10 - Toronto Notes 2011 - Family Medicine

FM
Family Medicine
Nicole Coles, Melisssa Loh and Mitch Vainberg, chapter editors Christophel' Kitamura and Michelle Lam, associate editors Janine Hutson, EBM editor Dr. Ruby Alvi, staff editor
Four Principles of Family Medicine ......... 2 Periodic Health Examination (PHE) . 2
Purpose ofthe PHE Sore Throat (Pharyngitis) ................. 47
Complementary and Altemative Medicine (CAM) .. 49 Primary Care Models .................... 50 Antimicrobial Quick Reference ........... 50 References
o
Health Promotion and Counselling

Motivational Strategies for Behavioural Change ................................ 3 Nutrition ............................... 4 Obesity ................................ 5 Dyslipidemia ............................ 6 Exercise................................ 7 Smoking Cessation ..... 8 Alcohol. 10
0 0 0 0 0 0. 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0.
52
Common Presenting Problems

Abdominal Pain ........................ Allergic Rhinitis .. o...... o.. o... o...... o . Amenorrhea ........................... Anxiety. o...... o...... o.. o... o...... o. Asthma/COPD .......................... Benign Prostatic Hyperplasia (BPH)o .. o... o . Bronchitis (Acute) ....................... Chest Pain Common Cold (Acute Rhinitis) ... Contraception .......................... Cough .. Dementia.............................. Depression ..... o...... o.. o... o...... o . Diabetes Mellitus (DM) ................... Diarrhea o...... o...... o.. o... o...... o . Dizziness .............................. Domestic Violence/Elder Abuse .. o...... o . Dyspepsia ............................. Dyspnea Dysuria. Epistaxis .............................. Erectile Dysfunction (ED) . Fatigue ............................... Fever o.. o...... o...... o.. o... o...... o. Joint Pain ............................. Headache ...... Hearing Impairment ..................... Hypertension ... o...... o.. o... o...... o . low Back Pain .......................... Menopause/HRT. Osteoarthritis ... Osteoporosis .......................... Rash Rhinorrhea ............................ Sexually Transmitted Infections (STis) o... o . Sinusitis............................... Sleep Disorders . o...... o.. o... o...... o .
0 0 0. 0 0 0. 0 0. 0 0 0. 0 0. 0 0 0. 0 0. 0 0
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
0.
11 11 12 13 14 15 16 17 18 19 20 20 20 21 25 25 26 28 28 28 29 30 31 32 33 34 35 35 39 41 41 42 42 43 43 45 45
Toronto Notes 2011
Famlly Medicine FMI
FM2 Family Medicine
Four Principles ofFamlly Medidne/Perlodic: Health Eum.ination
Toronto Notes 2011
--"(.,
l'ltiont-(ontrld CUnical Mltllod Explora'define patient problems and decide on m1111gamant togathlll' Consiur bath ndas and lind
Four Principles of Family Medicine

College of Family Physicians of Canada Guidelines I. The family physician ia a skilled clinician in diagnosing and managing diseases common to population served recognizes importance of early diagnosis of serious life-threatening illnesses 2. Fam.lly medicine is a community-based diadpline provides information and access to community services responds/adapts to changing needs and circumstances of the community 3. The family physician is a resource to a defined practice population serves as a health resource advocates for public policy to promote health 4. The patient-physician relationship ia central to the role of the family physician committed to the person, not just the disease promotes continuity of patient care
common ground
,, '
Apndu in hmily Medicm
History, physical, invatigation, diagnosis, plan
Doettl(s Aalllda
Patillnt'o Agenda FIFE fillings ldExpectmions
Periodic Health Examination (PHE)

