEALTH
Greig Health record: 6-i7yos, mimics adults very closely. Differences lie in immunizations (have
a different immunization schedule)
CHILD PREVENT HEALTH
Rourke Baby Recor that which has High grade
evidence was included!
all developmental screening is B evidence.
**follow local immunization schedule**
Physicals at every age: Height, Weight, Head
circumference, red/light reflex
Baby < l month:

Education: Car seat, crib safety, no guns in the house,
sleep on back, stop household smoking, no OTC cold meds, night waking
Investigations: Newborn screening (if 个 risk do additional screening), hearing test Other:
Nutrition (exclusive breast feeding with vitamin D supplementation),, corneal light testing.
Baby 2-6months old
Education: Car seat, crib safety, no guns, no smoking, night waking, poison control number
available, dental care, healthy lifestyle, no OTC cold meds Investigations/Immunizations: Per
immunization
schedule.
Other: Nutrition (Breast feed + solids when ready), corneal light testing.
Baby 9-15 months old
Physical: cover/uncover test, tonsil size, corneal light testing.
Education: Car seat, crib safety, no guns, no smoking, night waking, poison control number
available, dental care, healthy lifestyle, good sleep habits Other: Nutrition (Breast feeding +
regular foods. Homo milk),
18 month old
Physical: cover/uncover test, tonsil size, corneal light testing.
Education: Car seat, dental care, healthy lifestyle/sleep habits, no smoking
Other: Nutrition (Breast feeding + regular foods), developmental screening is big at this time.
**Nipissing developmental screen**.
Child 2-5 years

Physical: tonsil size, visual acuity (can stop head circumference at this age)
Education: booster seat, no guns, no smoking, dental care, helmets, good child/day care, no
OTC cold meds, healthy lifestyle and sleep Other: Nutrition (regular foods, regular milk)
PERSONALITY DISORDER
References: Mosby5s Family Practice Sourcebook
DSM5
Uptodate
CMAJ: Borderlines personality Disorder (2005)
BACKGROUND
Epidemiology: 4-13% of population
RISK FACTORS
Abuse, anxiety disorders and depression
TYPES r>l8vo^
Cluster A (odd or eccentric disorders)
• Paranoid personality disorder: characterized by irrational suspicions and mistrust of others.
• Schizoid personality disorder: lack of interest in social relationships, seeing no point in

sharing time with others, anhedonia. introspection.
• Schizotypal personality disorder: characterized by odd behavior or thinking.
Cluster B (dramatic, emotional or erratic disorders)
• Antisocial personality disorder: a pervasive disregard for the law and the rights of
others, (called Conduct DO if <i8yo)
• Borderline personality disorder: extreme "black and white” thinking，instability in

relationships，self- image， identity and behavior often leading to self- harm and impulsivity.
Borderline personality disorder is diagnosed in three times as many females as males.
• Histrionic personality disorder: pervasive attention-seeking behavior including

inappropriately seductive behavior and shallow or exaggerated emotions.
• Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration,

and a lack of empathy.
Cluster C (anxious or fearful disorders)
• Avoidant personality disorder: social inhibition, feelings of inadequacy, extreme

sensitivity to negative evaluation and avoidance of social interaction.
• Dependent personality disorder: pervasive psychological dependence on other people.
Obsessive-compulsive personality disorder:

characterized by rigid conformity to rules, moral codes and excessive orderliness
Use DSM criteria and screening tools to determine type of disorder.
âlways screen for other medical/psychiatric illness**
Also do your own assessments!!!

MANAGEMENT
Ântisocial and Borderline personalities are the ones requiring the most help**
l) Develop a treatment plan
Individual and group therapy (Dialectical CBT for borderline DO)
Medication
Self-education
Substance abuse treatment
Partial hospitalization, or brief hospitalization during times of crises.
2) Refer if significantly impaired.
3) Clinician patient relationship:
Mindfulness of one’s feelings
uBorderline pts obtain a sense of control if they can sabotage the interventions recommended
by their physicians”
Setting limits
Open line of communication.
4) Medications
SSRIs - for Rx depression; most evidence in controlling anger and anxiety
Mood stabilizers such as Lithium. Carbamazepine. Valproate. Lamotrigine and Topiramate may
help stabilize mood and reduce irritability and/or aggression.
Olanzapine may help reduce impulsive behavior, cognitive distortions, and issues related to
mental state
(dissociation, depersonalization).
Typical and atypical antipsychotics may be effective in treating irritability and aggression.
Antipsychotic medications have been shown to be effective in schizotypal personality disorder.
Benzodiazepines can lead to subjective improvement, but should be avoided due to their abuse
potential and possible disinhibition of impulses.
Lorazepam or Clonazepam best
should be prescribed only for a short period of time.
SSRIs, Seratonin-norepinepherine reuptake inhibitors
(SNRIs,) and Monoamine oxidase inhibitors (MAOIs),
can be effective in the treatment of avoidant personality
disorder.
5) Be mindful of new or existing medical or psychiatric conditions:
96% of Borderline pts have mood disorders.
Anxiety 88%
PTSD 56%
Panic DO 48%
Substance use DO 64%
Eating DO 53%
6) If all else fails, learn how to call it QUITS.
THE BOTTOM LINE
-these patients suck, don’t let them get to you, be a good doc
-set limits early. Big time
-always look for or clarify other things going on
***psychotherapy is key***
PNEUMONIA
References: Top Alberta Docs Guidelines (2008)
Anti-infective Guidelines (2013)
Essential Evidence plus
BACKGROUND
Epidemiology: 8-15/ 1000 per year Pathophysiology: most common organisms: S. pneumoniae,
Mycoplasma Pneumonia, Legionella, Chlamydia Pneumonia, H. influenza, viruses.
pseudomonas/fungus in really sick pts.
-COPD
-asthma
-chest trauma
-common cold/influenza
-acute bronchitis
-CHF
-malignancy
-aspiration
**JDO NOT MISS: PE, pneumothorax, hemothorax, malignancy, empyema**
Consider pneumonia in patients that present without respiratory signs and Sxs (ie. confusion,
failure to thrive, abdo pain).
HISTORY/PHYSICAL
-fever, chills, new cough, pleuritic chest pain, constitutional symptoms
-look for high risk signs: TB exposure, institutionalized, exposure to birds, EtOH (aspiration),
Travel, smoker, HIV, immunocompromise.
Physical findings: febrile, tachypnea, abnormal lung exam (review lung exam).
WORKUP:
-vitals!!
-CXR fdo not rule out pneumonia if CXR normal in pt with signs and symptoms)
-CBC
-gram stain and culture on sputum and blood (if possible)
MANAGEMENT
-assess and reassess airway; if resp distress consider bipap or other mechanical ventilation.
Antibiotics:
-first line outpatient: Amoxicillin
-2nd line outpatient: Doxycycline, macrolide
-use quinolones (Moxi/Levofloxacin) or Clavulin if
comorbid conditions
-choose different class if any therapy within last 3 months
-different abx therapies may need to be considered for inpatient setting.
-If co-morbid conditions in play consider treatment of both diseases:
1) COPD and pneumonia: use prednisone and Abx,
2) CHF and pneumonia: consider Lasix and Abx
Consider failure of first line agent if:
-Hemodynamic compromise OR clinical deterioration after 72 hours of antibiotic therapy OR no
improvement after completion of antibiotic therapy
-reevaluate diagnosis if treatment fails

Criteria for admission: refer to PORT scoring or CURB-
65 (0-1, treat as outpatient, >2 treat as inpatient):
Confusion
Uremia
Resp rate high
Bp low
Age>65yo
-if sending home provide proper instructions for f/u (red flag signs, reasons to return to
clinic/ER, etc.)
PREVENTION & FOLLOW-UP:
-Smoking cessation and avoidance of environmental tobacco smoke
-Limit the spread of viral infections (e.g., hand washing)
-Influenza vaccine (annually) and pneumococcal vaccine are recommended for high risk
patients (elderly, nursing home, debilitated, diabetes, COPD, etc)
-Rehabilitation and nutritional programs where appropriate
-Repeat CXR in 6 weeks to ensure resolution -notify public health if TB or legionnaires
SPECIAL CASES:
TUBERCULOSIS: see "immigrant" section FUNGAL INFECTION: usually in
immunocompromisedpts. Histoplasmosis
(Northeastern USA, bat exposure), Blastomycosis (central USA), Coccidomycosis (SW USA)
MRSA: May get on culture, abscess on CXR. Use IV
Vancomycin for Tx.

PSEUDOMONAS: Risk in those with cystic fibrosis, COPD, recently hospitalized/on steroids or
Abx. Treat with Tazocin, Ceftazidime, Ciprofloxacin, Cefixime (need two therapies until
sensitivities back)
THE BOTTOM LINE
-Have high index of suspicion for pneumonia for elderly or children
-Do not miss dangerous things (ie pneumothorax, empyema, PE, cancer)
effectiveness
-don’t forget prevention
POISONING
Mosby’s Family Medicine Sourcebook
Prevention
Discuss poison safety with parents before child is able to walk (12 mo). Tell them to keep
medicines and cleaners locked. Also give them local Poison control centre telephone number
and have it easily accessible in time of emergency.
Hx Stepwise Approach to Poisoning
Always CALL POISON CONTROLL FOR HELP
Ask the person/caregiver: WHEN was the poison
ingested, WHAT kind of poisons were taken, WHO took
the poison (aka PMHx etc), WHY was the poison taken (suicide vs accident).
Tx approach (ABCDDDEFG):
Airway, Breathing, Circulation, Drugs (ACLS/Universal Antidotes), Draw Bloods, Decontaminate,
Examine for toxidromes, Full Vitals, monitors etc. Give specific Tx **ALWAYS Tx ABC’s FIRST
BEFORE ANTIDOTES/DECONTAMINATION**
Examine for Toxidromes
Syndrom© Symptoms
Antcholinergic (TCA's) Blind as a Bat (Tpuplls), Dry as a Bone (Dry Skin), Red as a Beet
(Vasodilation) Mad as a Hatter (Delirium). The Bowel and Bladder Loose their Tone<urinary
retention /constipation), and The Heart qoes on Alone (Tachycardia)
Cholinergic (nerve gas. mushrooms, dementia meds) □UMBELS: Diarrhea. Urination.

Miosis. Bronchorrea^spasm. Emesis Lacrimation. Salivation
Opiods (Heroin) HHHS: Hypotension, hypothermia, hypoventilation, sedation
Sympathomimetics (Cocaine, asthma drugs) Think activation of sympathetic nervous system:
sweating. Tpupils, ?HR, ?BP, arrylhmia, agitated
Sedatives (EtOH. benzos) Confusion, unconsciousness
Serotonergic (SSRIs) Agitation, fever, myoclonus, tremor, rigidity
Draw Bloods
CBC, electrolytes, PT/INR, LFTs, BUN, Cr, magnesium, phosphate, glucose, blood gases,
osmolality, Serum ASA, Serum Acetaminophen/Tylenol, ECG, CXR AVOID ordering serum drug
levels. Order specific drug levels and treat the pt, not the drug.
Decontaminate
Several Options for decontamination: Best option is a single dose of activated charcoal. Other
options are Gastric Lavage, cathartics, and whole bowel irrigation. They can be used for
medications that are poorly absorbed by activated charcoal such as iron and
lithium. But they can often cause significant complications. Also, in hospital can do urine
alkalinisation and hemodialysis. AVOID at all costs Ipecac syrup and vomitus induction.
Drugs : Give specific antidotes/treatments Dextrose (routinely not indicated unless can't
determine BG rapidly), Oxygen Naloxone (if opioid toxicity suspected)
Thiamine (give before giving glucose)
CALL POISON CONTROL for current protocols. Here some examples:
Acetaminophen: N-acetylcysteine
Benzos = Flumazenil (in USA, varies in Canada)
P Blockers = Glucagon
Opioids = Naloxone
ASA = Urine Alkalization/hemodialysis
TCAs = Benzo’s，ICU ± Bicarb
PREGNANCY
Mosby’s Family Medicine Sourcebook,
Society of Obstetricians/Gynecologists Canada (SOGC) guidelines
Canadian Diabetes Association: Diabetes and Pregnancy (2013)
BEFORE CONCEPTION:
1. Preconception counselling: smoking, EtOH，folate
(lmg- 5mg/d based on risk)

2. Genetic testing: kissing cousins, t risk ethnicities, past Hx, recurrent abortions.
3. Optimize medical picture: STOP teratogenic meds!!!
FIRST TRIMESTER:
6 -12 Weeks: ((l THINK TM PREGNANT..."
Step 1： Dx— Sxs = fatigue, breast tenderness, amenorrhea. Serum PHcg
Step 2: Dates— When was your last normal menstrual period (LNMP)? Naegle’s = LNMP + 7days
minus 3 months
Step 3： KEY Hx on the 1st Visit—
GTPAL (full details on all past OB)

Last pap? Contraception? Wanted, planned? FmHx (see Genetic Testing above) Full life Hx
Social: abuse, finances, job, home life,
Any medical complaints?
Step 4： KEY Px on the 1st Visit—
BP baseline, Weight, Palpate for fundus PAP: if not done within provincial reccs.
Step 5: KEY BLOODWORK in the 1st Visit—
PHcg: if 个，think Molars, Multiples，or Mistaken dates CBC: iron deficiency, Hemoglobin
Group and Screen: Rho-Gam”able”
Infections: Urine，Rubella，HBsAg，syphilis，HIV 土 toxoplasmosis, CMV, tuberculosis, VZV
HYPEREMESIS GRAVIDARUM (SOGC2002)
个 Nausea/Vomiting in 1st trimester
Nonpharm: small frequent meals of favorite foods,

trigger identification, rest
Drugs: Diclectin lomg 2 tab qhs 土 bid 土 gravol
(drowsy) ***i^/0 OTHER METABOLIC/GI

CONDITIONS***
Tx: ABCs + IV + admission if very sick. IV nausea meds
1st TRIMESTER MILESTONES “vks、：
8 -12 = dating US if ? of accuracy

10 - 12 = Chorionic Villous Sampling (CVS, 1% risk of
pregnancy loss)
12 = Start measuring fundal height (SFH), fetal heart rate (FHR)
11- 14 = First Trimester Screen (FTS, only Trisomy 21) or Integrated prenatal screen (IPS) 1. Both
include a nuchal U/S and labs (PHcg/PAPP-a levels)
15 - 18 = Maternal Serum Screen (MSS) or IPS 2. Both include Maternal Serum
AlphaFetoProtein, PHcg, Estriol. IPS includes Inhibin A
SCREENING
IPS: best test/sensitivity, detects neural tube defects & both trisomies, | false +'s
FTS: earlier and better than MSS, only checks for Trisomy 21 (Down Syndrome)!!
MSS: screens all 3 DO, done later (good for late presenters,! sensitivity/ffalse +'s).
FU w/ CVS or Amniocentesis if + results
PRENATAL VTSITS (once a month)
Hx: complaints + 4 Horsemen (see below)
Px: BP，wgt，Leopold’s maneuvers, fundal hgt，FHR, Urine (protein, sugar)
THE FOUR HORSEMEN:

Always ask about them at every visit.
1) Rupture of membranes,
2) Bleeding
3) Cramping/labor
4) Fetal movement (FM)
2nd^rd TRIMESTER MILESTONES (wks^:
16 - term = amniocentesis if needed 18 = US for anatomy 20 = quickening
20 - term = HTN associated with pregnancy shows up 24-28 = 5〇g glucose challenge test for
gestational DM 28 = see pt q2 wks. Rhogam if Rh - , CBC 36 = Group B Strep. Swab, see pt
weekly
HYPERTENSION due to Pregnancy TSOGC 2014)
Risk = youth or old, 1st pregnancy, multiple gestation. Occurs >2〇wks gestation. BP> 140/90 If
HTN + proteinuria or end organ damage = preeclampsia (+ seizures = eclampsia)
Hx = vision, weight gain, edema Px = BP, weight, urine dip.
Complications = preeclampsia, HELLP syndrome, DIC, seizures, fetal badness,
Labs = CBC, Liver enzymes, Platelets, Lactate dehydrogenase, Bilirubin (for HELLP), INR/PTT,
fibrinogen (DIC)
Imaging = uterine artery doppler, biophysical profile (BPP).
Tx = Labetalol, Nifedipine, Hydralazine 磁 URGENT REFERALTO OB 磁
GESTATIONAL DIABETES (GDM^

Can occur anytime in pregnancy. Screen anyone who is
not a thin white young ? •(个 risk =previous Hx of GDM， strong FHx， macrosomia), screen in
1st trimester.
Complications: Shoulder dystocia, neonatal
hypoglycemia, septal defects, neural tube defects + others
Tx: Diet then Insulin then Metformin then Glyburide. PREFER TO OB & ENDOCRINE 料
BLEEDING:
Before 20 weeks: various types of abortions.
Cx open = inevitable. See "vaginal bleeding" section.
After 20 weeks..(buddies you must know!)
1. BLOODY SHOW: Most common. Loss of mucous plug.
2. PLACENTA PREVIA: multiple gestation/parity, anatomic problem of uterus. Painless
bleeding. DO NOT EXAMINE!! Transvaginal US. If only low-lying, repeat US to confirm ascent.
3. ABRUPTIO PLACENTAE: Risks: HTN, smoking, EtOH, cocaine. PAINFUL bleeding. Px:
Tender uterus. US = J, sensitivity. Kleihauer-Betke test = fetal cells in maternal blood. Neirhaus
test. Tx: ABCs, IV, watch for DIC.
4. VASA PREVIA: fetal bleed. Very bad. APT test (NaOH + blood = pink; yellow if mom).
Wright test (smear baby blood). STAT C-section.
INTRAUTERINE GROWTH RESTRICTION
Many causes: mom Dz，smoking, drugs, TORCH organisms, baby DO (chromosome, genetics)
Asymmetric = good, brain is spared. Symmetric = bad,
uniformly small. TORCH organisms, genetics.