Canadian Task Force on Preventive Health Care established in 1976, first published in 1979, last updated in 2005 mandate: to develop and disseminate clinical practice guidelines for primary and preventive care recommendations are based on systemic analysis of scientific evidence most notable recommendation is the abolition ofthe annual physical exam; replaced by the
PHE
Purpose of the PHE
', '
,,}-----------------,
Adult Pwriodic HHIIh Exam Mala and f1mala evidanc&-buld prevenllltive care checklist fonns are evailliH onlino It www.cfpc.ca.
primary prevention: identify risk factors for common diseases; counsel patients to promote healthy behaviour secondary prevention: presymptomatic detection of disease to allow early treatment and to prevent disease progression update clinical data enhance patient-physician relationship
Table 1. Pariadic Health Exam
Gnral Papulltian
DISCUSSION Dental hygi111e (conrnunity fluoridation, brusling. flossq) (A) Noise cortrol In! hearing pmteclion (A) Smokln: colll51ll on smoking cessation, pruvide Nicotine replacement therapy (A) Referral to 5flloking csssation 1J11Qillll (B) Diebry advi:e on leafy green vegelables In! fruits (B) Seat bd use (B) l"ll'f prewntion (licycle helmets, smoke detecloli) (B) Modnte plrjsicalaclivity (B) Awid sun expos118 and well" protective cladling (B) Problem screering and counselling (B) Counselling to protect 81J11inst Slls (B) Nu1ritio1111l coun&elling and dielll"y advice on fat artd
','
Clauilicmion of _ _.....no A GDINI avidii!Ca to racommand Ills clinical prwontativ. action. B fllr avidanca to recommend tha clinical prwontativ. action. C Existing evidence is c:onllic:liq 1111d d011 not allow to mab a
recommendlltion for or agailst use of tha clinicol prevantativliiiCtion; however, other factors may inlluence dacision-fllllking. D fllr avidanco to r.command qoi..t Ills clinicol prevantativa action.
s,ecilll Papuhdian
E Good avidii!Ce to racommend opinot Ills clinical prevantative IICtion. I lullici..t llvidance (in quantity or qualityIto mab a recommendation; howvver, othar factors may inlluence dacision-fllllking.
l'lditria: Home viii!& lor ri&k t.rnii (AJ lnqLiry into developmental milestooes (B) AdaiiiCIIII: Counsel on sexualaclivity and conlnlceptive methods(B) Counsel to prevent smoking irili!lion (B) Pari_...UIII wom; Counsel on osteoporo&is Counsel on risks/benefits of hormone repl111:ement therapy (B) Adulll >&5: Follow-up on cngiver concern of in..,airment (A) poRfallaSS86111111nt (A) l'ldltria: Repeated mmilations of hips. and hearing (especially in fim ye11 of life) (AI Serial heights, weij11s and head citurmrence (B) Visualaailytesling rfterage 2(B) Adulll >&5: Visualaaily (Snellefl sight ct.rtj (B) H11rilg impairment (inquiy, whispellld voice test. (B) Fill dag111 ralatiwl with mallnoma: Full body &kin ex1m (B)
cholesleltll (B)
PHYSICAL Clinical biiiiiSI tiXIITl (women age 51J.69) (A) Blood pressw meastJrement (B) BMI measuranent in obese ldiJis (B)
Toronto Notes 2011
Periodic Health Examination/Health Promotion and CounseJlins
Family Medidne FM3
Tabla 1. Pariodic Health Exam (continued) .....

MiJ!iphllse screening witl1 the llemoctiJI test (lldiJ!s age >511 q1-2yrs) (A) Sigmoidoscopy (dills >50] esllblished] (B) Bane minenl density: if 111 risk [1 major cr 2minor critaria] Fasting l..dprufile [C): VJomen 11118 >50 cr if Ill risk Men 11118 >40; if 111 risk (optimal frequency unknown, at least q5yrs) Fasting blood age >40 q3yrs (orsoaner and mo111 frequently if risk factors present] Syptilis screen if Ill risk (OJ Men: PSA testing screening glid&linas nat aslabilsh&d (1) Women: Mammog111phy (\Dillen age q1-2yrs (A] Pap smeanrully (women age 1B-69l ever sexually IICtNe, start alter sexllll debut]; q3yrs after 2norma119SiJ!s (more frequently if conc&ms) Folic acid SlWemeotatian to women of child-bearing 11118 (A) Varicela wccine fur children age 1-12and susceptible adclascanWIMUtB (A) vaccine for all noiJiRgnant women of chikHieariiV,l
,,
l'ldillrics: Raulile hillno;obin for high risk iTfanlll [B) Blood lead screening of high risk infants (B) Diabltics: Urine (A) Fundoscopy (B) Tltigh riilk fWps: Mantoux skin testing (A) mh9l risk f'OUpl: Voluntary Htv antibody screening (A) Gonorrhea screening (A] Chlamydia SCIVIIring in women (B) FAP: Sigmoidclcopy end genetic lestiJ,j (B) HNPCC: CaloiiDICDpy (B)
VVIum Ordllring Futing Blaodwalk Results 11111 Vllid only if atained wilh tlaurs of fasting. Remember, "ffssing" mel/IS no toad, no drinb (except smlll quantities of water). no gum, no limaking.
Prescription medications ant okay
unless Dlherwin specified.
.....
,,
Guldlltin AdviHry CDIJimilD (QACJcammllldatieMior Brwut Clllt:llrScre.mng Far warn., ag1d 40-69 ytlllr'l, t1Mir11 is fllir evidence 1D recommend that routine
Fldillrics: Routine imm111izltions (A) ll&patitis Bimmunizlllian (A) tnllem high risk fWpl: Outr811ch strllegias far vaccilation (A] ennual immunization (B), now recommended lor 1111 INH pruphytaxis for household contacts cr skin test . INH prophylaxis fur hiQh nsk (B) Pnauii10CDccal vaccile [A)
teaclling of br8llll salf-IIXIIminatian
(BSE) be excluded from 1he PHE. ReHin;h shows fair evidence of no b.mit 1D BSE lnd goad IIVidlnCI of
harm.
of hypertension will1 dBP >90 mmlig (adiJ!s age 21-&4, specific (A) 1B high TetaiiiS vaccine: routine boaster q10yrs if hed 1 series (A) Pertussis vaccine: routine boaster of acellular vaccine cnce during dllthood (cen b& giwo as d'Tap)
Clllssfficllicm ahammmandlllian illnc:kstl. Sell sidllbllr on IN2. llftence: Car1lllln Task Fon:e on I'IMnlllive Heailll Cn, 2005.

health promotion is the most effective preventative strategy
40-70% ofproductive life lost annually is preventable
there are several effective ways to promote healthy behavioural change, such as discussions
appropriate to a patient's present stage of change
Motivational Strategies for Behavioural Change

Tabla 2. Motivational Strlltagias for Behavioural Change
Patient's Stage af Changa Physician's Ain
Pre-contlmplation EncoLnge patient to consider the passibiity of Assess readiness for change 1nC1'811Se patient's awaneness of the problem nJ its risks UnclersbnJ patient's IITibivalence and encourage change Build confidence and gain commitment to change Expllll\l optians and choose cou11e mast appropriate to patient Identify higiHisk situations and develop strategies to prevent relapse ContiiJJe to strengthen canfidence and Help patients design 18W11rds for success Deielop strategies to prevent relapse Support and reinforce convictions towards lang-temn change Help patient maintain motivation Rsview identifying highii&k situations and &trlrtllgies lor preventing relapse Help patient view relapse as a Ieeming experience Provide support appropriate to present level of readiness post-relapse
Ct.nga. Mmlg SIMdtnl2001; 1612):45-52, 54-55.
Physici's Pilla
Raise issue in asensitive mamer Offer (not iq!ase] a neutral exchange of information to avoid resistance Offer opportunity to discuss pros nJ cans of change, using reflective listening
Conlllmplltian
Offer rlllllistic options for chqe and

oppcrtunityto discuss inevitable difficLJties
Al:tian
Mlintlnlnce
Re11p1e
Offer positive reinforcement and ways of coping with obstacles Encourage self-rewards to reinforce change Discuss progress and signs of irllJBnding relap&e Offer a nan-judgmental discussion about cirt:umstances sWTDunding relapse end how to avaid relapse in the future Reassess patient's readiness to change
Adllptlld from lbt P.
FM4 Family Medicine
Toronto Notes 2011
Nutrition
General Population
Canada's Food Guide is appropriate for individuals >2 years old counsel on variety, portion size, and plate layout (see Figure 1)
Tabla 3. Canada's Food Guida 2007 Recommendations for Adults Food Group Grain products Vegetables and Milkpndn:b Figura 1. Plate Layout Meat and alternatives 6-8 7-10 2-3 Children 2-B years: 2 Youth S.1 Byears: 3-4 Pregnant,.breastfeeding: 3-4 2-3
ChaDH Mara Oflln IJ\Ihale grain and enriched grain pnllilcts Dark green vegetables, arange vegetables and fruit Lowur-fat dairy producl8
Lean meat. poulby, fish, peas, beans, lentils
Cardiovascular Disease Prevention

ltl
lllndy Serving liD Com111rilona 3 oz msat, fish, -+ plllm of hand 1 dairy {rnilr/vovLrl) -+ sim of fill: BreaQ/grains -+ one slice, pam of hand cup rice/pasta -+ one hand cupped 1 of fruit/VIpbbl -+ two cupped hands 1 oz ch8818 -+ fullength of thumb 1 tsp ollbutter -+ tip of thumb Nul.tchiprlsnacb -+ plllm covered
Tabla 4. Dietary Guidalinas for Reducing Risk of Cardiovascular Disaau in Ganaral Population Food him ht Rllcamm.ndlllions Saturated fat <7% of energy Trans fat < 1% Dlenerw Cholesterol <300 mgtd servingf/wk Dl fish {esp. oily fish like salmon) <6QI'd {100 nmol or 2.3QI'd of &odium) drinlw'd lor men drink'd for women
Fat iniBkll <30% Dl total enelliY
Etfac:ts Lower LDL
Omaga-3 fitly acid ric:hfaoda Salt Alcohol
l.owerTG
Decreased: sudden death, death from CAD
....
,,
Lower BP Excess alcohol increases risk Dl hyperbiglyceridemia, HTN
Refamce&: Cftda's Food Gtide 111//ealthy 1.ii:t11el1Ril AH. et ai.IZ0061. Di IIIII t.fe#e Circulation. 114: 82-96.
Healh Canada. Last updend 2007. rMion 2!0: Asdenlific stllernenl ham the American Heart Associllion l-lltrition Committee.
Energy Content If Food Carbohydmn 4 kcaVg Protein 4 kcaVg