Px: lagging SFH (height = dates approx.)
Tests: Biophysical Profile (BPP), US Tx: prevention, optimize health, serial BPP/US, C- section
(avoid labor) when danger of baby out < danger of baby In. **OB referral**
POLYHYDRAMNIOS:
Maternal cause = GDM, Fetal cause = fetal hydrops, chromosomal DO, GI DO.
Px:个 for dates US. Consider amniocentesis. Refer early. OLIGOHYDRAMNIOS:

DDx = kidney DO, placental hypoxia, premature rupture of membranes (PROM)
Px: i for dates. Labs = doppler US.
Tx = IV fluid, vesicoamniotic shunt.
MONITORING
1. Fetal Movements TFM): >6 in 2hrs, drink juice, quiet room, call MD if < 6/2hrs.
2. NON-STRESS TEST fNST): monitor fetus or placental insufficiency. FHR vs. fetal
movement. I5bpm X issec X 2 per 2〇min. Normal, Atypical, Abnormal.
3. BIOPHYSICAL PROFILE: US for 3〇min for fluid volume + breathing + movement + tone =
8. Predicts mortality rates. Use if: nonreassuring NST, postdates, |FM, growth retardation, fluid
issues. Doesn't focus on anatomy.
4. CARDIQTOCOGRAPHY: Fetal heart rate (FHR) during contractions. Early, Variable, Late
decels. Variability good. Flatline bad (acidosis from hypoxia, sepsis, drugs).
个 FHR = fever，arrhythmia, bleed, hypoxia. |FHR=| sugar, cord prolapse, |blood.
PRETERM LABOR:
20-37 weeks. Many risks (maternal, social and fetal) Labs: Fetal fibronectin. US for cervix length.
Tx: same as Fetal Distress, consider Celestone (i2mg im q24 x 2) to help lungs no exams,
bedrest, transfer to place w/NICU, cerclage.
Tocolytics = Indomethacin & Nifedipine (CCB) have best evidence.
LABOR
Hx: 4 Horsemen. PMHx. Full OB Hx Px: BP, Leopold Maneuvers
Cervix: Position, Consistency, Effacement, Dilation, Station = Bishop Score
Fetal: Lie (long axis), Presentation (head), Position, Attitude (flexion), Station.
STAGES OF LABOR:
Latent: irregular contractions，<4cm dilated
1st = 4-iocm dilated + regular contractions

2nd = 10cm to baby out
3rd = placenta
4th = 1 hour postpartum
PREMATURE ROM (TROM)
Risks: same as preterm labor (broad).
Hx: gush or continuous leakage.
DDx = urinary incontinence.
Px:!!STERILE SPEC/NO BIMANUAL!! R/O cord prolapse.
Labs: 1) pooling 2)Nitrazine blue 3) Ferning. !!GBS
status!! if GBS +, induce or C-section. Tx: Celestone (if preterm), ABx.

FETAL DISTRESS:
FHR determined. Early decels ok. Late decels bad. ABCs, IV, 02, monitors (confirm FHR) call for
help, mom on left side, stop Oxytocin, vaginal exam for cord prolapse, scalp pH. C-section PRN.
POSTPARTUM HEMORRHAGE
ABCs. IV, 02, monitors. CBC, INR/PTT, Group and Screen.
Causes: 4 Ts
TONE: most common, (prolonged labor, multiparous, multifetal，polyhydramnios).
Oxytocin IM—ergotamine IM—Hemabate (carboprost) —packing — stat OR

TISSUE: retained placenta/clots (worsens a tone problem too). Scoop it out!!
TRAUMA: TEARS anywhere from vagina to uterus. Suture like mad!!
THROMBIN: coagulopathy. FFP /Platelets
AFTER BABY ARRIVES: THE 6 WEEK VISIT
BRAIN: Blues vs Depression vs. Psychosis. BREASTS: feeding, formula,
BLOOD PRESSURE: if gestational HTN BLADDER: incontinence, UTI BAGINA: bleeding, discharge,
odor, need pap? BABY: bonding, feeding, health concerns.
Sleep. Suicide. Substances. Support. Sex.
MISCELLANEOUS
VBAC: NO if Hx of uterine rupture, >1 C-section, classic C-section, multifetal, placenta

previa, >4kg baby. VBAC rupture rate <1%. Success 60-80%.
BREECH: US to confirm and r/o cord prolapse. Early referral to OB for planning.
MECONIUM: before or post-ROM, call Peds for suctioning, close FHR monitoring.
DYSTOCIA: Causes = Power (weak effort, hypotonia), Passenger (funny position, macrosomia,
shoulder). Passage (anatomy)
SHOULDER: brachial plexus injury. Turtle sign. Tx: McRoberts, suprapubic pressure.
POSTDATES: >41 = Risk of badness. Offer induction. BPP 土 US
POSTPARTUM FEVER: endometritis, Clindamycin and Gentamicin. Consider 5 W’s (wind, water,
wound, walking, wonder drugs)
PROSTATE
Prostate Cancer Referral Working Group (2015) CUA Prostate cancer screening: Canadian
guidelines (2011) CTFPHC: Prostate screening guidelines (2014)
Anti-infective Guidelines (2013)
Prostatitis Guidlines: Canadian Urologic Society (2011)
BACKGROUND:
Most common cancer in males, 1 in 7 males will get it, 1 in 27 will die
(? survive this terrible disease)
SCREENING:
DRE not as sensitive as PSA for cancer (however combined best)

***Canadian Task force = No need for universal screening, harms > benefits for testing general
public^
Canadian urologic association: Test PSA in asymptomatic patients if RISK: age >5〇yo, family
history or African Canadian, those who express concern (DO DRE ON THESE PEOPLE ALSOW)
Test may cost money in some provinces.
***Mwst offer pros and cons of screening tools，ie. High false positive testing^*
Everyone agrees: Test PSA in symptomatic patients (lower urinary tract Sx [LUTS]), abnormal
DRE, high suspicion or to follow Cancer
WHAT DO THE NUMBERS MEAN?:
PSA < 4 = normal (still -15% chance of cancer)
PSA 4-10 = 20% chance of cancer
PSA >10 = 50% chance of cancer
Rise of PSA >o.75ng/mL/year or doubling time <2
years is very suspicious {better predictive of Cancer)
Benign prostatic hyperplasia (BPH), Prostatitis, Prostate Cancer, UTI, STIs
PSA can rise with trauma...like biking, tickling by MD, doing the nasty, etc.
New diagnosis BPH or Cancer = LUTS symptoms: Urinary frequency, Nocturia, Urgency with or
without
incontinence, Hesitancy in initiating the stream, Weak stream, Dysuria, Sense of incomplete
bladder emptying, Post void or terminal dribbling.
If there is a history of Prostate Cancer: look for new LUTS symptoms, bleeding, bone
aches/pains/fragility fractures/spinal cord compression (primarily metastasizes to bone,
consider bone scan) for disease recurrence.
WORKUP:
***History/physical guided***
Urinalysis, DRE，PSA (be careful about “normal” result) For BPH /Cancer consider:
-post void bladder u/s -urine cytology -Biopsy

MANAGEMENT:
**First line treatment = treat for BPH first if none of the red flags listed below. Ask Urology later
if not working**
Referral to Urology for biopsy red flags: abnormal DRE, abnormal PSA level, abnormal rise in
PSA, frank hematuria, failed medical management
Cancer: treatment can include=
1) removal or prostate (complications are floppy penis, urinary incontinence and LUTS)
2) external radiation/brachytherapy (complications include GI symptoms, floppy penis,
LUTS)
BPH: treatment includes =
5-alpha reductase therapy (if large prostate) SE = floppy penis, boobies, teratogenic
► Finasteride (Proscar) = cheap
► Dutasteride (Avodart)
alpha blocker therapy (if small prostate) SE = |BP, dizziness, floppy iris
► Doxazosin (Cardura)
► Tamsulosin (Flomax)
► Terazosin (Hytrin)
Surgery is an option if neither work
PROSTATITIS
Symptoms:
Acute = fever chills, lower back pain in rectum or perineum, prostate is warm, swollen and
tender on DRE,
Chronic = not as severe as acute. May present as recurrent LUTs or UTI symptoms or
unrelenting bacteriuria.
^screen for high risk sexual behaviours (can be caused by STI and non STIs) **
Organisms: E. Coli, Staph, Enterococcus, other gram (- ),STIs
Investigations: Urine culture, urethral swabs and urine
Chlamydia/Gonorrhea
DRE + PSA warranted.
2 or 4 glass test - difficult to do in office
Management:
Acute: Septra or Cipro x 4 weeks Chronic: Cipro x 6 weeks
Severe: Ampicillin + Gentamicin, urology referral. Urology to see if no response to ABx.

Consider BPH meds as above based on Sx. Antiinflammatories.
THE BOTTOM LINE:
**PSAs and DRE are most sensitive in combination **all patients should be counseled about the
pros and cons of PSAs
**high index of suspicion for prostate CA in men over 5〇
**can treat BPH in office

**search out the psychological impact of the diagnosis and treatment modality
RAPE/ SEXUAL ASSAULT
References: CDC
Ontario Network of sexual assault and domestic violence, EPIDEMIOLOGY
l in 4 women, l in 10 men — known assailant in 75% of cases
APPROACH
ABCs
Ensure patient not left alone. Provide emotional support
Obtain consent! Medical exam + Tx, evidence collection, disclosure to police [notify police as
soon as given consent]
Sexual Assault Kit if <72hours. If child，<24h. Held for 6 months and then destroyed
Ontario Network of Sexual Assault/ Domestic Violence Treatment Centres

Must report if <16 yo!!!! Otherwise, do not report
unless patient requests
Offer community crisis support resources
INITIAL EXAM
DO NOT RE-TRAUMATIZE THE PATIENT. TREAT
SERIOUS INJURY FIRST
General overall exam and mental status
Put all clothes in paper bag. Prefer before
shower/urination
Document: lacerations/abrasions/bruises/ broken
teeth
Pelvic exam - hymen, signs of trauma, secretions, do PAP and swabs
Test N. gonorrhoeae and C. trachomatis from any sites of penetration
Vaginal swab for Trichomonas. If vaginal discharge, malodor, or itching is evident, the wet
mount also should be examined for evidence of bacterial vaginosis (BV) and candidiasis.
Serum sample, Bloodtype, Rh, PHCG STAT Baseline CBC, renal, LFTs, lipase - if starting HIV post
exposure prophylaxis, HIV, HBV, syphilis screen Other- fingernail scrapings, saliva, pubic hair.
FOLLOW-UP: COUNSELLING
Re-examine within 1-2 weeks of the assault- Repeat testing (swabs) if not prophylactically
treated Syphilis screen/HIV repeat at 6 wks, 3 mons, and 6
mons if initial test results were negative and infection in the assailant not R/O.
PROPHYLAXIS - because follow up can be difficult!!! Empiric Tx HBV
Post exposure hepatitis B vaccination, without hep B IGs, should adequately protect against
HBV infection. Administer if not previously vaccinated. Course: o, 2, 6 months
Empiric Tx
Chlamydia, Gonorrhea, Trichomonas, BV
Cefixime 4〇omg PO OD x l [OR] Ceftriaxone I25mg
IM xi
PLUS
Azithromycin lg PO OD x l [OR] Doxycycline loomg PO BID x 7 days PLUS
Metronidazole 2 g orally in a single dose
Emergency Contraception
PlanB (Levonorgestrel) - 2 tabs PO xi
Post Exposure Prophylaxis for HIV (HIV PEP)
Risk for Acquiring HIV Infection:
-consensual sex- vaginal is 0.1%-0.296, receptive rectal is o.5%-3%
-unknown frequency for sexual assault- specific circumstance might increase risk (e.g.,
trauma/bleeding, presence STI/genital lesions in assailant)
-HIV PEP stopped infection in post-needle pokes by 8〇%. Unknown for assault victims
-FUNDED by Government - begin within y2h of assault, duration = 2 8days
OFFER HIV PEP - discuss risk and lack of proven benefit
28-day Regimen: Combivir (300 mg Zidovudine and 150 mg Lamivudine) 1 tab BID + Kaletra
(200 mg Lopinavir and 50 mg Ritonavir) 2 tabs BID Major S/E: Anemia, pancreatitis, hepatitis
Common S/E: HA, nausea, GI sx, fatigue Cl- Pregnancy, < 12 years of age and <5〇kg, severe
liver/renal/blood disorder
No interaction with other common prophylaxis, including: Cefixime, Azithromycin, Plan B
Repeat HIV testing 6 weeks, 3 mos, 6 mos
BOTTOM LINE:
-comprehensive care to all patients who have been sexually assaulted, regardless of their
decision to proceed with evidence collection or not.
-Limit documentation in sexual assault patients to observations and other necessary medical
information (i.e., avoid recording hearsay information).
-counselling to all patients affected by sexual assault, whether they are victims, family
members, friends, or partners; do not discount the impact of sexual assault on all of these
people. Revisit the need for counselling in patients affected by sexual assault.
-Enquire about undisclosed sexual assault when seeing patients who have symptoms such as
depression, anxiety, and somatization.
-Apply the same principles of managing sexual assault in the acute setting to other ambulatory
settings (i.e. medical assessment, pregnancy prevention, STI
screening/treatment/prophylaxis, counselling).
-In addition to other post-exposure prophylactic measures taken, assess the need for human
immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually
assaulted.
RED EYE
Mosby’s Family Medicine Sourcebook
LIDS/ADNEXA
Blepharitis, Stye, Chalazion, Cellulitis, Dacrocystitis/adenitis
CORNEA
Corneal abrasions,
Ulcers, Keratitis
RED
EYE
CONJUNCTIVA &
SCLERA
ANTERIOR CHAMBER
Conjunctivits, Scleritis
Episcleritis, Pterygium
Subconjunctival
hemorrhage
Iritis, Acute angle closure glaucoma
Hx (Signs & Sxs):

Onset, Vision changes, Trauma, Pain, Photophobia, Foreign body (FB) sensation, Discharge
(clear/coloured), Previous episodes, Eye Hx (surg.),
Bilateral vs Unilateral, Contact lens use, PHx.

Px:
Visual acuity, movements，Pupil reactivity, Pupil shape, Look for consensual photophobia, Slit
lamp exam, looking for edema, defects, opacification, 土 fluorescein, eye pressure
measurements via topometry (IOP), evert eyelids as necessary (when looking for debris),
eyelids, lacrimal gland, nasolacrimal sac, orbit, conjunctiva, sclera, cornea, iris & uvea.
Labs:
General no labs unless concerned about systemic or bleeding DO. Consider CBC, INR/PTT, ESR,
ANA, RF, HLA-B27 (gene for some autoimmune Dz). CT to examine orbit if needed.
SPECIFIC DISEASES:
Blepharitis
Yellow flakes/scales in lashes, inflamed lid margins from buildup of gland secretions 土 bacterial
overgrowth.
Rx: lid hygiene measure.
Acute Hordeolum CStye)
Blockage of eyelid gland (hair follicle or meibomian gland), Chronic = chalazion.
Rx: warm compresses, ± I/D. ABx if systemic.
Dacryocystitis
Infection in the nasolacrimal sac.
Rx: oral Abx + Surg. to restore patency.
Dacryoadenitis
Bacterial (strep, staph) or viral infection of lacrimal gland.
Rx: oral/IV Abx, ± I/D, REFER out.
Eyelid redness, edema, tenderness, no
proptosts. normal EOM, Staph, StreporH Flu
Tx: PO ABx
Eyelid redness edema, tenderness, proptosis, limited EOM, pain wth EOM Tx:CT scan, IV ABx
piscleritis
Localized redness, mild pain, normal vision, usually idiopathic
Tx: Topical steroids
Scleritis
Difuse or localized redness, marked pain, scleral thinning, bluish hue
Tx refer
CONJUNCTIVITIS
Sx Bacterial Viral Chlamydial Allergic
itch +
Redness ++ + + +
Discharge Pus water mucus Clear
Tears + ++ + +
Lymph Nodes ++ +
Rx: Lubricating drop, ABx drops (consider
pseudomonas coverage in contact lens wearers). In neonates look for a systemic cause and
treat it with Abx if needed
Subconjunctival Hemorrhage:
Traumatic or spontaneous.
Rx: traumatic = REFERRAL, spontaneous will resolve in 10 days otherwise CBC, INR/PTT and BP.
Endophthalmitis
Inflammation and infection between layers of the
sclera, +hypopyon
Rx: URGENT REFERRAL.
Keratitis
Inflammation of the cornea, fluorescein show pinpoint
spots if superficial, or white and opaque if deep, typical causes: dry eyes, UV burns (welders
flash), eyedrop toxicity.
Corneal Abrasion Co meal Ulcer
Acute (Hrs>, Hx of trauma, Fluorescein defect, Intermediate (days), contact lens involved, clear
cornea or mild edema, normal corneal Fluorescein defect, white necrotic lesbn, thickness
crater defect
Acute Angle Closure Glaucoma
Red eye, pain, blurred vision, headache, fixed mid- dilated pupil, cornea appears hazy.
Rx: Emergent REFERRAL, pblocker, Acetazolamide, prostaglandins, cholinergics.
Open Angle Glaucoma:
Peripheral | vision，not usually red eye,个 IOP，maybe nerve damage.
Rx: Azetolamide, Xalatan (prostoglandin), Timolol. Iritis