Fat9 kcaVg Elhanal7 kca(lg
Tabla 5. Introduction to Yrtamins and Minerals V"damii/Mineral

Faille {vi II,)
Dietary Source
Signs of Deliciencr
Signs of TDIIicity
Macrocytic anemia, dilllhea, Green leafy vegatables, 0111an msat&, dried yua&t,. dried beans, gla5$itii, lethq, 51Dmirtiti& legumes. citrus, fortified grains
None known from foods; seizunl& None known from foods Osmatic dian11ea, N/'1. oxalate kilhly stones, irrlaference with anticoagulation 1herapy
Calcullllq Total Daily Energy Expendibi'ITDEE)

activity Iawl
Roughly 35 kciiVklJfdll'( Varies by age, weight. sex. and AV811Q8 200021 oo kcaVd for
Cyanacabllamin (vit B ) Meats, organ meats, beef, pork. Megaloblastic anemia, glossitis, 12 leukopenia, weakness, periphenll mik. cheese, fish nauropalhy (asp. foDI drop) Citrus fruits, tomatoes, patatoes, Scurvy, keratosis Dl hair follicles, Alcolbic acid (vit C) red berries, peppers impaired wound healing. anemia, deprassion, lethalliV, bleeding V"damil A Fish liver oils, egg yolk. dairy Dennatitis, niglrt blindnass, products, g18811leafy or orangw ksratamalacia, xaroplrthalmia yellow vegetables and fruit Fish, fish liver oils, fortified milk. Osteomalacia, muscle weakness egg yolk. sunliglrt bone pain, hypor,ilosphatemia. hypocalcemia Pdylnaturetad vegatable ails,
11.1ts, eggs, wheat genn. whale
women. 2700-2900 kcaVd for man
.._,,
,l------------------,
NIV. headache, dizziness, deep bone pain, peeling skin. alopecia. hepatDtDxicity
Excess bone and soft tissue
CIIMIIiu C.ncer Solliely {CCS) IR8111m811UtiDna fur Vitamin DUM Based an CCS rasnrch on Vrlllmin Dllld the prevention of colorectal, breast and prosta11 cancw. In consullidioo with their healthcare provider, the Society is racommenmg that Adult$ living in Canada should considartalcing V"rtamin D supplemerrllltion of 1,000 inllmllional units {IU) a day during the fall and winter. Adult$ at higher risk of hiVing lower V"rtllmin Dlevel& should
1111 year round. This includes
V"lllmil D
V"damil E
calcification, kidney stones, hypercalcemia, anoraxia, renal taiba Rare hemal'flis, anemia. neuronal Prolonged dotting time, IIXDnoputhy, myopathy impaired neutrophil function Bleeding. purpura, bruising. prolonged clotting time Tetany, an11ythmias, congestive heart failure, altEred nerve conduction, osteomalacia Jaundice Metastatic calcification, weakness, renal faiure, psycha&i&
grains V"amiiK
Calcillll
Green leafy vegetables, liver, vegetable oils, intestinal flora Dairy prowcb, dark. green and leafy vegetables, fortified say, fortified orange juice
considertalcing V"rtllmin D supplementation of 1,000 IU/day
paopla: who are older, with dar11. skin. who don"t go outside often. llld who Wllf clothing that covers most of their skin.
Toronto Notes 2011
Health Promotion and CoUDBe11ing
Family Medicine FMS
Tabla 5. Introduction to V"damins and Minerals (continued)

uf Toxicity
Magnllium
Soy, chrns, wheat genn,

almonds, dairy products, gram leaves, nuts, cereal grains, Sllll!ood
Weakness, convulsions, neuromuscular irritability and dysfunction, failure to llrive

Polyuria, impaired mJscle
HypotEnsion. cardiac
disturbances, respiratory failure
Meat. mil, bananas, prunes, raisins, orange, grapafruit.

potlltoes, legumes
Mental confusion, hypotension, weakness, ECG changes (prolonged ar intervaL prominent (flattened P-waves, peaked U-wavesl, peritoneal distention, T-wavesl, pnysis, cardiac dyspnea, pnlysis, cardiac cisturbances contraction, ECG clalges
disturbii1C8&
Meat. fish. poultry, org!ll meat&, Glossitis, fatigue, tachycardia, Nutritional hBITio&idurosis, 11'1111 eggs, prunes, peas, be111s, lentils, microcytic hypochromic anemia. organ diiTIBge soy, raisins, fortified grain koilonyc:hies, enteropathy prolllcts Adllpt8d from MOiby's Fnly l'nlctice Sourcebook: to c 4th 8lition. edited by lk rhael Evans IPP. 343-3451. ... c 2006 BIMr Cllllda, 1 dvisiali Reed EIIIVier Canlle, Ltd. AI riglds 1'8Sl1Wd.llepridad by pennission of Elswil' Canada, 2009.
Table 6. Macronutrient Distribution Ranges