Signs - Small pupils (miosis), redness at the corneal scleral junction, cells in anterior chamber.
Sx: Pain, photophobia, | vision. Etiology: 50% unknown, ocular DO, systemic DO (autoimmune,
sarcoid, syphilis, TB). Rx: URGENT REFERRAL.
Macular Degeneration:
Usually not red eye. Cause of | vision. Amsels criteria. Can be dry or wet.
Rx: stop smoking, vitalux (vitamin A), ophthalmology. Herpes Simplex Keratitis
Viral replication in the eye, dormant in CN Vi, unilateral, irritation, photophobia, pain, FB
sensation, i vision, dendrite seen with fluorescein.
Rx: REFER for topical antivirals, NO STERIODS for HSV and fungal infections.
Herpes Zoster Ophthalmicus
Reactivation of HZV in CN Vi dermatome. Eyelids generally involved, suspect ocular involvement
if tip of nose is involved (Hutchinson’s sign).
Rx: REFER if eye redness, pain OR blurred vision occurs.
When to refer: RED FLAGS of optho emergency
Change in visual acuity (rapid), Eye pain, Photophobia, Corneal ulcers, Ciliary flush.
Pediatric Eye Conditions
Strabismus ocular:
Misalignment of any kind like esotropia, exotropia, hypertropia, hypotropia, Amblyopia (lazy
eye = can lose vision in this condition). Look for Hirschberg reflex (light falls in center of pupil
when child is looking straight at you).
Rx: patching, glasses, surgery.
Leukocoria:
Red reflex shows white pupil which indicates something behind eye like retinal detachment,
coloboma, cataract, retinoblastoma.
Rx: Urgent REFERRAL.
Nasolacrimal Duct Obstruction:
Discharge, crusting, increased tear lake.
Rx: 3mons of massage, resolve with 8mons of massage.
Opthalmia Neonatorum:
Purulent conjunctivitis. Etiology: Chlamydia,
Gonorrhea, Chemical from Abx drops.
Rx: urgent REFERRAL.
Summary of Differentiation of 4 common Red eye problems:
Acute
Conjunctivitis Acute Iridocylitis Acute
Glaucoma Corneal
trauma Anfectton
Incidence Very common common uncommon common
Discharge None None watery
Vision No effect Slightly blurry Very bluuy UsuaNy blurry
Pain Variable Moderate Sever© Moderate-severe
Conjunctival
injection Diffuse Circumcorneal Diffuse Diffuse
Cornea Clear Clear Hazy Change in clarity related to cause
PupH size Normal Small Fixed/d Hated Normal
Pupilary light response Normal Poor None Normal
Intraocular
pressure Normal Normal High Normal
SCHIZOPHRENIA
Canadian Psychiatric Association Practice Guidelines (2005) Mosby's Family Medicine
Sourcebook
r MEDICAL CONDITIONS:
Tumor, head trauma, dementia, delirium, metabolic imbalance PSYCHOTIC D/O: ’
Brief psychotic, schizophreniform, schizophrenia, delusional, schizoaffective, D/O not otherwise
secified
1 錢 Caus es of
1 Psycl hosis
AFFECTIVE/DRUG
D/O:
Depression, bipolar, Substance withdrawal ^ or intoxication PERSONALITY D/O:
Schizotypical, schizoid, borderline, paranoid,
OCPD ^
EPIDEMIOLOGY:
-Prevalence is about 1% worldwide -$ = ? w/ average age $ ：2iyo & ? ：27yo
-prodrome may last years

DSM Criteria:
1) Characteristic Sx w/ 2 of the following for >imons: Delusions, Hallucinations,
Disorganized speech, Disorganized or catatonic behaviour, Negative Sx
(if running commentary, bizarre delusions, 2 voices talking, only need 1 of above)
2) Social & Occupational dysfunction
3) Exclude schizoaffective & mood DO 5) Not due to general medical condition TYPES: Brief
= criteria for <imons Schizophreniform = criteria i-6mons Schizophrenia = criteria >6mons
(Signs of disturbance of >6mons w/ >imons of active Sx)

Subtypes:
1. Paranoid - preoccupation with delusions or frequent auditory hallucinations, otherwise
well preserved cognitive functions and affect
2. Catatonic - >2 of motor immobility, excessive motor activity, extreme negativism,
mutism, peculiar voluntary movement, echolalia, echopraxia.
3. Disorganized - disorganized speech/behaviour, flat affect
4. Undifferentiated - meets DSM criteria, but doesnJt fall into another subtype
5. Residual - no delusions, hallucinations, disorganized speech or behaviour problems.
Continues to have negative symptoms and still meets criteria 1 briefly
Sx:
1. Positive Sxs: delusions, hallucinations, disorganized speech and behavior, agitation
2. Negative symptoms: blunted affect, alogia, avolition
3. Prodromal Phase: change in behavior, irritability, withdrawal, trouble concentrating, etc.
Investigations
1. Labs = CBC, lytes, Cr, TSH, Prolactin, sugars, Lipid profile, HIV, hepatitis screen in
indicated, urine drug screen (RO DRUG CAUSES)
2. Imaging = CT head possibly
ACUTE MANAGEMENT:
-nondrug measures: safety/seclusion

-obtain past med Hx
-determine route of drugs (oral preferred)
If oral refused/inappropriate:
Haloperidol2-5mg IM + lorazepam 1-2mg IM/SL
Or Olanzepine2.5-1 Omg !M
No response: Repeat as required q60-120min
Max haloperidol 20mg, lorazepam 8mg and
olanzepine 20mg in 24hrs
Success: Start or increase oral second
generation medication (ceptfor clozapine)
L .
CHRONIC Tx:
Psychosocial: Social skills training, CBT, family therapy, vocational rehabilitation, diet and habits
(harm reduction, smoking cessation), ACT team. Routine FU to ensure plan is working and Sx
under control.
Medications:
SIDE EFFECTS:
Atypicals: QT prolongation，个 prolactin，metabolic DO Typicals:
Acute Dystonia Tonic muscular contractions Benzos, Benztropir>e. p-blocker

Pseudo-parkinsonism Increased muscle tone (rigidity), bradykinesia, akinesia Benzos.
Benztropine. Parkinson's drugs
Akathesia Involuntary movements Benzos, Benztropine, Parkinson's drugs
Tardive dyskinesia Permanent involuntary chorioform movements No effective Tx
*BE AWARE OF SUBSTANCE USE/ABUSE, CHECK
AND RECHECK AND TREAT ACCORDINGLY, BOTH AS CAUSE AND CONSEQUENCE OF

SCHIZOPHRENIA ***
SEIZURES
References: Uptodate Essential Evidence Plus Mosby’s Family Medicine Sourcebook Approach
to internal medicine
Epilepsy Ontario Guidelines for Acute Seizure Management
(2015)
Background:
-4% of people before age 80 -After single seizure: 1/3 recur >2 episodes: 3A recur
个 recurrence if: Previous CNS injury, FHx, Complex partial, abnormal EEG
Precipitating Factors:
EtOH and drug abuse/withdrawal, Drugs (NEUROLEPTICS, TCAs, BUPROPION, street drugs),
Neoplasms, Neurocysticercosis, Infections, Previous head injury or CVA
DIFFERENTIAL: (DIMTOP)
Drugs, Infection, Metabolic, Trauma, | Oxygen, Post seizure
IMITATORS OF EPILEPSY: Syncope
Psychological DO, Sleep DO, Paroxysmal movement
DO, Migraine
Miscellaneous neurologic events, More common in the elderly: Transient ischemic attack,
Transient global amnesia, Drop attacks
Causes of | LOC: see "loss of consciousness" section
Seizure Vasovaqal Syncope
PMHx Seizures, head injury, tumor, stroke none
Pre-event
Event Awake or asleep, no warning, ?Aura Vocalization at onset, tonic-ctanic Usually
upright, warning, lightheaded No vocalization, occasional
convulsions, cyanotic, incontinent, injuries, tongue biting movement, pale, less injured,
rare tongue biting or incontinence
Post-event Confused, tired, sleepy, muscle aches Alert, diaphoretic
Types of Seizures (Sz):
Partial Seizure: Simple or Complex (may/may not 1LOC)
Generalized (lose consciousness): Tonic-clonic (grand mal), Absence (Petit Mai), Atypical
absence, Myoclonic, Tonic, Atonic
^status epilepticus = seizure >3〇min^
Febrile Szs:
6mo-6yo. Lasts <i5min. No focal signs. <1 Sz/24hrs.
幺 2% turn to epilepsy30% recur.
Tx: I temp + below management

Hx/Px:
DIMTOP questions + Neuro exam/focal signs. MANAGEMENT:
ACUTE: ABC,02, IV, Labs (ABG, CBC, lytes, Cr, sugars, Tox screen, AED level, extended lytes with
albumin).
Rx: Benzos = Lorazepam 2mg qi-3 min IV or
Diazepam rectal.
Phenytoin 20 mg/kg (CARDIAC MONITOR! not if ETOH withdrawl).
IF Sz Continues: 3rd line = Midazolam 0.05-0.3 mg/kg
over 20-30sec, repeat PRN.

4th line: Propofol 50-100 mg/IV bolus (INTUBATE!)
MgS04 if EtOH or eclampsia
If |BS = thiamine lOOmg/IV, D50
Assess for precipitants if previously controlled (lifestyle,
compliance, substance use, change in meds)
EEG/Head imaging warranted in all new onset without cause (as outpatient)
LONG TERM SEIZURE MANAGEMENT
Tonic clonic +++ +++
Absence ♦ +
Status +
Partial ♦ ♦ ♦■ +±+
Myoclonic +
Phenytoin, Carbamazepine, Valproate, Phe no barbital, Lamotrlgine, Gabapentin, Topiramate,
Ettiosuximide. ± = adjunct, ♦ = works
Ensure compliance/avoid precipitants. No seizure + no SE = CONTROL

BROAD SPECTRUM epileptic med (AED):
Efficacy: V>L>T>Zonisamide
2nd Line: C>P>G>Tiagabine> Oxcarbazepine
Assess for further need: Some pts can be taken off
meds if Sz free >2yrs on Rx (67% remission).
Children may be taken off Rx in 6-i2mons.
Temporal Lobe epilepsy: need surgery
Notify ministry of transport/ Assess for safety
concerns. Laws vary for getting pt’s license back
SE OF Common Antiepileptic Drugs (AED):
Carbamazepine: Rash, SJS, Interaction w/ other AED, leucopenia Aplastic anemia. Preg D. CBC
q3-4mons (1st yr) then q year.
Valproate: /Weight, | hair, liver failure. CBC, liver enzymes, levels annually. Preg D: causes
Heart
issues/spina bifida
Phenytoin: messes w/ OCP/ Anticoags/ other AEDs (adjust dose of affected meds). Rash,
gingival hypertrophy, hirsutism, blood dyscrasia, Toxicity = tremor, diplopia/nystagmus/ataxia
Annual levels， CBC， liver, folate. Preg D: causes! growth, facial dysmorphia, 8z; hypoplasia of
the distal phalanges. Vit K lomg daily last 4wks of pregnancy The following are Pregnancy
Category C Lamotrigine: Rash, diplopia, Introduce slowly. Topiramate: Renal stone, fatigue,
glaucoma, | weight. Dose adjust based on Sxs and level.
Ethosuximide: GI irritability, depression, psychosis, leucopenia. CBC, levels annually.
PREGNANCY: DO NOT GET PREGNANT!!!!
Known Sz: 25% |or 个，50% no change w/ preg. Birth defects if No Rx: 4% (general population:
2%). W/ Rx: 5-10%, |w/ # of AED. Folic Acid lmg for all young ?. 5mg if planning or in 1st
trimester. 1 mg PO od for trimester 2-3. OCP metabolism is affected (3.1% failure rate). IUD 土
hormone good option. Lamotrigine reasonable in preg.
SEX
Mosby’s Canadian Practice Sourcebook
SOGC Female Sexual Health Consensus Clinical Guidelines (2012)
CUA Practice guidelines for erectile dysfunction (2015)
History
1) Sexual History (Sex ASAP)
Sexually Active/Sexual Preference ( ? , $ , Both)
EXes (how many? STI?)
Activities (vaginal, oral, anal)
STIs (previous, protection)
Abuse
Pregnancy (GTPAL, Contraception)
2) Sexual Function History
Sexual function divided into 4 stages: desire, arousal, erection & ejaculation
A) Desire: How often do you feel sexual desire? How would you rate your level of sexual
desire?
B) Arousal: Do you feel sexually attracted to your partner? How is your issue affecting your
relationship? Satisfactory sexual relationships with past partners?
C) Erection: Do you get morning/ nighttime erections? Can you get an erection when you
are masturbating? Can you get an erection while you are with your partner? Is your erection
hard enough to penetrate your partner? Are you able to maintain your erection after you have
penetrated your partner? In ? ask about DYSPAREUNIA and VAGINISMUS
D) Ejaculation: Are you able to ejaculate when you are masturbating? Are you able to
orgasm when you are with your partner?
3) Cardiovascular Health
Always ask about this since it a major cause of organic sexual dysfunction, HTN, Lipids, DM,
Smoking/EtOH/Drugs, Hx/FHx of CAD
4) Always Screen for Depression and Anxiety- see relevent sections

5) Always ask about any new drugs
Most common offenders are (3Blockers, SSRIs, 5a reductase inhibitors,
6) In older men, think prostate surgery. In women get a GYNE history
Screening
SOGC reccomends screening. CCFP suggests:
1) All people during annual
2) Teenagers (part of HEADSS)
3) Pregnant Women/Postpartum
4) Menopausal/Perimenopausal women
5) All people with any CVS Risk Factors
6) Men post Prostate CA Treatment
VAGINISMUS
painful vaginal contractions during intercourse Tx with TCA, physio
Pregnant Women and Sex
Sexual Activity is NOT restricted during normal pregnancy. In later pregnancy women may find
some positions more comfortable including side position and top position. May need to restrict
sexual activity in pt with placenta previa, premature ROM, threatened abortion etc.
If complicated pregnancy refer to OB/GYN Postpartum
Decreased libido is NORMAL in the postpartum period. Sexual response usually returns by 6-12
weeks post¬delivery. It is safe to resume sexual activity once the perineum has healed & |
bleeding
(Peri)Menopausal Women and Sex
A) Dyspareunia (2nd to atrophic vaginitis)
Common cause of sexual dysfunction
Treatment can include water based lubricants (REP LENS), topical conjugated estrogen creams
(PREMARIN), estradiol rings, and estradiol vaginal tablets.
B) Jdn libido. Ordering testosterone levels is not recommended by the SOGC (poor
correlation with level of sexual desire). Androgen therapy can be considered in patients with
acquired sexual dysfunction (surgical menopause) or hypoactive sexual DO.
Andropause in men/Male Hypogonadism
Little data about this. CFP suggests ordering AM total testosterone level in men who are
symptomatic (erectile dysfunction, decreased libido, poor morning erections). If you suspect
2nd hypogonadism can order LH (which would be low) and prolactin.
Can treat with testosterone therapy (IM, Oral, Transdermal) if no history of PROSTATE
CANCER/BREAST CANCER.
Erectile Dysfunction
A) Causes of Erectile Dysfunction
Brain = Psychogenic, Anxiety and depressive disorder,
Performance anxiety, Past sexual Trauma, | sexual
attraction
Hormonal = Low testosterone (Hypogonadism), High Prolactin, Hypo/Hyperthyroidism Spine =

Spinal Cord Injury, multiple sclerosis, Peripheral Nerves (Around Prostate)
Pelvic Trauma = Pelvic surgery, Prostate CA Tx Vessels = HTN，DM，个 Lipids，CAD，vascular

dz Penis = Peyronie’s (Gonzo’s nose)
DRUGS = Lots of Drugs do this. Remember EtOH, PBlockers, SSRIs, 5a reductase inhibitor.
B) Investigations
Lipids, fasting BS, HbAic, Total or Free testosterone (better)，LH，prolactin (pt with
gynecomastia)，TSH. You would not order specialty tests: US doppler for flow and penile
tumescence, Nocturnal penile tumescence
C) Treatment
Non Pharm: Counseling (Couple or alone), Drug review, Lifestyle (Exercise, Diet, Weight Loss,
Smoking Cessation, Alcohol intake, Stress Reduction)
Pharm: Optimize CAD risk factors, switch meds if possible (SSRI to Bupropion or Mirtazapine)
1st line: Phosphodiesterase inhibitors = Tadalafil， sildenafil. Contraindicated in people taking
nitrates due to hypotension
2nd line: Prostaglandin E = Alprostadil intercavernosal
injection. Muse urethral suppository
Vasodilators = Papeverine
a-2 blocker = Phentolamine
3rd line: Vacuum devices, Penile Implant surgery
SEXUALLY TRANSMITTED DISEASES
References: Anti infective Guidelines (2013)

British Columbia treatment guidelines: sexually transmitted infections in adolescents and adults
(2014)
Public Health Canada Guidelines (2013)
Prevention:
Risk Factors: Hx of STI, Sexual contact with person with STI, Sexually active < 25 yo, new sexual
partner OR > 2 sexual partners in the past 6 months, multiple partners in the past, No
contraception OR sole use of non-barrier contraception, Drug use (eg: Ecstasy, Crystal Meth,
Pot, IV drugs), Risky behaviours: unprotected intercourse (vaginal, anal, oral), sex with blood
exchange, sharing sex toys, anonymous sexual partnering, Sex workers and their clients
Screening - see ’’cancer” section
SCREEN 个 RISK Pts FOR: HIV serology (infectious
window 3 months), syphilis serology (infectious window

6 weeks) Hep B/C (serology), Chlamydia /Gonorrhea
(first catch urine, urethral swab, cervical swab).
Herpes need to look for lesions; or Hx of lesions
**STI testing involves both serology and other testing**
Counselling:
When pts are contemplating initiation of sexual activity promote partner testing prior to
becoming sexually active. Encourage use of barrier contraception.
Serial Monogamy = False Illusion of safety.
I Risk by = I EtOH/drugs. Not possible to assess the chance of your partner having an STI based
on knowledge of sexual hx. Transmission can occur via vaginal, oral or anal sex. Abstinence is
only 100% way
to ensure no STL Condoms do not provide complete protection for viruses. Nonoxynol 9
(spermicide) disrupts genital/anal mucosal lining and may | risk of infection/transmission of HIV
and STIs.
Complications of STIs:
Infertility，Persistent discomfort/chronic pelvic pain,个 risk for reproductive system CAs,

Chronic liver disease/cirrhosis (HepB/C), t risk of HIV, | risk of ectopic pregnancy，risk of
transmission to fetus，个 risk of pelvic inflammatory DO, tubal infertility，个 risk for
epididymitis
Hx:
Current relationship, Past relationships, Sexual orientation, urinary Sx associated with STI
(dysuria, discharge, abdo pain, testicular pain, rashes, lesions), Assess risk factors, PMHx/Social
Hx, past STI, past screening and Tx. Reproductive health Hx: last pap, GPTAL, Drug/sexual
abuse, prostitution.
MANAGEMENT:
Tx patients as below. If 个 suspicious，Tx before labs confirm. If labs negative，do not exlcude
STI if 个 risk. In a pt w/ a confirmed STI, initiate:
Tx of partners
Partner-notification: index case notifying and offering Tx to contacts still controversial; may
have merit in high risk/hard to reach population.
Tx also through public health
Contact tracing through public health -
Public health acts supersede confidentiality. Done by
pt, physician or Public Health. Notify Public Health if
patient’s safety is threatened
Reportable STIs: Chlamydia (LGV and
serovars), Gonorrhea, Chancroid, syphilis,
B/C. Trace back periods vary by STI
non
HIV,
LGV
Hep
l m th« cn$ia(
I mealus. mealai
urethral dHcharg*.
burning on urination.
irrA«lk>n i
urethral mealus.
erythema
cervical mucoptirutont
discharge, cervical
friability, vaginal
discharge, strawberry
cervix
.p«pul«s.
«P»>
•l lymp pathy
Epidldyniltls: (torsion /trauma； tumor on DDx)
Chkimydfa. Gwrcrmo^. TrtffsmoM^ HSV. MycopUtsm6 g^nmnum. Ur^tptasm

Chtamydia. GonorrtroM. Herpes. Trichomonas
urtthra «wab or first catch urine
Gonococcal: 4〇〇m9 x 1 +A2«hf〇mycm
1 gx 1 dos^. Non-Gonococcal: D〇)tycyclin« lOOmg POlvifk# d«iy x 7d«y* OR Azithromycin ig x

1
cewkal swab or Chlamy<fias Azilhromycan 1g x 1 dose is«fe in
r> or Doxycy
Gononliea * C«1bclm« 400 mg x 1 (saf« In pregnancy> + Tx for Chlamydw
granuloma
n {LGV),
Lymphoma
v«ntr«iim \
HawnophUus ducrByi
(chancroid), Ktebsietta
granutomtiis
Vpfesent. vaginal
swab for
trichomonas.
«wal>* ttixl
serology for
typhius
Unitat^ral (t$ticular
tend«rn«ss and swellirvg,
potsibl« trythtma. viHh oc Conform
wtthoul ur«4hra discharge.
Chkimydlo. G〇fr〇frh0s, urtthral $wab,
PswdomoM. urine for collfon

Conform «nd •m*rtc
if *yph«* ■ Pflmary. SKondary. Eaity Laum： P#o G 2.4 mHon unHs IM x 1 dos« (2 dos«s. 1
w««l( apart in pregnancyK Lat« Urttnl: P«n G 2.4 million unis IM weekly x 3 doses.
Neurosyptiilis: Pen G S-4 million units IV q4Hrs x 10-14 days.
If herpes: 1st •pteod»: Acyclovir 200m9 5x a day x 5- 10 days OR Valtrex 19 PO twice daiy x 10
days. Recurr*nt «plso<t*s: Valtrax SOOH19 t^c* daiy x ^ d«yt OR Acyclovir 200«ng 5x « day x
$ days. Supprts«lvt irverapy (^6/yr):
Valtr«x SOOmg dairy OR V«Hr«x ig daily (>9/yr> OR Valtrex 500mg twice daily in pr«^nanl
wom^n Doxycydin« 100 mg tv4c^ daiy foe 10-I4dav$ Ceftriaxorw 250 mg IM x 1 dose
Papular anal/
0«tiKal l««ions:
abdo pain, de^p
inia. abnormal
ftvtr. c«ivlcal
motion l«nd«rr>*$$.
adnexal t«ndern«ss.
suprapubic pain
Chlamydia/ Gonorrlrêi (If young), urinary tract <f oldtr).
Myc^pkism^, otti«r bact«rl« cuflur* (gram stain. PH 祕 st.
torsion
pHCG. ESR, CRP Ceflriaxorw 250 mQ IM x 1
ctrvkal swab or d^Ry x 14 days
uhn«. vaglr>al "R«<〇«mn*nd addHI〇4i of Fl»gy1 500 mg twkt <taHy %
14 to tov#r ana«rob*$ and to lr#at b«cl«rfal

mucopurulent rectal Chlamydia. Gonorrfrea,
discharge. aoor«<tal pain. Syphifia. H^rp^s. LGV.
constipation, bloody stool, other enlenc organis
Q. nausea, abdQ
diarrh
p«ln. Moating, f#v«i
muHIpi#/ potymorpNc,
d$ymm#ttical. no«v
Inflaimnalory. prurtili.-
condytoma dccuminata
caufiflower-lice
condyloma lata <flal
asymmetric lesions
man papUfoma virus »V.6/11 cau*. wart*. 18 caust CA.>. sWn
Human
<HPV.6i
16M：
MoHuscum.
carcinoma (chronic lesion/ irregular pigmentation), normal variations (p«arly penie papules,
vestibular
pap 籲 a 料
whiff test wet

moiint)
consider anoscopy ifenleritrs = Ceflxime 400mg x 1 dose <f Doxycycline
and ractal swabs. lOOmg tw*c# dally x 7>10days
r culture,
stool for c ova. para
visual #xamlnallon; If HPV = Aldara - App»y 3x a for S-8 bit (max 16 PAPs 幻.Cryo«n#rapy
HIV
Cause: STI is subtle when first transmitted
Sx: Typical viral illness, may present like mono, AIDS
bad
Labs: PCR (time 0) or ELISA (3mons) for screening, western blot (6mons) for confirmation. Check
all
chronic infections. CDC and viral load count Tx: Need combo treatment.
Nucleotide/side inhibitor (Combovir) + binding inhibitor (efavirenz) + protease inhibitor
(Ritanovir). When in doubt, start Kaletra. Tailor therapy to resistance.
Vertical Transmission: Prophylaxis with AZT for 8 weeks pre delivery.
Prophylaxis:
Pneumocystis Pneumonia: fCD4 count <2〇o)jSeptra DS l tab daily OR Dapsone daily
Toxoplasmosis: fCD4 count <ioo) Septra DS l tab daily MACL(CD4<5〇) Azithromycin 1250 mg
PO once weekly
Others
Lice = Permethrin (Nix) 1% cream
Scabies = Nix 5% cream: apply to body from neck
down, leave 8-i4hr, then shower
Vaginal discharge in low risk pts = see 'Vaginitis” section
SKIN DISORDER
References: Skin Disease and Diagnosis (2nd Edition) by Thomas Habif
Mosby’s Canadian Practice Sourcebook Uptodate
Hx: Ask about Scalp, Travel, Eyes, Drugs, exposures Immunizations, Joints, Bowels. Need to RO
things that can kill you.
Px: Check SCALP, EYES, MUCUS MEMBRANES, PALMS/SOLES，JOINTS, “Does it blanche?!!?”

colour， character etc
Tx: take biopsy of anything you don't know. Admission for serious things.
Steroids: Mild = Hydrocortisone, moderate = Betamethasone valerate, high =
Betamethasone
diproprionate
ACNE
Comedones/Papules = embarrassment, Pustules, Nodules (inflamed), Nodulocystic/scarring =
badness **DON，T FORGET “BACK-NE” too**
Think: PCOS, Hyperandrogenism, Anabolic Steroids, t estrogen

Nonpharm: gentle warm water, avoid scrubbing, non- comedogenic makeup, avoid excessive
hair product, TOPICALS: Azaliec Acid bid x 2mons. Benzoyl peroxide qhs + Clindamycin topically,
Tretinoin.
Pharm: OCP (Diane or Yasmin)
minocycline loomg po bid x 3 months (SE = sun sensitivity, bad liver/kidneys, not allowed in
pregnancy) ACCUTANE (not to be used in primary care): SE = liver damage, teratogen (need
contraception x 2)，个 triglycerides， IWBC, psychosis，photosensitivity，dry skin
ROSACEA
Sx: flushing, injected eyes, runny nose. ACNE + telangiectasia + redness + EYES
Nonpharm: No EtOH/hot drinks, jwind, jsun/ spicy
foods. Use green-based makeup. |stress
Pharm: Minocycline loobid x 4 weeks, could use
Metrogel.
PERIORAL DERMATITIS
NO STEROIDS! Metrogel 土 Minocycline
SEBORRHEIC DERMATITIS
Note the flaking. Selenium Sulphide, Ketoconazole 2% shampoo
ATOPIC DERMATITIS
Watch out for superimposed infections!!
Flexors first. Trigger identification Avoid overbathing in hot water, Lots of lotions /V aseline,
Light cottons, Avoid excessive sweating. Associated with allergies and asthma Tx: Steroids,
protopic, wet wrap
PSORIASIS
Many different forms:
Guttate (“teardrop”)，Plaque Psoriasis

Affects NAILS (pitting, oil drop sign) and JOINTS
(extensor surfaces) and SCALP! Worse w/ trauma and
drugs
Tx: “Sun，Dirt，and Drugs” =
Ultraviolet B or PUVA 3_5X/week，Synergistic w/ topicals. Tar topically, Steroids topically. Lots

of moisture.
May need immunosuppressants.
ACTINIC KERATOSIS
PRE-Cancerous!!
Monitor for changes.
Biopsy. Tx: Cryotherapy
or 5-Fluorouracil
BASAL CELL
CARCINOMA (BCC)
"Rat-bitten", Tx: removal
SQUAMOUS CELL
CARCINOMA (SCC)
‘Actinic Keratosis’ Ugly
Cousin”.
Tx: removal
SEBORRHEIC KERATOSIS
Not cancerous.
“stuck-on” appearance,
"Disgusting old Bubble-

gum". Watch out for Leser-
Trelat
MELANOMA ^serious***
Subungual acral lentiginous
melanoma = EXCISIONAL BIOPSY!!
These can be itchy too. UseABCD rule. Don't miss
these, need CA workup.
^th Disease /Parvovirus BIQ
“Slapped Cheeks”， + Lacy erythema on arms. PREGNANT ? RUN!! Once rashy, no longer
infectious, lasts 1-3 weeks
Herpes SIMPLEX I & II
Do viral culture, see sexually transmitted disease section
VARICELLA ZOSTER
Sx: vesicles in dermatome pattern.
Tx: Acyclovir 800 mg 5x/day for 10 days. Zostrix topically. Remember the vaccine!! Zostavax.
Watch for postherpetic neuralgia. Had chicken pox in past.
Impetigo /ERYSIPELAS/ FOLLICULITIS
see "infection" section
MENINGOCOCCEMIA...NEVER MISS—They will die. Petechial see meningitis section

Diaper Candidiasis
Sx: Red + Satellite lesions
Nonpharm: Open air, Frequent diaper changes, Barrier creams, Avoid aggressive bathing/wipes
尸 harm: CLOTRIMAZOLE 土 steroid
Diaper Rash/Contact dermatitis

Tx: Barrier cream ± steroid. Remove precipitating cause if possible
BUGS
Pediculosis = Lice = Nits
Scabies on Body (Itchy, excoriations, burrows, worse at night)
Tx: put it in your PERM-ethrin" and Nix the outbreak. Systemic = Ivermectin. Sulfur crotamitan
for pregnant ONYCHOMYCOSIS Dx: Fungal culture. Tinea rubrum DDx: Psoriasis
Tx: Lamisil (Terbinafine) lacquer daily X 12 weeks (for toes). Fluconazole 300mg q weekly X 6
months. Remember reasonable expectations
TINEA VERSICOLOR
(AKA Pityriasis Versicolor, tinea corporis)
7"x: Stay dry. Reassurance about pigmentation. Selenium sulfide 2.5% daily X 10 days.
Ketoconazole 2% X 5d. Ketoconazole 400mg X 1 CANDIDIAL INTERTRIGIO (or
Corooris/ Cruris/ Caoitus)
Dx: KOH Wet Mount, Scrapings from the edge.
Tx: Ketoconazole 2% bid (or Miconazole) X 10 days. Fluconazole 100mg po daily X 10d
Tinea Pedis
Sx: itchy toes, infections in between toes
Tx: antifungal topical or oral. Flip flops in shower/dorm rooms Tinea Caoitis Dx: hair
fungal culture Tx: grisofluvin, itra/fluconazole, avoid immunosuppresants
LUPUS (DISCOIDor MALAR)

FACE: Discoid Rash, Scarring Alopecia, Malar Rash. See joint disorder section.
ACANTHOSIS
NIGRICANS
"Wash that dirty neck!"= CA BADNESS. INSULIN RESISTANCE, PCOS. 7x. Lactic Acid Cream bid
PYODERMA
GANGRENOSUM
"Painful Pizzas", IBD, RA 7x. Intra-lesional Steroids
DERMATOMYOSITIS
"Purple Sun Eyes" **THINKCA BADNESS** Dz is worse in kids! Check Creatinine Kinase. Stop the
statin. Gottron's Papules SCLERODERMA
"CREST Syndrome"= Calcinosis, Raynaud's, Esophageal Problems, Sclerodactyly. Telangiectasias.
HENOCH SCHOLEIN PURPURA ♦♦serious*^ "Palpable Purpura" Kids with: Arthralgias
Abdo Pain, Renal Dysfunction.
STEVEN^JOHNSON SYNDROME (SJ3)

If it looks bad. think SJS. & stop the drugf Polymorphic, Red. NON-blanching. Blisters, Large
area. Mucous Membranes. Painful ^NEVER MiS$^ TOXIC EPIDERMAL
NECROLYSIS
-SJS minus patient's skin -TENs* FULL-thickne$s desquamation. Start treating it like a really bad
bum. vAW probably kiR the pt. ^NEVER MISS^ Staph (or Strep) Scalded Skin
Svndrome ”As bad as it sounds.. .，’ PARTIAL-lhickness desquamation. Mucus membranes +
Rash + Fever + SHOCK = Death **NEVER M/SS00
KAWASAKI DISEASE
"I Heart this disease '. 5/6 Findings. . . FEVER of Unknown Origin, Bilateral CONJUNCTIVAL
INJECTION, LIPS or mucus membrane changes, Cervical LYMPHADENOPATHY, Palms and soles
painful or EDEMA Mixed RASH - "polymorphous" NEVER MISS
BOTTOM LINE:
-In high-risk pts examine the skin even when no specific skin complaint is present & treat
apparently minor skin lesions aggressively.
-check on pt’s personal and social life
SMOKING CESSATION
References: Canadian smoking cessation clinical practice guideline (2012),
Rxfiles
BACKGROUND
20% of Canadians smoke
157 billion dollars wasted on health care
SCREENING:
Always ask about smoking^^
Grade A evidence in periodic health review
approach to smoking cessation:
Ask if they smoke
Advise on quitting
Assess willingness (see below)
Assist in quitting (see management)
Arrange follow up
Assess willingness to quit:
Precontemplation: NO Contemplation: I should quit Preparation: I am ready to quit Action: I
have quit Maintenance: I have stayed quit Replase: Whoops
MANAGEMENT:
Precontemplation: Advise in sensitive manner about the effects of smoking. Offer your help if
they wish Contemplative: Offer pros/cons, whatJs stopping you from quitting? How can I help?
Preparation: Game plan. **set quit date**
Action: Where the money is, see below for treatment options
Maintenance: Encourage and motivate. Warn of relapse
Relapse: Whoops, but its ok. LetJs try again? Help to eliminate the causative agent if possible.
Nonpharm Tx: and quit rate_
1) Psychosocial therapy: 13%

2) Behaviour modification: 2%
3) Acupuncture: doesn’t work
4) Hypnosis: ?data
5) Cold turkey: 5-15% - motivation dependant Pharmacological Tx:
1) Zyban (bupropion) = C in preg. Insomnia, tremors, Cl in Sz disorder. ^Covered by Gov^^
Quit rate 18- 30% (get up to 40% by adding NRT), Number needed to tx (NNT) 8
2) Nicotine patch (NRT) = D in preg. Skin irritations, headache, insomnia, can’t do in CV dz.
Quit rate 10- 20%, NNT 18
3) Nicotine Gum (NRT) = C in preg. Cough, throat sore, can’t use in dental issues. Quit rate
27% NNT 9
4) Nicotine inhaler (NRT) = D in preg. Throat irritation, cough, stomach issues. Quite rate
17%, NNT 13
5) Champix (Varenicline) = C preg. Nausea, vivid dreams. ^Covered by Gov^^ Start 1 week
before quit date. Quit rate 22% NNT 8 (14 if compared to Zyban)
6) Nortriptyline: D in preg. Antichol SE. Quit rate 17%, NNT 10. Consider if comorbid pain,
depression, insomnia
SOMATIZATION
www.phqscreeners.com

SOMATIZATION D/O
0.2-2% ? ； 0.2% 8 .
Somatization suspected in cases where the patient is preoccupied with Sxs, the Hx is vague or
inconsistent, there is a lack of exacerbating or alleviating physical factors, and Sxs are not
related to findings on the Px. Depression, anxiety & personality D/Os occur frequently in
patients with somatization.
Important to perform a thorough Hx/Px. Ancillary lx should be judicious, and ordered only when
specific Dx are suspected. Clinicians should avoid the debate of whether somatization is a
psychiatric or nonpsychiatric illness,
Somatization encompasses many different D/Os described in DSM-IV. Pts w/ somatoform D/Os
don't intentionally/consciously produce their Sxs.
Pts w/ factitious D/O intentionally produce their Sxs to assume the sick role, and pts w/
malingering do so for personal gain.
The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire screens for &
provides categorical DSM-IV Dxs for somatoform, depressive, anxiety, EtOH & eating D/Os.
DDx:
Psych: Depression, anxiety D/Os, substance use D/Os. Medical: Multiple sclerosis, SLE, acute
intermittent porphyria & hemochromatosis
DSM-V for Somatic symptom and related D/O
A: Somatic Symptoms: One or more somatic symptoms
that are distressing and/or result in significant disruption in daily life.