Age IJaanJ
Protein
1to3 4to 18
19and older
Mlcranutriant 11 'l'o uf Daily Cllarial Fat Carbehydrm

30-40 25-35 2035 45-65 45-65 4565
5-20 10-30 1035
Obesity
body mass index (BMI) = weight (kg)/height (m)Z = weight (lbs)/height (inch)Z x 703 waist circumference (WC) should be measured in all adults to assess obesity-related health risks spedfic cutoff points exist for different ethnic backgrounds (as recommended by the 2006 Canadian Clinical Practice Guidelines on obesity) measurement of waist-hip ratio has no advantage over waist circumference alone
Table 7. Classification of Weight by BMI, Waist Circumference, and Associated Disease Risks in Adults
BMI (k;fml)
U1d.weigllt Obity
\,,
Burning filt 3500 kcll of anargy n produced fur every pound of human fat burned during activity.
it'' Weiabt Lotina
CIIA
Men .s.1OZ em (40 in) WunJen .S,88 cm (35 il)
Men >102 em (40 ill Wum1111 >88 Cll (35 in)
<18.5 18.524.9 25.fl.29.9 30.fl.34.9 35.fl.39.9 40.0+

Increased
High Very High High Very High Very High Extremely High
Results in 12 lb (D.>1 kg) weight
Ai'n for caloric inllka 500-1 000 kcaVd less thiln total daly ene!IJY expendibre (IDEE)
Nannll
Ovurweigllt Obllily Extreme Obesity
loss par W118k Achiwld by combination of incnasld activity ancllor decreased caloric intake
.....
Ill
Exlranely High
Ffom: Cllssilicltian al OvarlwigN IIIII Dbasity by Weist CirMhrance, Md A&soi:iltlld lileul Risks, Nltionalll'lllilull Hadll, NltiOilll Hlllft Llllg and Bbod lllltilule, (l)asity E4Jcalilrllnitiltiw, http1Mw.v.nhlbi.nih.!PI/llllltl\lidllirJheartfobesitWloM_ wtlllri_dis.lrlm
Low BMI i Auoc:il.ted with: Ost.oporosis Eating di&Oider&
Under-nubition
Pregnancy complicali-
Epidemiology 16% (4 million) of people years old are obese, 32% (8 million) are overweight in Canada, according to StatsCan (2007) obesity rate in people of aboriginal origin is 1.6 times higher than the national average proportion of children aged 6-11 who are overweight has more than doubled in the last 25 years; percentage of overweight adolescents has tripled overweight and obesity rates in children are directly proportional to screen time (see Exercise, FM7) only 10-15% of population consume <30% fat daily obese persons generally consume more energy-dense food which tends to be highly processed, micronutrient poor, and high in fats, sugars, or starch
.....
,
Dyslipidamia
Osteoartmtis
Alive,. Mlllicll CoMequenca of

Ollaity TYPIZDM CAD
S1rok8 HTN
Sleep lplllll Certain cancers

CHF Low back pain lnCI'8HIId total mortality
Gallbladder dis Non-alcoholic
rtaatohepatitis Complications of
pr.gnancy
FM6 Family Medicine

. . . ..... : rltM Mill,.,...., Wlqlt w.tdlln.IIIIZtnl.lll 1.- W.ijd 1811 _. llellt Da.lllk lllddlion JW.4 m; 29311):43-53
Toronto Notes 2011
OVIrweight or ollllse lduH Meesure BMI Measure waist circumference if BMI is > 25 and s35 kQfm'
l'lrpale: To .... ttw llllc:tiwnmllld ldllerenc:e ll1ls allu piJjllllr Uti larweiglt loss IIIII raU:Iicirlll C."lldiiC rilklidn.
If BMI > 25 kGfm' or waist circumference is lbcve cutoff point
ICidlri:ll'llldic:al Cfii1W il Bostun. MA; , llO pirticipltds- rllldomilld tD Aikins (cllbGIIydrlll rwh:lila),l.n blllncld 111d 1owglojamic lold), W.ightWR:hlll l1ow cdlrie/PIIIion lile), or Onish lilt reslriclila)
illl
Conduct dinicel and llbonrtory investigations 1D a111111 comortlidities {Blood pressure, hellt rate, fasting glucose, lipid profile [!Dill cholesterol, triglycerides, LDL and Hill choiiSIIrol. and ratio of tolll cholesterol to HilL cholesterol )I Anen and screen for deprenion, eating and mood disorders
Important m11uge A modest weight loss of 5-1 0'1. of body waigllt is benrrficill Weiglrt maintenance and prevention of weight regain should be considered as long-tenm goals Devise goals and lifestyle modification program for weight loss and reduction of risk factors Weight loss goal: 5-1 0'11. of body weight. or 0.5-1 kQ (1-2 lb) par weak for 6 months
Heelth 111m to advise lifestyle modification program