B. One or more of: Excessive thoughts, feelings, and/or behaviors related to these somatic
symptoms or associated health concerns:
1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms
2) Persistently high level of anxiety about health or symptoms
3) Excessive time and energy devoted to these symptoms or health concern
C. Chronicity: Although any one symptom may not be continuously present, the state of
being symptomatic is persistent and lasts > 6 months.
Not a result of malingering or factitious D/O
Severity:
Mild: Only 1 of the B criteria fulfilled
Moderate: 2 or more B criteria fulfilled
Severe: 2 or more B criteria fulfilled plus multiple
somatic symptoms
Other info:
Primary Gain: somatic Sx as a result of unconscious psych conflict; serves to | anxiety and
conflict Secondary Gain: the SICK ROLE; external benefits obtained or unpleasant duties
avoided (e.g. work) Malingering = Fakers to gain external reward Factitious D/O = Fakers to
assume sick role where external reward absent
Pain D/O
Pain is primary Sx. Sufficient severity to warrant
medical attention. Usually no organic pathology, but when existent, reaction is excessive
Conversion D/O
Symptoms affecting voluntary motor control or sensory function that suggest a neurological or
general medical condition (e.g. paralysis, seizures)
Precipitated by stressors or conflict 11-300/100,000. 1-3% of outpatient referral to mental
health clinics. More common in rural population w/ little medical knowledge
Hypochondriasis
Preoccupation w/ fear of having, or idea that one has, a serious dz based on misinterpretation
of physical signs. No evidence to support Dx. Fear of having D/O despite medical reassurance.
Belief is delusional as person acknowledges unrealistic interpretation. Duration > 6mons. 4-9%
in general practice; ? = 6
Body Dysmorphic D/O
Preoccupation with imagined defect or 个 concern around slight anomaly. Usually related to
face. $ = ?. May lead to avoidance of work or social situations
Tx of Somatoform D/O:
Assure the pt there is no evidence of a life-threatening illness, emphasize the Sxs are real but
are not well understood & assure the pt that the presence of a psychiatric disturbance or D/O
does not negate the reality of their suffering
Do adequate lx, don't assume new symptoms as related, coordinate necessary lx.
Brief frequent visits. Limit number of physicians involved in care

Focus on psychosocial not physical Sx Minimize medical investigations; find common ground
Biofeedback psychotherapy - conflict resolution. i psychotropics (anxiolytics in short term only,
Antidepressants for depressive Sxs)
BOTTOM LINE: do adequate work up before Dx somatization and don’t assume it’s somatization
every time!!!
STRESS
References: AAFP Toronto Notes
Pts presenting w/Sxs that could be attributed to stress, consider& ask about stress as a cause or
contributing factor
COUNSELLING:
-Supportive FU is recommended to check on pt5s status and to reinforce his/her positive efforts
-Reinforce even the smallest gains as it increases pts’ resilience, which should allow them to
handle future crises more successfully
-may assist the patient to focus on potentially positive outcomes related to the crisis, including
improved self- discipline, feelings of competence, an appreciation of life, and a sense of future
ability to cope with adversity
-Assess progress regarding the specific plan of action -In patients not coping w/ stress, look for
and diagnose, if present, mental illness (e.g., depression, anxiety DO). See appropriate sections
In pts not coping with the stress in their lives.
Clarify and acknowledge the factors contributing to the stress,
identify sources of stress, make a list Modify environment/events to | stress Advise
reduction/elimination of caffeine Encourage balanced exercise program
Explore their resources and possible solutions for improving the situation.
-Explore Options for dealing w/ the Crisis:
l. Obtaining additional information
2. Gathering situational support (eg. Family and friends)
3. Employing positive coping mechanisms (eg. Exercise and hobbies)
4. Using positive and constructive thinking patterns (those that change the ptJs view)
5. Homework assignments involving gathering additional info for the topic of concern
6. Self-monitoring of Sxs, thoughts, or activities
7. Find strengths or other resources that may have been overlooked
8. Experimentation with new coping behaviours that can empower pt to take action
-Offer psychotherapy or counselling w/ Psychologist/Counsellor/ Social work -Community
resources including: Credit counselling,
Job search/employment agencies，Job skills retraining， Legal advice, Substance abuse/detox

programs, Religious organisations, Support groups for specific traumas/conditions/DOs,
Family/marital counselling, Cultural groups or refugee help centres
In pts experiencing stress. look for inappropriate coping mechanisms Ce.g.. drugs, alcohol,
eating, violence).
STROKE
References: Canadian Stroke Network Guidelines (2016) BC advisory Guidelines (2015)
Mosby’s Canadian Practice Sourcebook Essential Evidence Plus
BACKGROUND:
Epidemiology: top 3 cause of death, -700 000 cases a year
Pathophysiology:
TIA
interrupted blood supply to brain, lasts min-
hours (< 24hrs).
Stroke = acute loss of brain function caused by lack of blood, (lasts > 24hrs)
80% ischemic cause, 20% hemorrhagic
Migraine, Intracerebral hemorrhage, Head trauma, Brain tumor, Todd's palsy (paresis, aphasia,
neglect,
etc. after a seizure episode), Functional deficit (conversion reaction), Systemic infection
Temporal Arteritis, Toxic-metabolic disturbances (hypoglycemia, acute renal failure, hepatic
insufficiency, exogenous drug intoxication)
**Must do quickly，timing is important**
Vitals
Hx of stroke, CAD risks, arrhythmias, blood clots, heart abnormalities, blood thinners
Neuro exam (cranial nerves, reflexes, motor and sensory, neglect, speech, etc)
Carotid bruits/pulses, Heart murmurs Seizure signs (incontinence, tongue)
Trauma to head
FAST exam = Face (asymmetry) Arm (drift) Speech (slurring) Time (<4.5hrs)
-pt with even l of these signs has 72% chance of stroke **iVeed to differentiate ischemic vs
hemorrhagic stroke.…would be nice to have CT everywhere**
PREVENTION:
quit smoking，healthy diet, physical activity Health conditions: control HTN，cholesterol, DM,
arrhythmias (see respective sections about this)
**m Pts w/ no Sx and carotid artery stenosis, guidelines unclear as to when to treat**
WORKUP:
lx: CBC, Lytes, Glucose, Cr, Lipid profile, Urine (infection? drug screen?) INR, ECG CT non
contrast fif available)
After the Acute phase: MRI, Carotid dopplers, Holter monitor, Lipids/BS, Echo
MANAGEMENT:
Involve allied health professionals or
physio/occupational therapy, speech, social worker,
Neurologist etc to get best care for patient
Continue pt/family centered approach (code status, NG
tubes, aspiration, etc)
Be realistic when it comes to prognosis of recovery/further issues
Acute Management:
*If patient has acute onset of symptoms and time of onset is known，may treat patients with
thromboly tics within 4,5hrs of symptom onset *
Exclusion criteria for tPA: Stroke or head trauma in the previous 3 months, previous intracranial
bleed, surgery in last 14 days, GI or urinary bleed in past 21 days, MI in last 3 months, arterial
puncture in last 7 days, non-convincing diagnosis of stroke, coagulation abnormalities.
Relative Cl: Uncontrolled HTN, dementia, pregnancy, ulcers, severe dz.
Thromboly tics: IV Alteplase (0.9 mg/kg up to 90 mg; 10 percent as a bolus, then a 60 minute
infusion). Streptokinase as alternative.
Other Pharm: ASA i6o-3〇omg

Treat BP only if SBP >220, DBP >120 in first 48 hrs if ischemic stroke (if Tx required, only J, by
15%) □ Labetalol Tx of choice
Non-pharm: Neuro vitals q 4 hrs (it would be nice to have a stroke unit)
NPO (for swallowing issues) Treat source if discovered

Chronic/Prevention therapy:
Rehab for physical disabilities
Carotid dopplers: If occlusion = 70-99%,
endarterectomy needed (? risky a surg. otherwise). Recommended to do <2 wks.
Antiplatelets need for secondary prevention: first line is ASA (8〇-325mg), or Plavix 75mg or
Dipyridamole 2〇omg + ASA 25mg (do not use if on Warfarin) Stronger Tx for DM, HTN, atrial
fibrillation, Lipids (see respective sections)
New:? early Prozac (& possibly Celexa) Tx can expedite/ 个 motor recovery
Revaluation:
MMSE/neuro exam to help determine lasting effects. Evaluate patients to help optimize
function (ie. Need a walker? home care? etc). Review for signs of dementia.
Complication Prevention:
Decub ulcer = regular position changes, good mattress, increase mobility
Depression = screen for this (1/3 patients)
Cardiac = higher threshold for evaluation DVT = assess need for prophylaxis & treat accordingly
Dysphagia/Malnutrition/Dehydration = consider position, enteric feeding, food texture to
reduce aspiration risk
Shoulder hemiplegia = rehab, support brace, pain management, elevation to | swelling
THE BOTTOM LINE: Time of Dx and Tx of stroke is important. Ensure proper attention to
secondary stroke prevention and management of stroke complications.
SUBSTANCE ABUSE
References: CIWA protocol Uptodate
Canadian Center for Substance Abuse
Definitions: DSM 5 for Substance Use Disorder:
Criteria
1) Taking substance in larger amounts and for longer than intended
2) Wanting to cut down or quit but not being able to do it
3) Spending a lot of time obtaining the substance
4) Craving or a strong desire to use substances
5) Repeatedly unable to carry out major obligations at work, school, or home due to
substance use
6) Continued use despite persistent or recurring social or interpersonal problems caused or
made worse by substance use
7) Stopping or reducing important social, occupational, or recreational activities due to
substance use
8) Recurrent use of substance in physically hazardous situations
9) Consistent use of substance despite acknowledgment
of persistent or recurrent physical or psychological

difficulties from using substances
2-3 criteria is required for a mild substance use
disorder diagnosis, while 4-5 is moderate, and 6-7 is
severe
Tolerance as defined by either a need for markedly increased amounts to achieve intoxication
or desired effect or markedly diminished effect with continued use of the same amount. (Does
not apply for diminished effect when used appropriately under medical supervision)
Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid
withdrawal (Does not apply when used appropriately under medical supervision)
3 Cs of Dependence: Compulsive use, loss of Control, Consequences of use
Alcohol screening
CAGE:
C- ever felt the need to cut down on drinking?
A -ever felt annoyed at criticism of your drinking?
G -Ever felt guilty about your drinking?
E- ever need a drink first thing in the morning/eye opener?
Positive screen = 1/4 for women, 2/4 for men
General Assessment -when was your last drink?
-do you have to drink more to get the same effect?
-do you get shaky or nauseous when you stop drinking? -have you had a withdrawal seizure?
-how much time and effort do you put into obtaining alcohol?
-has your drinking affected your ability to work, go to school, or have relationships?
-have you suffered any legal consequences?
-has your drinking caused any medical problems?
Alcohol Withdrawal
-occurs within 12-48 hours after prolonged heavy drinking has stopped, 20% mortality if
untreated -stage 1- 6-12 hours after last drink: tremor, sweating, agitation, anorexia, cramps,
diarrhea, sleep disturbance
-stage 2- onset 1-7 days after last drink: visual, auditory, olfactory, or tactile hallucinations -
stage 3- onset 12-72 hr and < 7 days: seizures, usually tonnic-clonic, nonfocal, brief
-stage 4- onset day 3-5: delirium tremens, confusion, delusions, hallucinations, agitation,
tremors, autonomic hyperactivity (fever, tachycardia, hypertension)
-management = CIWA protocol
CIWA scores various symptoms. If agitation score high =you need meds:
Diazepam io-2〇mg PO/IV q 1-2 H until Sx abate Haldol for hallucinations
Always add in Thiamine, multivitamins, Glucose and fluids.

Wernicke-Korsakoff Syndrome
-alcohol induced amnestic disorder due to thiamine deficiency
-necrotic lesions: mammillary bodies, thalamus, brain
stem
-Wernicke’s encephalopathy (acute, reversible): Confusion, Ataxia, Nystagmus (CN VI palsy)
-Tx Thiamine 100 mg po od x 1-2 weeks -Korsakoff syndrome (chronic, only 20% reversible
w/Tx): anterograde amnesia, confabulation, must persist beyond usual intoxication/withdrawal,
cannot occur during acute delirium or dementia; Tx Thiamine 100 mg po bid/tid x 3-12 months
Treatment of Alcohol Dependence
-non-pharmacological: behavior modification,
supportive services, psychotherapy, medications -pharmacological: Naltrexone, Disulfiram
(Antabuse) -can go to residential Tx program
Consequences of chronic EtOH use:
Hepatitis/cirrhosis
Cancer (liver, breast, bladder, oral)
Wernicke’s/ Korsakoffs Cardiomyopathy
Heroin/Opiates/Narcotics:
Tx with Methadone or Buprenorphine Withdrawal won’t kill anyone
BOTTOM LINE
-In all patients opportunistically screen for substance use and abuse
-Screen for blood-borne illnesses and offer relevant vaccinations to intravenous drug users -
Discuss substance use or abuse w/ adolescents and their caregivers when warning signs are
present
-Look for substance use or abuse as a possible factor in problems not responding to appropriate
intervention -Support pts and family members affected by substance abuse.
-Determine whether or not patients are willing to agree with the diagnosis.
-Routinely determine willingness to stop or decrease use by users/abusers.
-In patients who abuse substances, take advantage of opportunities to screen for co-
morbidities (e.g.， poverty, crime, sexually transmitted infections, mental illness) and long-
term complications (e.g., cirrhosis).
SUICIDE
References: Gliatto, M. F. & A.K. Rai. Evaluation and treatment of patients with suicidal
Ideation, Uptodate Medscape
CPS Suicidal Ideation and Behaviour (2015)
Suicideprevention. ca
BACKGROUND:
• Suicidal ideation is an emergency
• Suicide is the 10th leading cause of death in North America
>age 65)
个 w/ age (个 risk group is $
>90% have underlying psychiatric D/O

20-25% are intoxicated at time of suicide
10-40 attempts/completed suicide
RISK FACTORS:
Greatest risk = previous attempt (5~6x risk) Adolescents and ? have more attempts, 6 have
more completed acts
Single, Hx of abuse, FHx of suicide, t altitude, springtime, access to firearms (57% in US), living
alone, recent loss
Psychiatric illness: major depression, substance abuse, anxiety, insomnia
个 risk in early stages of psychiatric illness (exception = alcoholism)
个 risk in the 1st week post-discharge from psychiatric admission
schizophrenia:个 during periods of remission Medical problems: cancer, head injury, AIDS,
dialysis, COPD, asthma (adolescents), multiple sclerosis, quadriplegia, burns, CHF, peptic ulcer
disease. Rarely in the absence of comorbid psychiatric disease Occupations: police/public safety
workers, physicians (especially palliative care), dentists, prisoners, unemployed
Medications fFDA warnings): SSRIs, Gabapentin， Lamotrigine, Oxcarbazepine, Tiagabine,

Tramadol
PROTECTIVE FACTORS:
• Social contacts
• Pregnancy
• Parenthood
• Religion
ROLE OF FAMILY DOCTOR:
• 75% of patients who have committed suicide had contact with their family doctor in the
preceding year, and 45% in the preceding month
• family doctor largely unaware of suicidal ideation despite established relationship

around psychiatric illness
• No data demonstrates that screening for suicidal ideation decreases mortality
ASSESSMENT:
〇 Direct questioning will not precipitate
suicidal action
〇 Ideation, plan, intent
〇 Ideation: content, duration, change
〇 how are thoughts controlled
(“what stops you from acting?”）
〇 Plan: specifics, accessibility, lethality,
likelihood of completion, preparations 〇 Intent: hopelessness, impulsivity, social

support
Complete mental status exam:
〇 appearance: signs of suicide attempt
〇 affect: flat
〇 thoughts: command hallucinations,
delusions, obsession w/death 〇 judgment
〇 orientation/memory (especially elderly,
delirium, dementia)
〇 Always screen for homicidal ideation
〇 Always screen for substance use (CAGE)
〇 Address recent stressors
〇 Collateral hx important (pt more likely to
divulge ideation to family members)
〇 In trauma patients, consider attempted
suicide as the precipitating cause
MANAGEMENT:
High risk = hospitalization (Provincial forming system)
〇 do not leave patient alone
〇 remove any dangerous
objects
〇 ask patient for any weapons
Moderate/low risk = contract for safety (poor evidence) -rapid followup

-appropriate FU instructions if escalation of Sx
Meds: Aggressively tx underlying psychiatric illness, majority are inadequately treated 〇

1st line = SSRL 个 in SSRI can
i suicidal ideation by 25%
〇 CBT
〇 lithium shown to | mortality
in bipolar D/O
〇 ECT in severe cases
〇 avoid drugs w/overdose
potential: TCAs, MAOIs, SNRIs
〇 Aggressively Tx anxiety and insomnia Sxs:
short-course of benzos -rarely fatal in overdose (unless combined w/EtOH)

〇 In suicidal patients
presenting at the emergency department with a suspected drug overdose, always screen for
ASA and Acetaminophen overdoses, as these are common, dangerous, and frequently
overlooked.
POSTVENTION:
〇 Most families appreciate meeting
w/physician
〇 Be available for FU
BOTTOM LINE:
Suicidal ideation is a psychiatric emergency In any patient with mental illness (i.e., not only in
depressed patients), actively inquire about suicidal ideation
Evaluate risk factors, ideation, plan, and intent Always screen for homicidal ideation and
substance abuse
Aggressively treat underlying psychiatric illness Aggressively treat anxiety and insomnia
THYROID
References: Essential evidence plus Top Alberta Doc Guidelines (2014)
Etiology
Low Serum TSH High Serum TSH
Hyperthyroidism
1) Grave s Disease
2) Mu!tinodu!ar goiter
3) Autonomous hot nodule
4) Toxic phase of thyroiditis Hypothyroidism: 1)HashimotoJs thyroiditis 2 )L ate phase
thyroid it ts 3)Post-partum thyroiditis
Drugs
1) Amiodarone
2) lodine
3) L-Thyroxine Drugs
1) Amiodarone
2) Iodine
3) Lithium
Screening
Only consider in high risk groups:
Women over 5〇yo
Women trying to conceive

Women during 1st trimester
Women 6 weeks to 6 mo post-partum
Pt on Drugs such as amiodarone/lithium/ thyroxine
Elderly
Pt with FHx of thyroid disease
CA red flags: Hx of radiation, FHx, big or fast growing goiter
HISTORY
Hypo Hyper
T Bradycardia Tremor (restingy Tachycardia
H Hair loss Hair change- shiny
Y Yawn - fatigue Yawn-can't sleep
R Depression/Weight Gain Restlessness/ Weight Loss
0 Oligomenorrhea Oligomenoritiea
1 Intolerance Cold Intolerance Heat
D Constipation Diarrhea
PHYSICAL
BP (Diastolic vs Systolic Hypertension)
Pulse (Brady vs Tachycardia/arrhythmia)
HEENT = Lid Lag vs Exophthalmos (in Graves), Goiter (in both hypo/hyper)
MSK = Proximal Muscle Weakness Neuro = Carpal Tunnel vs Resting Tremor Delayed Relaxation
of Reflexes vs Hyperreflexes Skin = Dry Skin vs Myxedema
Test TSH ONLY when needed (change in meds, yearly for stability, new Sxs etc.)
Treatment
Hypo: Levothyroxine 0.025 mg/0.05 mg/0.075 mg.
Start low and go slow especially in elderly and patients with CAD; it takes 6-12 weeks for TSH
levels to stabilize.
Hyper: Antithyroid Drugs: Propylthiouracil (safe in Pregnancy, but hepatotoxic)/ Methimazole
Non Selective PBlockers: Propanolol (for Sx relief and prevent bad outcomes)
Radioiodine ablation (avoid in Pregnancy)/ Thyroidectomy
Thyroid Dz:
Sub clinical Thyroid Disease (aka asymptomatic patients w/ abnormal TSH)
Treat Subclinical Hypothyroidism if:
-TSH > 10 mU/L，T thyroid peroxidise antibodies, Goiter, Pregnancy
-Treat Subclinical Hyperthyroidism if: Elderly (to decrease chance of arrhythmia),

-Post-menopausal ? (to | chance of osteoporosis)
Hashimoto’s
Most common cause of hypothyroidism. Circulating
anti-thyroid peroxidase Abs, autoimmune destruction of thyroid gland

Graves
Most common cause of hyperthyroidism. Circulating IgG antibodies that activate TSH receptor
(test for TSHr antibody)
Euthyroid Sick Syndrome
Normal TSH, abnormal T3/T4. Usually acute transient condition caused by various stresses. Very
common in hospitalized patients. No treatment.
THYROID NODULES Tnot covered here”）
95% Benign (colloid nodule/cyst, multinodular goitre, follicular adenoma). 5% Malignant

(papillary, follicular, medullary, anaplastic). Use proper technique (i.e., from behind the patient,
ask the patient to swallow), to find nodules.
Follicular Cells
Solid
Suspected CA
Cystic
Single, large
2：2cm: Send to
Surgery
Multiple, small：
Radionuclotide
scan: COLD
Radionucleotide
scan: HOT
Send to surgery
Follow: if
recurrence or
changes, send to
surgery
Treat with T4
suppresion: if
unsuccessful,
send to surgery
Send to surgery
TRAUMA
References: ATLS course book (9th edition)
Uptodate
Overview
(1) Start with quick assessment of vitals.
(2) Next is rapid primary survey.
(3) Next is resuscitation of vital functions.
(4) Next is more detailed secondary survey.
(5) Last is initiation of definitive care, transfer of pt.
Primary and Secondary Survey Details
A - Airway + C-spine finline Traction)
-relieve airway obstruction! Jaw thrust, Suction, tubing prn for definitive airway
B - Breathing &: Ventilation:

-breath sounds, chest wall stability, tracheal deviation, jugular venous distention (JVD)
-give 02 & ventilation
-tension pneumothorax = tracheal shift, JVD, | BP, | air entry, SQ emphysema — needle
decompression 2nd intercostal space/midclavicular line & tube thoracotomy
-open pneumothorax — cover with occlusive dressing -massive hemothorax: | BP, shock ^
volume & tube thoracotomy
-flail chest: paradoxical chest movement segment —stabilize
C - Circulation:
-heart sounds; organ perfusion: LOC, skin colour, pulse rate & character (carotid BP felt at BP of
6〇, femoral at 70, radial at 80)，BP - narrow pulse pressure, Tmean arterial pressure
—IV 2 large bore，Ringers 2-3L warmed —Blood for type/cross，CBC，PHcG — Blood

products: 2 units for: shock，hct<3〇%, observed blood loss >5〇〇ml, gross GI bleed -Cardiac
tamponade - soft heart sounds, | BP—pericardiocentesis and surg.
-Major hemorrhage^direct pressure

D - Disability:
-LOC (Alert, Verbal, painful stimuli, unresponsive), GCS, pupils, lateralizing signs -Treat T
Intracranial pressure
E - Expose and examine, environment
-keep warm, log roll, prevent hypothermia Adjuncts:

-Foley (contraindications: blood meatus, perineal hematoma, high prostate)
-NG tube (contraindications: CSF rhinorrhea, otorrhea, periorbital ecchymosis, mid face
instability)- OG tube then
-Monitors (vitals, ECG, pulse oximetry, end tidal C02), blood gases
-Diagnostic imaging: CXR, pelvis, C-spine, peritoneal lavage, FAST (focused abdominal
sonography for trauma)
-Transport to another center?
-Don't send pt for lx if unstable!!!
Secondary Survey - goals is to detect non-life threatening injuries, head to toe assessment,
“fingers/tubes in every orifice”
-AMPLE Hx: Allergies, Medications, PHx/Pregnancy, Last meal, Events surround injury -Head to
toe exam: Deformities, contusions, abrasions, penetrations, paradoxical movement, burns,
lacerations, swelling, tenderness, instability crepitation -Special Dx tests: Urinalysis, other blood
work, CT, urography, angiography, U/S, ECHO, Bronchoscopy, Esophagoscopy, xrays (chest, c-
spine, pelvis)
-Continuous re-evaluation
-Definitive Care: surgery, ICU, specialized center transfer: ambulance, flight etc.?
Life threatening complications:
-tension pneumothorax — needle thoracentesis @
midclavicular line 2nd intracostal space, then chest tube -Between anterior/midclavicular line
5th intracostal space
-open pneumothorax (sucking chest wound) cover with sterile dressing taped on 3 sides, then
chest tube remotely
-flail chest ventilation, humidified 02, fluid resuscitation and analgesia
-pulmonary contusion ventilation, humidified 02, fluid resusitation, and analgesia
-massive hemothorax — simultaneous blood transfusion and decompression of chest cavity -
tamponade — pericardiocentesis Remember: hyperresonance confirms pneumothorax and
dullness confirms massive hemothorax on percussion
Triage
There are two types of triage situations:
1. Multiple: In this scenario the # of pts and severity of injuries do not exceed the ability of
the facility to render care. Pts w/ life-threatening or multiple-system injuries are treated first.
Use pre-hospital care protocols (Trauma Scores, e.g. Pediatric Trauma Score, Injury Severity
Score, Revised Trauma Score, includes GCS) to identify and facilitate care in the field.
2. Mass: In this scenario the number of pts and severity of injuries exceeds capability of
facility and staff. Pts with greatest chance of survival and requiring least expenditure of time,
equipment, supplies and personnel are treated first.
Rule out abuse in child trauma cases Advise on trauma prevention when able
TRAVEL MEDICINE
CDC traveler website
Travel Consult >1 month before leaving Websites great for travel advice:
http://wwwnc.cdc.gov/travel/ http://www.who.int/ith/en/
Greatest incidence of infections abroad:
Travelers’ diarrhea (30-80%)
E.coli diarrhea (10%)
Malaria (<0.01-1.1% based on destination)
Respiratory infections 1%)
Hepatitis A (-0.3%)
Dengue (-0.2%)
Typhoid (0.003-0.03%)
Gonorrhea (0.05%)
DONrT FORGET TO ADVISE:
Non-infectious perils of travel (e.g., accidents, safer sex, alcohol, safe travel for women)
Advise patients to check insurance coverage issues especially in regard to recent changes in
chronic disease and any recent Tx changes. Advise patients traveling with medications to have
an adequate
supply, documentation of need for use, and to transport them securely (e.g., carry-on bag)
Review drug interactions of medi
Malarone: | Warfarin metabolism
Mefloquine: interact with antiarrhythmics
HIV meds: | metabolism of malaria meds
Think about timing adjustment for insulin when
travelling east to west
02 needs 个 w/ 个 altitude (supplemental 02 maybe needed by people w/ COPD).
DON?T FORGET ROUTINE VACCINES!!!!

Tdap (one time Adacel for adults & >6syo)
MMR (6-11 mo may need one vaccine prior to leaving, series at i2mons)
Influenza, Varicella, Polio (complete series for adults with no primary series)
Other vaccines (check CPC website^:
Yellow fever,
meningococcal (Menactra)
Typhoid (IM vs Oral)
Hepatitis A and B,
Rabies pre-exposure vaccine (wildlife/high endemic/animal handlers)
Japanese and tick borne encephalitis vaccine.
Traveller^ Diarrhea:
Low risk (<io%) in Northern Europe, Australia, New Zealand, the United States, Canada,
Singapore, Japan Moderate risk (10-20%) in Caribbean Islands, South
THOSE WITH CHRONIC PIS
Africa and countries bordering the Mediterranean Sea High risk (>30%) in Asia (exception of
Singapore), Africa (outside South Africa), South and Central America and Mexico
-Travelers' diarrhea is common, can be a variety of bacteria, viruses and parasites.
-Stool ONLY if diarrhea > io-i4days, fever and colitis, upper intestinal Sx, Giardiasis is likely, or
immunocompromised pts.
Tx: Fluid replacement (see "diarrhea" section). Should give Abx to fill and take w/ pts in case
diarrhea develops:.
Norfloxacin (400mg once daily) or Ciprofloxacin (50omg once daily) or Bismuth subsalicylate (2
tablets chewed 4 times daily) -Medical care should be sought if 个 fevers, > 10-14 days,
abdominal pain, bloody diarrhea, or vomiting ensues. -Antimotility not necessary for mild-
moderate diarrhea & should not be used in severe diarrhea except in association w/ Abx Tx.
-PREVENTION better than CURE!: Attention to choices of food/drink, water purification, and
Abx prophylaxis are all means of preventing travelers' diarrhea.
Dukoral: for -7% of diarrhea, protects against E. Coli/V. Cholera, ages >2yo
MALARIA:
Check CDC website for updates.
-Can present up to 33TS post exposure (in case of P. Falciparum)
-Prevention: DONT GET BITTEN BY MOSQUITOES or don’t get transfused!
Avoiding outdoor exposure between dusk & dawn (when Anopheles mosquitoes feed). | the
amount of exposed skin. Insect repellant. Sleeping within bed nets treated with insecticide
(permethrin). Well-screened or air-conditioned rooms
DEET (30-50%) protective >4hrs. DEET is safe for infants and children >2mo.
Permethrin for clothes/mosquito nets (effective >1 week even after washing)
CHEMOPROPHYLAXIS:
Atovaquone/Proauanil: blood/tissue (hepatic)
schizonticide. Take 2 days prior to trip until one week after. For chloroquine sensitive and
resistance SE: diarrhea/nausea, insomnia, headache, rash, mouth ulcers. Can^ use in
pregnancy.
Mefloquine: lx/week from > 2 wks prior to 4wks after. Limited data w/ pregnant, may be safe?
For chloroquine sensitive and resistant.SE: | heart rate and 个 QT, depression，anxiety，
confusion，seizures Chloroquine: once weekly, 1-2 weeks prior to 4wks after exposure. Safe for
pregnant
Doxycycline: daily, 1-2 days prior to 4wks post exposure. Not for pregnant & kids <8yo. SE:
Photosensitivity, GI upset, candidiasis Primaquine: can cause G6PD haemolysis CHILDREN: safe
to use Chloroquine, Mefloquine; Atovaquone-proguanil if >5kg
Altitude sickness
个 altitude illness (HAI) collective term for Acute mountain sickness，个 altitude, pulmonary
edema & HA cerebral edema
Can be experienced at >2500m above sea level.
Factors for f risk for HAI: PMHx of HAI，Rate of ascent, Vigorous exertion prior to
acclimatization, Substances (eg, EtOH) or conditions that interfere w/ acclimatization,
comorbidities interfering w/ respiration (eg, neuromuscular D/O) or circulation (eg, pulmonary
HTN). Prevention better! Don't climb Mt Everest! Gradual ascent, avoid vigorous activity during
acclimatization, iHorsing around!
Meds for prophylaxis and Tx (if 个 risk for HAI/previous HAI): Acetazolamide: 125 mg po Daily,
Dexamethasone, NSAIDs for headache
UPPER RESPIRATORY TRACT INFECTIONS
References: Uptodate Anti-infective Guidelines (2013)
TOP Alberta Docs: Acute bronchitis guidelines (2008)
TOP Alberta Docs: Acute bacterial sinusitis guidelines (2008)
Differential. Hx/Px and some Dz states covered in ’’cough”，’’croup” and ’’

earache” sections
Acute Sinusitis
What = Infection of sinuses
Causes = Viral (MAJORITY), Bacterial (M. Catarrhalis, S. Pneumonia, H. Flu), Fungal
How can I tell Viral from Bacterial Sinusitis? Nasal purulence (green discharge) + facial pressure,
pain, fullness and/or hyposmia, anosmia, and/or >14 days and/or getting worse Labs = None,
transillumination of sinuses
Prevention = Hand washing

Tx = Decongestants (Pseudoepehendrine), Saline Rinses, Netti Pot, Analgesia/Fever control
(Tylenol/Advil)
ABx for Sx of bacterial infection or > lodays: Amoxicillin/ Doxycycline/Septra
Pharyngitis
What = Infection of the pharynx
Cause = 90% Viral, 10% Bacterial (Group A Strep)
How can I tell Viral from Bacterial Pharyngitis? McISSAC Strep score:
HOT Fever > 38°C,
Lymphadenopathy Age 3-i4yo (>45yo is -1)
Cough Absent
Exudate or swelling of tonsils.
If score 2-3 then Culture. If score 4-5, Treat.
Lab = Culture, rapid strep (Specific NOT sensitive)
Tx = Penicillin/Amoxicillin. Macrolides if allergic, Cephalosporins if only rash to penicilins.
Why do I treat Strep Throat?
1) To shorten course and severity
2) To prevent complications: Rheumatic Fever (carditis, arthritis, chorea) Scarlett Fever,
Post Strep Glumerulonephritis, Pharyngeal Abscess (look for deviation in throat), PANDAS
What about Mononucleosis? Suspect if not improving on Abx, if generally unwell prominent
lymphadenopathy/ splenomegaly. Do CBC, Monospot Test (high false negatives in 1st week of
illness), or EBV
antibodies.
Tx =Supportive Tx, avoid contact sports, steroid if pharyngeal swelling
Bronchitis
What =Inflammation of trachea Causes = Viruses Tx = Supportive Tx
ABx for COPD exacerbations. Can use Amoxil or Macrolides if needed
Otitis Externa (see "earache” section)
What = Inflammation of external auditory canal
Who = Swimmers, Hearing Aid users
People exposed to hot humid weather
Cause = 90% Bacteria (Pseudomonas，Staph and
Sfrep)，10% Fungi (CancMa)
BOTH OF THESE GUYS LOVE MOISTURE

Sx = Otalgia, Ottorhea, Erythema of ear canal w/
purulent discharge. PAIN on manipulation of pinnae
Labs = Can try to culture discharge
Prevention = Use ear plugs while swimming. Avoid
prolonged exposure to moisture 2% Acetic acid after
swimming (modifies flora)
Tx = Pseudomonas likely,
Ciprofloxacin / Hydrocortisone drops, Acetic Acid/Hydrocortisone drops, Polysporin
Otitis Media
see earache section
Mastoiditis
What = Infection of the mastoid bone
Who = Pt with recurrent otitis media,

Immunocompromised, Pt with cholesteatoma
Causes = Strep Pneumo most common
Sx = Fever, Otalgia, Otorrhea, Postauricular erythema,
Edema, Tenderness
Labs = CBC, Blood Culture,
Maryngiotomy/Tympanocentesis, X-rays, CT, Bone Scans
Prevention = Treat bacterial otitis Tx = IV Ceftriaxone
VACCINATIONS
Who gets the flu vaccine? Everyone but especially any chronic diseases, DM,
immunosuppressed, age >65, kids 6 mo to 23 mo in age, healthy pregnant women Who gets
Pneumococcal vaccine? Any Chronic diseases, DM，immunosupressed
age > 65, Asplenia, Sickle Cell, homeless, druggies and smokers.
What about Tamiflu (Oseltamivir)? Can be used for treatment and prophylaxis for influenza.
Need to start it < 48 hours of Sxs/contact with infected person. Tx for 5 days, prophylaxis for 10
days
OTHER PRACTICE POINTS
-Take appropriate history and/or physical examination to differentiate life-threatening
conditions (epiglottitis, retropharyngeal abscess) from benign conditions and manage the
condition appropriately -In high-risk patients (e.g., those who have human immunodeficiency
virus infection, chronic obstructive pulmonary disease, or cancer) with upper respiratory
infections: Look for complications more aggressively,
and follow up more closely.

URINARY TRACT INFECTION
References: Uptodate Anti-infective Guidelines (2013)
Diagnosis and Management of Simple and Complicated Urinary tract infections (2012)
Definition: Presence of pure bacterial growth of > 105 colonies/ml of urine.
Clinical Presentation:
• Dysuria, frequency, urgency, enuresis, abdominal or suprapubic pain, and/or hematuria
• Fever/systemic complaints generally not part of the presentation
• Fever > 38°C, chills or flank pain may suggest upper urinary tract infection
Check for UTI in young/elderly folks acting weird.