modmc.ti.. program Nutrition: Reduce energy intake by 5001 000 kcaVday Phytical activity: initially 30 minutes of modarall inllnsity 3-5 limer/Wk; eventually >60 minutes on most days. Add endurance exercise lnlining. {Medical evakllltion is advised before sllrting activity progrem) Cognitive behaviour thrnpy
Pri:ipl* Adulls 221D 72 v-l'litll known KIN. dfllipidernil. or l?jpergljcemiL Asanrilg lhlll puqw wllo discanliurd 111&1t!Jdy lll1l'lllilad It blllllirw, lila m Wlight ball 1 111111111 .. IIIICIId dielllyadlleranca ra111 per tafraportj ware 2.1 kg far AlldDS (53\alpirticipns P=0.0091, 3.2 kg lar the Z.(65% of !*lic\llnls CDU"j1llllld. P=O.OOZ), 3.0 kgfarw.ijaWelchlll 1Mcompleted, P<0.001l3.3 kg for Omisll jmcomplalad, P=O.OOJI. Elch dial !iPCirdtf recM:ed1be Ulftllhtio by-10'J.(P<O.D5l
Treat comortlidities and ather haalth risks pnasent Assess reediness to change behaviours and bruriers to weight loss
Mil ldl'n1ciiMI(r = 0.60; P<.001) but not Mil = om; P = o WIQit 1r111 AO). far elldllkt wasligniliclndy assoc:iderl v.1tll ra!Ub in IMis (r=D.36), C-radw pralaillr=OJ7L IIIII inluln {r=0.3t), Mil no between diets. C.. . Elch populltdiatWIS IIUQCQI wilb modlltwa9d loss IIIII lllllction rl-.1 ciRfilc rilkflctln. Arlllllnc:IIMI, IIIII not dial type. was tha l1lOII impol1lm pr8li:tor rl Might loss llld iDIII: risk faciDr reducb.
gLicaiL Amount. wiQit -
-aocilllrl
r-
Satisfllctory progress or goal achieved? Yes! lllgua.r monitoring Assist with weight maintenance Reinlorca haalthy ellting and physical activity advice No No
J J+-
Weight 111intan111Ct1 nd prawntiiMI of -ight regain Nutrition therapy Physical activity Cognitive-behaviour therapy
Phlrmaclllherapy BMI ;?.27 kQfm' + risk factors or BMI <!:30 lqr'm'

Adjunct to lifestyle modificllions: consider if plltient has nat lost 0.5-1 kQ {1-21bl per week by 3-6 month& alllr lifestyla changas
Bariatric surgery BMI <?:35 kgfm' + risk factors or BMI ;?.40 kgfm' Consider if ather weight loss attempts have failed. Requires lifelong medical monitomq
.....
',
AddT811S other risk fllclors: periodic

monitoring of weight. BMiand waist circumference avary 1-2 years
Hypedipldemill Sig111 1. Alheromalll- plaques in blood vessel walls 2. Xanthoma -plaques or nodules comprned of lipid-laden tu.lioc;ytes in tha skin [ssp. the ll'f8lids) 3. Tandinous Xllnthoma -lipid daposit in lindon [esp. Adlilles) 4. Comlal arcus (arcussanilis)-lipid deposit in cornea
Figure 2. ZOO& Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Childran (summary)
Adlpild fnlm CMAJ 2001; 176:S1-S13.
Dyslipidemia
see Endocrinology. E2 defined as abnormal elevation of plasma cholesterol or triglyceride levels increased risk associated with obesity, DM, alcohol use
LDL cannot ba calculated when TG <!:4.5 mmoVL.
.....
',
factors:
ainicl o.liniti.. of lhtabofic Syndrome Central obesity M.n- waist citurnt.wlc <!:94 em Women-Mist cin:wnference <?:80 em i*Js any TWO of the following four
lilt Fadlr
TGIMI
HIX..(Ievel: Men Woman
<1.0 mrrd'L {40 rnw'cl..l <1 .3 mrrd'L (50 rnw'dl.l Blood ,_,. <?:131m mmHg Fasting glucose level <?:5.6 (100
Assessment measure fasting serum TC, LDL-C, HDL-C, and TG screen with full fasting lipid profile in males over age 40, females over age 50 or who are menopausal, or any adults with additional CAD risk factors ql-3yrs assess for presence of other CAD risk factors screen for secondary causes: hypothyroidism, chronic kidney disease, DM, nephrotic syndrome, liver disease risk category estimate using the model for 10-year CAD risk developed from the Framingham data primary target of therapy is LDL-C levels; the alternate primary target is ApoB optional secondary targets once LDL-C/apoB is at target include apoB:apoAI ratio, TC:HDL-C ratio, hs-CRP, non-HDL-C and serum TG levels emerging risk factors (from Framingham group) lipoprotein a metabolic syndrome genetic risk hormone replacement therapy infectious agents
Toronto Notes 2011
Family Medicine FM7
Table 8. Target Upid Values for Primary Prevention of CAD in mmoVL (mg/dL)
Risk Cltlgary
llodlllfurc.atilllhiiO,.ulliltofCADil
lnililll Tl'lllment if:

LDirC
Primry TII'IJIIs
Allllmlltl
Elillll c.di_..Dileala', u.q

Fnni. . DIIll
High (10-yr risk Df CAD or history Df DM or any a1herosclerotic diseaseI Moderate (10-yrrisk 1119%1
Consider tnllllmant in all patients

LDL-C >3.5 mmon TC'HDL-C >5.0
<2 mmoUL or decrease in LDL-C <2 mmoi/L or decrease in LllL-C
apoB <0.80 g/L
STEP 1: DEIErt: RISK PURTS

llill<l'lilll llilkl'liil llilkhctlr ... .... lliii<Ftdlr ........ AI&"flU
apoB <0.80 giL
l!HI
Hs-CRP >2 miJil
411-41
Men >50yetn \Nomen > 60 years
Low (10-yr risk s10%1
LDL-C
mmoVL
decrease in LllLC
1"1111---...., a a
<4.14
-3
1
511i4
"' 5!>51 a -4 1a658 23 J0.14 3 I
6.22-7.24
2725
5.1H.Z1
illllaanCII: J Gllnast. RMcl'barlon, J Frohlicli, at 11. 2009 Canldian Cardiovescular Sociaty/Canldian Qlidalinas fur1ha diagnosis and 1RIItmBnt of IIM11Iion cl cardiMICulll disaase in the aduk-2009 Cll! JCllllfo/ 2009; 25l101:567579.
<0.!0 0.91-1.11 <12D 12012'1
llll..l:lanl. ...
2 1
131-Ul
S!ldi:lllld _
1.171.21
Management
intensity and type of treatment is guided by "risk category" assigned 1. health behaviours (can decrease LDL-C by up to 10%) smoking cessation - probably the most important for preventing CAD dietary modification - reduce saturated fats, refined sugars, alcoho4 increase fruits, vegetables and fibres physical activity - 30-60 min of moderate to vigorous activity on most days employ consistent lifestyle modifications for at least 3 months before considering drug therapy; high risk patient should start treatment immediately with concurrent health behaviour interventions 2. phannacologic therapy (can decrease LDL-C by up to 40%) for a comparison of dyslipidemia medications, see Endocrinology. ES statins (HMG-CoA reductase inhibitors) currently recommended as 1111 line monotherapy following unsuccessful lifestyle modifications risks: myopathy and hepatotoxicity - must follow LFTs every 6 months other agents: bile acid sequestrants, nicotinic acid, fibrates, psyllium, cholesterol absorption inhibitors (e.g. ezetimibe) after initiating drug therapy fasting lipids should be measured after 6 weeks, and at 3 months if adequate response is achieved, evaluate fasting lipids q4-6months monitor ALT, AST, CK at baseline then 6 weeks later for signs of transaminitis or myositis; tolerate rise in CK within 10 times upper limit ofnormal. or creatinine of repeat ALT, AST and CK with lipid bloodwork isolated hypertriglyceridemia normal HDL-C and TC, elevated TG mild mmol/L mg/dL); marked mmol/L mg/dL) principal therapy is lifestyle modifications weight loss, exercise, avoidance of smoking and alcohol, effective blood glucose control in diabetics, increased omega-3 fatty acid intake drug therapy nicotinic acid fi.brates
.....
,.,.
D 1
......... -3 146-15!1
D I 2110
0 2
-3
Yes
IJEP J: CALCUlATE IISI' 0