Ddx of Dvsuria:
see ’’dysuria” section
• Infectious (Pyelo, cystitis, urethritis,
prostatitis, epididymitis, orchitis, cervicitis,

vulvovaginitis, TB)
• Neoplasm (renal cell tumour, bladder ca, prostate ca, BPH)
• Calculi (renal, bladder, ureter)
• Inflammatory
• Hormonal (endometriosis)
Trauma (catheter) Psychogenic

Risk Factors for Acute Cystitis
? , Sexual Activity, Abnormalities of urinary system (vesicoureteral reflux, polycystic kidneys),
Dysfunctional elimination syndrome, Fecal Impaction, Paraplegia and other neurologic
conditions, Sickle cell anemia, Hx of Kidney Transplant, Diabetes, Bladder Stones
Immunodeficiency, Bladder catheter or recent instrumentation
Causative Agents:
Klebsiella Pneumoniae, E. Coli (85%), Enterococcus, Proteus mirabilis, Staph Saprophyticus,
others
Physical:
Temp, Abdo exam, CVA tenderness, Pelvic exam (if Hx suggests urethritis or vaginitis or STI)
Labs:
Urine Dipstick: culture if -ve leukocytes/nitrites and urinary symptoms
Urinalysis: midstream, Pyuria (leukocytes) present in almost all cases of cystitis
Urine Cx: persistent Sx despite Tx or UTI Sx recur < 1 month after treatment. Gold standard of
Dx
Tx: (Only Tx asymptomatic in pregnancy or pre surgery)
1st Line: Septra 1 DS tab BID x 3d Macrobid loomg BID x yd (not for pyleo)
2nd Line: Amoxil 250-50omg TID x yd Ciprofloxacin 25〇mg BID or 50omg OD x 3d 3rd Line:
Cephalexin 25〇mg QID x yd Levofloxacin 25〇mg OD x 7d
Recurrent UTI in women

Early recurrence <1 mons: culture and Tx for 10- I4days.
If > 3 infections/year, consider prophylaxis.
Lifestyle changes: change contraceptive (spermicide use)，postcoital void，个 fluid intake，

cranberry Antimicrobial prophylaxis (SE = candidiasis, GI Sx): daily for 6mons. Post coital
prophylaxis (single postcoital dose) if related to sexual intercourse. 1st line: Septra DS V2 tab，
Macrobid loomg，Keflex 25〇mg.
UTI in Pregnancy
Asymptomatic Bacteriuria: 2-7 % of pregnancies, often < imons of pregnancy. Associated w/ 个

risk of preterm birth, \ birth weight & perinatal mortality.
Dx on culture of urine (2 voided specimens w/ same bacterial strain or single catheterized
specimen w/ 1 bacterial species isolated)
Tx: 1st Line = Keflex 25〇mg 4 times daily X 3 days OR Amoxil 25〇-5〇omg three times daily X
7 days, with f/u culture negative or
Acute Q/sriris: 1% of pregnant ?. Dx w/ urineCx. Tx w/3-7 day course of Abx as long as they do
not have Sx suggestive of pyelonephritis (eg flank pain, nausea/ vomiting, fever (>38°C), and/or
CVA tenderness). Pregnancy Contraindications =Quinolones, Septra, Macrobid in ist/3rd
trimester.
Pyelonephritis
Clinical Presentation: Flank pain, abdo/pelvic pain, nausea, vomiting, fever > 37.8 °C (strongly
correlated), CVA tenderness. Sx of cystitis may or may not be present.
Physical Exam: Focus on vital signs and abdo, pelvic exam and CVA tenderness
lx: Urinalysis: pyuria almost always present, white cell casts = renal origin of pyuria.
Urine Cx: E. Coli most common.
Tx: Admit patient if severe illness w/个 fevers, pain， disability, inability to maintain oral
hydration or PO meds, pregnant or concerns about patient compliance PO meds: Levofloxacin 5
〇omg daily or Ciprofloxacin 5〇omg twice a day
IV meds: Ceftriaxone i-2g q24H or Ciprofloxacin 4〇〇mg qi2H (DM & pregnant pts require
Ampicillin 1- 2g q4_6h to be added empirically to treat S. saprophyticus).
Tx for 10-14 days. If switching from IV to oral, switch after 3-4 days when Cx results are
available Complicated Pyelonephritis = Progression to renal abscess, emphysematous
pyelonephritis or necrosis.
CHILDREN:
Hx: Temp, Urinary Sxs, vomiting, recent illness, previous Abx, sexual activity
Previous UTI, abnormal growth, renal abnormality.
Px: Vitals/Temp, Growth parameters (poor weight gain/failure to thrive may be caused by
chronic UTI), Abdo for mass/ tenderness, Suprapubic and flank tenderness, examination of
external genitalia for anatomic abnormalities (phimosis, labial adhesions)
vulvovaginitis, vaginal foreign body, STL

Labs: Urine Dipstick, Urinalysis (leukocytes, bacteria),
Urine Cx
lumbar puncture (< imos w/ fever & + urinalysis (^1% with UTI have meningitis).
Imaging: Renal U/S in ? < 3yo w/ 1st UTI, 6 of any age, Pyelo, first UTI of any age with FHx of
UTIs, abnormalities of urinary tract, abnormal voiding pattern, HTN or poor growth.
Urethrogram if US abnormal.
Tx: 1st Line = Bactrim/Septra 5-iomg/kg/ day, Nitrofurantoin 5_7mg/kg/day (not to be used in
infants cimos). 2nd Line = Amoxil 4〇mg/kg/day.
Tx duration: <2yo w/ febrile or recurrent UTI Tx for 10 days. If >2yo, afebrile Tx for 5-7 days.
Expect response in 24-48 hrs, if not reconsider Abx.
RETENTION
Causes: EtOH, neuro DO, obstruction (CA, prostate, fibroids, stricture, prolapse).
Labs: urinalysis, US.
Tx: underlying cause, Foley, Flomax if nothing else works.
VAGINAL BLEEDING
References: Uptodate Dynamed
Mosby's Family Practice Sourcebook Essential Evidence Plus
SOGC: Abnormal uterine bleeding guidelines (2013) TOP Alberta docs: Investigations of
Amenorrhea (2008)
DDx of Bleeding in PREmenopausal:
!!! pregnancy!!!，anovulatory bleeding/ DUB (Dx of exclusion).
SYSTEMIC PROBLEMS: endocrinopathy (thyroid, prolactinoma, Cushing’s), PCOS, OCP/IUD

(breakthrough bleeding; tolerate for 3 mons), coagulopathy
LOCAL PROBLEMS: PID, Trichomonas, BV, cervical CA, endometrial stuff (see below) ovarian
cysts, trauma/abuse
ALSO: Think anatomically for work up: vulva (exam), cervical/ vaginal (spec exam), uterus/
adnexa (bimanual and transvag US) & BW lx: phcg, Pap, CBC, TSH, prolactin, pelvic or transvag
U/S, anything else.
Tx: MEDICAL: Tranexamic acid, treat underlying cause, | estrogen dose (the OCP method!!),
OCP countdown method: Day 1 = 5 tabs, Day 2 = 4 tabs, etc. Then stay on OCP for 1 week then
switch to progesterone-only pill
SURGICAL: dilation/curettage, hysterectomy, uterine artery embolization
DDx of Pregnant Bleeding:
Ectopic Pregnancy,
Abortion/Miscarriage (Missed = open Cervix [Cx] + non-viable products of conception [POC],
complete = POC out, incomplete = some POC left, septic = infected, threatened = closed Cx +
live POC, inevitable = open Cx)
Placental abruption Placenta previa Vasa previa
Ix: Group and Screen, Transvaginal US! phcg!
Acute Management:
ABCs, IV fluids, 02, monitors & BW. IV bolus 1-2L NS. Rhogam 3〇omg IV if applicable. Call Gyne
to figure out definitive plan, call for ICU backup.
DDx of POSTmenopausal Bleeding:
Atrophy - see Vaginitis, Dx of exclusion, Cancer!!! Endometrial Stuff: polyps, hypertrophy,
fibroids， hormone replacement Tx (estrogen alone + intact uterus), systemic bleeding DO, PID,
STDs.
Labs: Bleeding diathesis (platelets, INR/PTT, fibrinogen, mixing study, liver enzymes as
indicated). PID = swabs for STD. Vaginosis = Bacteria, Trichomonas, Yeast.
Cancer screening: Cervical = pap, Endometrial = Transvag US (endometrial thickness) +
Endometrial Biopsy, Ovarian = Transvag US
PUBERTY:
Onset 7-i3yo
1. Thelarche (unilateral breast bud)
2. Adrenarche (body hair/odour, acne)
3. Growth spurt
4. Menarche (mean age i3yo)
Problem: Irregular Menses common around puberty. OCP only if very troubling.
Problem: Delayed Puberty (nothing by i3yo), Usually constitutional, Hx of developmental delay,
ovarian radiation, chemotherapy. Px for chromosomal DO (Turners), growth chart.
Primary Amenorrhea 二 never had a period DDx: GENETIC (50%): Turners XO, XY w/ androgen
insensitivity syndrome
PITUITARY: think prolactinoma, atypical
antipsychotics (| Prolactin)
THYROID: hypo or hyperthyroidism (TSH) HORMONES: PCOS, adrenal tumor, Congenital
Adrenal Hyperplasia (AM testosterone + DHEAS test) OVARIES: gonadal dysgenesis (XO),
radiation, chemotherapy, PCOS
EQUIPMENT: imperforate hymen, cervical stenosis, abnormal uterus
Hx: Secondary sexual characteristics, sense of menses, FHx (constitutional delay, PCOS, thyroid
DO) Sxs of pituitary tumor (visual fields, headaches, diabetes Insipidus)
Px: Malnourishment. Secondary sexual characteristics (genetic), Virilisation (PCOS, adrenal
tumor/hyperplasia)
Pelvic exam: imperforate hymen, other anatomic causes
Bimanual: absent uterus = androgen insensitivity
syndrome
Labs:
Step 1： TSH, Prolactin.
Step 2： Progesterone challenge: if no bleed, then no uterus. Bleed = no Estrogen.
Step 3: FSH/LH: if 个，then ovaries are broken. If I，then hypothalamus/pituitary broken.
Secondary Amenorrhea = stopped having periods DDx: PREGNANCY!!!I weight, Stress, Systemic
illness (anything), Pituitary tumor, Thyroid, PCOS, Premature
Ovarian Failure (see “Menopause” section), Antipsychotics!!(个 Prolactin)
Px: weight, visual fields, thyroid exam, skin, pelvic

exam
Labs:
Step 1： PHcG.
Step 2: TSH/prolactin
Step 3： FSH/LH (if T，then ovaries are broken = premature ovarian failure)
Polycystic Ovarian Syndrome (PCOS^)

Cause: insulin resistance, too much androgen, anovulation.
Hx: HEAD: acne + HIRSUTISM + male pattern
baldness
TRUNK: obesity
GYNE: oligomenorrhea / irregular periods/
menorrhagia + INFERTILITY
Labs : phcg, free testosterone + DHEAS test (most sensitive)，TSH 土 prolactin.
Imaging^ optional): pelvic US for cysts.

YOU MUST R/O BADNESS (other causes of virilisation): late onset congenital adrenal
hyperplasia (serum 17OH progesterone), Prolactinoma (serum prolactin level), Androgen-
secreting tumor (referral to endocrinology) ^SCREEN FOR: DM &fcholesterol^ Tx:
NONPHARM = exercise, | weight,
PHARM = OCP for periods, Metformin, HIRSUTISM = OCP (Diane-35, Yasmin)
ENDOMETRIOSIS
Sx : DYSMENORRHEA + Dyspareunia, dyschezia,
chronic pelvic pain, Infertility!!

Px: normal exam
Labs: Bhcg, US pelvis to RO other pathology! LAPAROSCOPY!!
Tx: QCP. Mirena，NSAIDS 土 opioids Surg. useful for Dx + Tx of pain & infertility
VAGINITIS
References: SOGC guidelines (2015) www.aafp.org
Mosby family practice sourcebook Essential Evidence Plus Anti-infective Guidelines (2013)
Definition: irritation/inflammation, discharge,
pruritis
ÂLWAYS R/0 STI AND UTI in vaginal discharge***
Normal Vaginal Discharge
• 1-4 ml fluid/24 hrs. White or transparent, thick, usually odourless. pH 4-4.5
•个 with high estrogen states: pregnancy，OCPs，mid- cycle， PCOS， premenarchal
• Concerned if changes in colour or amount
Prepubertal Vulvovaginitis DDx:

-nonspecific (25-75%), infectious (group A strep, shigella, STI), Candida, foreign body,
pinworms, trauma, lichen sclerosis -counsel on hygiene
-R/0 child abuse，immunocompromise，DM
,ichen Sc ID IDS is
Cellophane testx3d •• area ofwhifc crackV cârctfc paper". pruriti:. Tissue paper com m
on!!
M ebendazofc (w /repeat in 2 w ks) Topcalstemid Irrigatk>n & rcm oval
Vulvar/Vaginal Cancer **any suspicious lesion
should be biopsied***
• usually postmenopausal > 6syo
• Etiology: squamous (>90%)，basal，melanoma，Paget’s， adenocarcinoma
• Risks for HPV: Immunocompromise, smoking, whoring out
• Sx: most Asymptomatic!! Pruritis, lumps/masses, ulceration, discharge, bleeding,

dysuria. Can be warty/cauliflower-like 土 lymphadenopathy
• can occur on lichen sclerosis or hypertrophic epithelium (<5% malignancy potential)
• Dx: BIOPSY and refer
Atrophic Vaginitis
► postmenopausal or hypoestrogenic state
► Sx: dyspareunia, dysuria, postcoital bleeding, pruritis
► Dx: visual inspection [thinned skin, petechiae, bleeding points，dryness，erythema]. If

unusual 口 BIOPSY
► Tx: Vagifem (1 tab daily x 2wks, then twice weekly), Premarin cream (may require prog
esterone if intact uterus), HRT (if vasomotor sx)
CAUSES OF VAGINITIS
Bacterial Vaginosis 45% Vulovagmal Candidiasis 25% Trichomonas 15%

Cause Gardnerella vaginalis Mobiluncus sp., Mycoplasma hominis, Peptostreptococcus sp
Risks: Pregnancy, IUD, douching C albicans (90%),
C tropicalis & C glabrata (5%)
Risks:
Immunocom promise Tnchomonas vaginalis Flagellated ”STI*“ Risks: Unprotected sex w/
multiple partners, IUD, smoking
(DM, AIDS),OCPr IUD, chronic Abx, pregnancy
Sx 86% asymptomatic Fishy odour 20% asymptomatic Pruritus 20-25%
asymptomatic
Profuse malodourous
Absence of Vulvar candid iasis= discharge
vulvar/vaglnal irritation burning, dyspareunia, dysuria Dysuria, pruntis, post-
coital bleeding
Discharge/Px Grey, thin
homogeneous
discharge Thick, odourless cottage cheese
Swollen, mflamed Profuse yellow-green foamy d/c
"Strawberry cervix" +
genitals. Satellite petechiae
lesions. Red, swollen genitals w excoriations
Dx 3 of 4 Amsel’s pH <4 5 pH >4.5
criteria:
1 pH>4 5
2. homogenous vag discharge
3 ^ whiff test (with KOH)
4 >20% clue cells on Hyphae & spores on
wet mount Whiff test negative Flagellated protozoan on wet mount (80-90% sensitivity)
Many WBC
wet mount
Tx ONLY TREAT in
pregnancy, symptomatic, scheduled for pelvic surg.
Flagyl 500mg twice daily x 7 days_ or Clindamycin 300mg po twice daiy x 7 days (both class B in
preg) 了 oplcals- Clotrimazole (Canestan), Mlconazote (Monistat>-1,3,6 day regimens- ok in
Pregnancy Oral - Fluconazole 150mq x 1 (class C) Severe: 7-14days topical or Fluconazole 1S0mg
q72hrx 2- Flaavl 2a x 1 fok in Preg)
Alternative 500mg twice daily x 7 days Lactation - hold Breast feeding 24 hrs after last dose of
Flagyl Treat partners
FAJ 1 mo after treatment. 3doses
Acidophilus in diet
Complication Pregnancy - ? risk PROM, preterm labour, ?birth weight. Endometritis, PID,
Pregnancy - ? risk PROM, preterm labour, LBW
vaginal wound infection REPORTABLE
post gyne surgery PI^ÂÊ
VIOLENT/AGGRESSIVE PATIENT
References: CJRM (2000)
Mosby family practice sourcebook
Causes of Violence:
“Although aggressive behaviour can be a symptom of medical or psychiatric illness, most

violent behaviour in our society is simple criminality, unrelated to "Zness”-CJRM 2000.
In managing your practice environment draw up a plan to deal with patients who are verbally
or physically aggressive, and ensure your staff is aware of this plan and able to apply it.
Risk Factors for Violence:
-Male, Drugs or EtOH, Past Hx
-Family or friends use words such as "out of control," "wild," "crazy" or "angry" to describe the
patient.
Signs of impending Violence:
anger, agitation, a clenched-fists posture, loud behaviour, yelling.
Potential Causes to RO:
Psych: Mania, schizophrenia
Organic: dementia, delirium, anything causing altered sensorium
Drugs/EtOH: self-explanatory
Behavior/Personality DO: probably can’t figure out in one or two visits
Dealing with Violence:
Have apian of action before assessing the patient *** Call for help^* = most violent and
aggressive behaviour is criminal in nature, and should not be dealt with via the health care
system. Call the police immediately if the patient: makes any threats, verbal or physical; acts
destructively); is noisy, hyperactive and
won't quiet down after one or two requests; is armed (e.g., gun, knife, broken bottle).
-Do not inform the patient that you have called the police — this may make him even more
aggressive -Do not try to negotiate with a person displaying this level of aggression.
Assess after aggression suppressed:
-stay calm，don’t argue, offer a snack -have reinforcements if needed -passive body language
-check for weapons -easy exit if needed
to use physical restraints if any safety concerns to staff or patient (beware of risks with
restraining)
Meds:
1) Short acting benzos acutely (atypical antipsych if applicable)
2) Management of illnesses
WELL BABY CARE
References: Canadian Pediatric Society Rourke,
Mosby's family medicine sourcebook,
CPS nutrition guidelines (2013-2014)
When recent innovations (e.g. new vaccines) and recommendations (e.g. infant feeding,
circumcision) have conflicting, or no guidelines, discuss this information with parents in an
unbiased way to help
them arrive at an informed decision

Growth:
-all infants/children should be plotted on WHO growth curves (height/weight) from age
o_5yo; head
circumference until 〜2yo
-remember that infants with GA <37 wks need to plotted for their corrected age until 24-26
months
RED FLAGS:
Loss of >10% within first 2 wks Does not regain BW within first 2 wks Does not gain > 2〇g/day
Growth plots at <3rd percentile or > 85th percentile OR sharp incline or declining growth curve
or flattening of growth curve
Colic:
-irritability, fussiness or crying without obvious cause -episodes lasting > 3 hr/day for > 3
days/week for > 1 week.
-no failure to thrive -usually from 0-4 months -etiology of colic is unknown
-dietary changes may help colic only in a small minority of babies
-for severe colic consider mild protein allergy; a 2 week trial of extensively hydrolyzed formula
may be tried -for breast fed babies; may consider having mom restrict dairy from diet
-no recommendations for lactase, probiotics or soy formulas
-if having reflux can consider thickening formula
Nutrition:
-recommend breast feeding > 6 mo (|GI/resp
infections，个 cognitive development，| allergies，| rates of SIDS)
-ankyloglossia (tongue tie) is not a reason to stop breast feeding

-breast feeding is contraindicated in HIV and first few weeks of Tx for TB, or if there are breast
lesions with shingles or herpes
-breast feeding should be continued if parent has mastitis
-many meds are safe in breast feeding, but if mother is on specific meds check safety profiles
(ie. lithium, chemo, etc are contraindicated in breast feeding)
-EtOH transferred in breast mild. If mother is having a few drinks recommend waiting 2hrs from
time of drink (pump and dump)
-Anticipate and advise on breast-feeding issues
-if formula feeding ensure iron-fortified formula
(approx. i5〇mL/kg/d)
-give 400IU of vit D to breast fed infants or to infants

getting <iooomL of formula/day
-Start adding iron containing foods (cereals, meet, egg
yolk, tofu) at 4-6months. Work towards adding fruits
and vegetables, Discuss choking safe foods, No water or
juices
Insufficient data to HOLD OUT on allergen foods (nuts, eggs，fish，etc.)
-Add whole homogenized milk, yogurt, cheese around 9 mo
-Homo milk 500-750111L/ day, encourage cup over bottle at 〜lyo, may start honey
-Switch to 1-2% milk, lower fat diet; follow Canada food
guide at 2_3y〇
Education and advice:

At each assessment provide parents with anticipatory advice on pertinent issues
Car Safety: Childrensi3yo should sit in the rear seat. Keep children away from all airbags. Install
and follow size recommendations as per specific car seat model and keep child in each stage as
long as possible. Use rear-facing infant seat until at least lyo AND 10kg (22 lb). Use forward-
facing child seat > 1 yo AND 10-22 kg (22-481b) and <122 cm (48,J). Maximum height/weight
may vary with model. Use booster seat from 18 - 36 kg (40 - 80 lb) and <145 cm (4,9，>). Use
lap and shoulder belt in the rear seat for childrens8yo who are >36kg (80 lb) and 145cm
(57”）& fit vehicle restraint system Wear bike helmets
Drowning: bath and water safety; pools should be fenced in; children should always be
supervised around water
Burns: use electrical socket protectors, install smoke detectors, keep hot water temp < 49°C
Poisons: keep all medications and cleaners out of reach of children
Falls: use baby gates near stairs and windows; never leave child unattended on change table or
high surface; baby walkers are banned Ask about family adjustment to the child
child presents with injury. Always consider child abuse^*
Sleeping:
co-sleeping not recommended, sleep on back; alternate
the side of head that child is placed on, don't use sleep positioners; ensure crib meets
regulations, no firearms in house
Other advice:
-Fever advice: temp >38°C in infant < 3 mons needs urgent evaluation. Fever = temp >38°C
(rectal or ear) & >37,5° (axilla or oral). Tx w/ ibuprofen & acetaminophen recommended
-Sun exposure/sunscreens/insect repellents: Minimize sun exposure. Wear protective clothing.
No Sunscreen or DEET if <6mo; 6-24 months 10% DEET apply max daily; 2-i2yo, 10% DEET apply
max 3/day.
-avoid second hand smoke
-avoid OTC cough and cold meds
-pacifier | SIDS, not recommended if recurrent otitis
-screen for lead paint exposure
-avoid swaddling
-discipline with consistent and positive reinforcement, -encourage healthy diet and physical
activity -encourage reading to children
Dental:
use rice size amount of toothpaste or water and assist child in brushing teeth. Once 3yo child
may be able to brush own teeth; encourage only pea sized amount of toothpaste to prevent
fluorosis all teeth come in between 6-241110.
Anemia:
All infants from 个 risk groups for iron deficiency anemia require screening
between 6 and i2mo, e.gjSES; Asians; First Nations;

low-birth-weight and premature infants, and infants fed whole cowJs milk during their first year
of life.
Screen all neonates from high-risk groups: Asian, African & Mediterranean
Developmental:
use rourke (see "periodic health exam" section); tasks on rourke are set after normal
development of those milestones, so abnormal development on this should raise flags
-do nipissing at 18 months
-if concerns about development: r/o hearing, vision, or language problem; ensure that social
situation isn’t influencing development
-if trouble with vision, motor, or cognitive function, referral to peds and/or utilization of
community resources
-any concerns in emotional/social/ communication domain consider screening for ASD at 18-24
months with M-CHAT
Physical: see Aperiodic health examfr section
Full newborn exam; if normal only have to do the following: Red reflex for cataracts and
retinoblastoma, Corneal reflex for strabismus, Screen for hip dysplasia until at lyo, Screen for
hearing, Screen for snoring, Muscle tone, Fontanelles (posterior closes at 2mo and anterior at
18 mo)
Immunizations
See "immunization" section
Influenza: All household contacts of infants <23 mons of age should be vaccinated to protect
the baby. All
premature infants starting at 6mo need influenza vaccine.

RSV: All Infants born at <32 wks gestation who are <6 mons of age at the start of RSV season.
Infants between 32 -35 wks in isolated communities. Infants < 241110 with bronchopulmonary
dysplasia who need 02 or medical therapy who are 6mo at the beginning of RSV season.
Children with cyanotic or acynotic congenital heart diseases
With parents reluctant to vaccinate their children, address the following issues so that they can
make an informed decision:
-their understanding of vaccinations
-the consequences of not vaccinating (congenital
rubella, death)
-the safety of unvaccinated children (e.g no Third world travel)
Circumcision (Canadian Pediatric Society 2015):
CPS does not support recommending circumcision as a routine procedure for newborns.
Results in an approximately I2x reduction in the incidence of UTI during infancy.
The rate of the complications of circumcision is 0.2% to 2%. Most complications are minor, but
occasionally serious complications occur.
Results in a reduction in the incidence of penile cancer and of HIV transmission. However, there
is inadequate information to recommend circumcision as a public health measure to prevent
these diseases.
Do in high risk populations
ABBREVIATION LIST:
(D)Dx (Differential) diagnosis
(E)RCP (Endoscopic) Magentic Retrograde Cholangiopancreatography
(F)BG/S (Fasting) blood slucose/susars
(G)DM (Gestational) diabetes
(N) (Non)(ST elevation) myocardial
(STE)MI infarction
(N)ICU (neonatal) intensive care unit
(S,D)BP(systolic, diastolic) Blood pressure
S/? Male/female
AAA Abdominal aortic aneurysm
Ab, Ag Antibody, antigen
ABC Airway breathing circulation
Abdo Abdomen
ABG Arterial blood ga.s
ABx Antibiotics
ACEI ACE inhibitor
ACR Albumin/creatinine ratio
ACS Acute coronary syndrome
ACT Assertive community treatment team
AD(H)D Attention deficit (hyperactivity) disorder
AED Antiepileptic drugs
Afib Atrial fibrillation
ALP Alkaline phosphatase
ALS Amyotrophic lateral sclerosis
ALT Alanine transaminase
ARB Ansiotension receptor binding
ARF Acute renal failure
AS Aortic stenosis
ASA Apirin
ASO Antistreptolysin 0 titer
AST Aspartate aminotransferase
AV Atrioventricular
Benzo Benzodiazepine
BID Twice daily
BMD Bone mineral density
BPH Benign prostatic hypertrophy
BRCA Breast cancer gene
BUN Blood urea nitrogen
BV Bacterial vaginosis
BW Bloodwork
Bx Biopsy
CA Cancer
CAD Coronary artery disease
CBC Complete blood count
CBT Cognitive behavioural therapy
CCB Calcium channel blocker
CCS Canadian cardiovascular society
CD Conduct disorder
Cdiff Clostridium difficile
CF Cystic fibrosis
CFS Chronic fatigue syndrome
CHF Congestive heart failure
Cl Contraindication
CKD Chronic kidney disease
CMV cytomegalovirus
CP Chest pain
Cr Creatinine
CSF Cerebrospinal fluid
CT (scan) Computerized tomography
CTFPHC Canadian task force for preventative health care
CV Cardiovascular
CVA Costovetebral angle，stroke
Cx Culture
CXR/AXR Chest x-ray/abdominal x-ray
Def. Deficiency
DHP Dihydropyridine
DIC Disseminated intravascular coagulation
DKA Diabetic ketoacidosis
DO, D/O Disorder
DRE Digital rectal exam
DUB Dysfunctional uterine bleeding
DVT Deep vein thrombosis
Dz Disease
EBV Epstein barr virus
ECG Electrocardiogram
Echo Echocardiogram
EF Ejection fraction
EOM Extraocular eye movements
Eps Episodes
ESR Erythrocyte sedimentation rate
EtOH Alcohol
FEVl Forced expiratory volume in l second
FFP Fresh frozen plasma
FmHx, FHx Family history
FOBT/FOB Fecal occult blood test
FRS Framingham risk score
FSH/LHFollicule stimulatin/luteinizing hormone
FU, F/U Follow up
FVC Forced vital capacity
GAD General anxiety disorder
GBS Group b Streptococcus
GCS Glascow coma scale score
Gens Generations
GERD Gastroesophageal Reflux Dz
GGT Gamma-Glutamyl transpeptidase
GI Gastrointestinal(olosist)
GU Genitourinary
HB (C，D，A) Hepatitis B (C,D,A) virus
V
HDL High density lipoprotein
HgB Hemoglobin
HIT Heparin induced thrombocytopenia
HIV Human immunodeficiency virus
HOCM Hypertrophic obstructive cardiomyopathy
HPV Human papilloma virus
HR Heart rate
HRT Hormone replacement therapy
HTN Hypertension
HUS Hemolytic uremic syndrome
Hx History
I/D Incision and drainage
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
ICS Inhaled corticosteroid
IM Intramuscular
Info Information
INR International normalized ratio
IOP Intraocular pressure
IUD Intrauterine device
IUGR Intrauterine growth retardation
IV Intravenous
lx Investigations
K, K+ potassium
LAAC Long acting anticholinergic
LABA Lons acting beta-agonist
LDL Low density lipoprotein
LFTs Liver function tests
LMP Last menstrual period
LMWH Low molecular weight heparin
LOC Level/loss of consciousness
LP Lumbar puncture
LTRA Leukotriene receptor antagonist
Lytes Sodium, potassium, Chloride

MAOI Monoamine oxidase inhibitor
MAP Mean arterial pressure
MD Doctor, Macular degeneration
Med(s) Medication(s)
Mets Metastasis
MMR Measles, mumps, rubella vaccine
Mon ⑼， MO Month(s), Months old
MRI Magnetic resonance imagins

MRS(S)A Methicillin resistant (sensitive) S. Aureus
MS Multiple sclerosis
MTX Methotrexate
Na Sodium
NASH Non-alcoholic steatoic hepatitis
Nebs Nebulizer therapy
Neuro Neurology/neurological
NG Nasogastric
NNT Number needed to treat
NOAC New oral anti-coagulants
Non-pharm Non pharmacological therapy
NP Nasopharyngeal swabs
NPH Normal pressure hydrocephalus
NPO Nothing by mouth
NS Normal saline
NSAIDs Non steroidal anti-inflammatories
NTG/nitro Nitroglycerin
NVS Neurovascular status
OCD Obsessive compulsive disorder
OCP Oral combined contraceptives
OD Once daily, overdose
ODD Opositional defiant disorder
OPQRST History taking technique (onset, provocation, quality, radiation,
severity, timing)
OSA Obstructive sleep apnea
OT/PT Occupational/physiotherapy
OTC Over the counter medications
PCOS Polycystic ovarian disease
PE Pulmonary embolism
PFT Pulmonary function test
Pharm Pharmacological therapy
PHE Periodic health exam
PHQ Patient health questionnaire
PHx, PmHx Past medical history
PID Pelvic inflammatory disease
PIH Pregnancy induced HTN
Pits Platelets
PM At night, night time
PMR Polymyalgia rheumatica
PO Orally (per os)
PPD Tuberculosis skin test (purified protein derivative)
PPI Proton pump inhibitor
Pres Pregnancy
PRN As needed (pro re nata)
PSA Prostate specific antigen
psych Psychiatric
Pt⑼ Patient (s)
PTH Parathyroid hormone

PTSD Post traumatic stress disorder
PUD Peptic ulcer disease
PUVA Psoralens Ultraviolet A Tx
Px Physical
RA Rheumatoid arthritis, reassess
Reccs Recommends
Resp Respiratory
RF Risk factors
RO, R/O Rule out
ROM Rupture of membranes, range of motion
RSV Respiratory syncytial virus
Rx Prescription, prescribe
SAAC Short acting anticholinergic
SABA Short acting bronchodilator
SC/SQ Subcutaneous
SE, S/E Side effects
SES Socioeconomic status
SJS Steven johnson syndrome
SL Sublingual
SLE Systemic Lupus erythematosus
SOB Shortness of breath
SOGC Society of
Obstetricians/Gynecologists of Canada
SS(N)RI Selective seratonin (norepinephrine) reuptake inhibitors
Staph Staphlococcal infections
STI/STD Sexually transmitted infection
Strep Streptococcal infection
Surg Srugery, surgeon
SVT Superventrciular tachycardia
Sx Symptoms
TCA Tricyclic antidepressant
Temp Temperature
TG Triglycerides
TMJ Temporal mandibular joint dysfunction
Trop(s) Troponin(s)
TSH Thyroid stimulating hormone
Tx T reatment/therapy
TZDs Thiazolidinediones
UC Ulcerative colitis
UFH Unfractionated heparin
URTI, URI Upper respiratory infection

US, u/s Ultrasound
UTI Urinary tract infection
VF/VT Ventricular fibrillation/ tachycardia
VS Vital si^ns, vitals
VZV Varicella zoster virus
w/ With
WBC White blood cell count
Wgt Weight
Wks Weeks
WU Workup
Yrs, Yo Years. Years old
3HCG Human chorionic gonadotropin

Adult

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The Ninety-Nine ®:

Study Guide for Canadian Family Medicine Residents

-The night before...stay in town...don’t fight traffic...it sucks

distracted...or distract others

Things that will kill you:

Will patient croak? if so call for help，get your surgeon.

ABx: Ciprofloxacin and Metronidazole for perforation, obstruction or foreign body.

DON’T MISS: Ectopic pregnancy，AAA，Perforation， Obstruction, Cancer signs!

Recognize a surgical abdomen and act on it!

NEW THINGS (in 2015):

5) AMIODARONE 300 mg dose 1，150mg dose 2 if Epinephrine not working

6) Continue to cycle steps 1-3

UNSTABLE (CF, ↓BP, ↓LOC, etc.):

Synchronized Cardioversion = Biphasic 100-200J or Monophasic 200-360J

UNSTABLE (CF, SOB, ↓BP, ↓ LOC, etc.):

SYNCHRONIZED CARDIOVERSION Consider premedication

TREAT REVERISIBLE CAUSES

Emergency treatment of anaphylaxis in infants and children: Canadian Pediatric Society

*** ensure stability，don’t forget ABCs***

-Treat the underlying disorder

TYPES: ↓iron, thalassemia, blood loss, kidney failure?

Types: ↓ Folate, ↓ B12, liver disease,↓thyroid, EtOH abuse, drugs, myelodysplasia.

blood loss (hemorrhage), hemolysis, or ↓ production.

- increase retic count, ↑ LDH, ↑ unconjugated bilirubin, and ↓ haptoglobin = Hemolysis.

TREATMENT for Macro/Normocytic Anemia: treat underlying cause

SICKLE CELL ANEMIA

Panic Disorder = Lifetime prevalence 〜5%

Phobias = Lifetime prevalence 〜10%

PTSD = Lifetime prevalence 6-9%

Acute Care Management (in ER):

Chronic Care Management:

Epidemiology: 个 with age, no sex preference. (5-10% of >65yo)

Drugs you should know:

Chronic TX(more relevant to primary care)

STEP 1： S-SETTING UP the Interview

STEP 4： K-Giving KNOWLEDGE and Information to the Patient

Behaviours in Dementia: Covered in ’’Dementia” section

-protected sexual intercourse -HPV vaccination - Gardasil and Cervarix

1/10,000. ^Initiation/cessation of screening varies by province** CTFPHC and SOGC disagree:

Atypical Cilandular cells：

Anything that sounds like Cancer；

ASCUS/LSIL： -Repeat pap in 6 mons

Colon Cancer (CTFPHC 2016^

GENERAL TREATMENT SUGGESTIONS for anyone Dx with CA:

CXR: pneumonia, pneumothorax

Stress Test, Perfusion Studies, Angiography (see “Ischemic Heart Disease”）

ACS = ASA i6〇-3〇〇mg chewed stat if suspecting MI + Clopidogrel 3〇o-6oomg.

Atorvastatin 8〇mg. Nitro spray/Morphine for pain.

May need to give thrombolytics if not close to a cardiac center.

elevations, think pericarditis)

-Don’t forget GI causes!!

counseling, exercise, Tai Chi/yoga

comprehensive ( 、 Proceed w/Opiates?

Patient presents assessment

Progressive, incompletely reversible airflow obstruction.个 Frequency of exacerbations as time

Spirometry in all smokers/ex-smokers >4〇yrs w/: Persistent

Moderate = SOB requiring rest 〜loom (few min)，FEVi 50-80%

Severe = Breathless after dressing, resp/cardiac failure,

FEVl < 50%

iVO 7GS (/Zoueny as monot/zempy -个 risk of infections

No SAAC + LAAC if you can help it, ++SE

needed in short Tx. Hospitalize if applicable. 02 as needed, BIPAP/CPAP etc. if needed.

SCREENING: w/ all pts, especially adolescents, young S, postpartum & perimenopausal 9，

* ensure stability，don’t forget ABCs*

ACEI for nephropathy