TIIIIIIM 10-ywllk'l Tllllllllill< 10-ywlillr.%
--3 4
10 13
7 8
l'lil1l 10 11 12
13 14
15 11
......... l!i 10 31 11 l1 13
46
15
18 2D 24
11
211
17
>Z1
If 1110-W llllb:llu
lhgSI{ety 2000; 23(3);117-213 S1udy: IIMw ...,...: I. Thn isnoftidlnceiDQI)Illllhet llllin 1llatlpy leldllll inCRIUid incideoce cl Cllllllctlannltian. 2. Slltin ll1e!lpy does 111111ead 1D slltisticdy siglificant diitiJIIIIIIC:e in aep or cagran compnd fa pllceba. 3. The ilcidence af hlpiiDIDiicity and liMIId dlpandl on llldin dost. .. d 5blils IIVtimi!. in thei". af ivertclcic4 4. S1llils mellbolizal CYP3A4 lowtlltin, tirMSildil, aiDMIIItin. cftutatin) ..., nm likaff fa red in ilepiiDIIIcicit or dllbilllmjolysil ifUl8d in COIIDnltion CYP3A4 drug (e.Q. kulllc:anlmlu.ljllllllfrut 11Vf!IQIIil).
Exercise
Epidemiology
25% of population exercises regularly, 50% occasionally, 25% sedentary screen time (time spent watching TV/movies, playing video games, or using the computer) has been increasing steadily in the last several years, while time spent being physically active has been decreasing excessive screen time can lead to obesity, encourage violent and antisocial behaviours, and foster attention deficit difficulties current recommendation from international pediatric societies is that children (>2 years old) should limit their screen time to less than 2 hours/day
l'lllnll 11111111 dlifiil-,_.. JAAM 2004; 212(21 ):2585-25110
--.arl..,............,.ilil
l'lllnll: 2524Sl pDa ll'lltld with ipid-
Sludr:llelrolpectMI cohort n..d.
lllil Dllanle: Rllbdomyuft!is bolpilllimliarL 11116: 11252460 patianD. 24 Cllll al halpilalimliln acCIIIIII. Incidence Illes per 10000 95\ Cl
Allmllldii 0.5410.221.1Z)
kr.wrirG lglllll.
Ceriva111in PrMs111in 0 IG-1.11) Sii!NIIIItin 0.49 (0.06-1.76)
Ftnofibrat&O IG-14.51)
lncidanca clltilbdomyolylis inc181sad 10 5.111 (95\Cl, 0.72-216.0) plVIIII1il Of sinMIIII!in- US8d with a1htt, and up ID 1035
Gal11fimlljJ.70(0.76-111.82)
witlallillle.
(M Cl, 389-2117) i carivulatii was CGI!Dilld
FM8 Family Medicine
Toronto Notes 2011
Use with caution when prescribilg combined stalin and fibnltelhenpy IS tfun hill bun 111C8nt CDnCIII!II regarding 1he llfBty Ill certain combination&.
Management assess current level of fitness, motivation and access to exercise encourage warm up and cool down periods to allow transition between rest and activity and to avoid injuries exercise with caution for patients with CAD, diabetes (risk ofhypoglycemia), exercise-induced asthma balanced exercise program incorporating all types of exercise 1. aerobic (endurance) exercise for 15-60 min, 4-7 times/wk improves cardiac function, lowers BP, increases HDL, increases insulin sensitivity target HR: 60-80% of maximum HR maximum HR=220-age 2. weight-bearing (isometric) exercise 10-20 min, 2-4 times/wk builds muscle strength, improves bone density, improves posture 3. stretching routine 10-12 min, 4-7 times/wk prevents cramps, stiffness, injuries, back problems other benefits of exercise improves feeling ofwell-being, libido, quality of sleep, self-esteem decreases depression and anxiety weight control
Smoking Cessation
--------------------------------------
.... .......e..n. C<me Bllllllse Rel'lilws ZUlli; 1lil spllmllic llilw af 11 trig camp1111d brill ldW:e by 'die pbysic:ilnvei1US na ...........D:SimplelllvicaCIII Illes by I to 3\ Molt inl!llshle liNea snd pnHilh;j llll\'ful1illr iiCII!IIe tile quk Illes.
-2
Epidemiology smoking is the single most preventable cause of premature illness and death 70% of smokers see a physician each year 2008 Canadian data from the Canadian Tobacco Use Monitoring Survey (CTUMS) on population age 15 or older 18% are current smokers (lowest since 1965) highest prevalence in age group 20-24 {28%) 15% ofyouth aged 15-19 smoke (decreased from 25% in 2000): more males smoke than females (18% vs. 13%; 23% vs. 27% in 2000), cigarettes consumed per day also decreasing in 2006, smoking rate decreased significantly among youth aged 15-19, from 18% down to 15% Management general approach identify tobacco users, elicit smoking habits, previous quit attempts and results every smoker should be offered treatment make patient aware ofwithdrawal symptoms low mood. insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite counselling sessions > 10 min each with 6-12 month follow-up yield better results 14% abstinent with counsellingvs. 10% without counselling (OR 1.55) approach depends on patient's stage of change {see Motivational Strategies for Behavioural Change, FM3) willing to quit follow the 5 As (see sidebar) provision of social support, community resources pregnant patients: advise to quit first without pharmacotherapy; use pharmacotherapy only if benefits >risks; consult Motherisk Nicotine Replacement Therapy (NRT) 19.7% abstinent at 12 months with NRT vs. 11.5% for placebo {OR 1.66) no difference in achieving abstinence for different forms ofNRT reduces cravings and withdrawal symptoms without other harmful substances that are contained in cigarettes use with caution: immediate post-Ml, serious/worsening angina, serious arrhythmia Bupropion SR (Zyban) 21% abstinent at 12 months vs. 8% for placebo {OR 2.73) Varenicline {Champa-) partial nicotinic receptor agonist (to reduce cravings) and partial competitive nicotinic receptor antagonist (to reduce the response to smoked nicotine) more effective than bupropion
111 S AI for Plltianls Wl&q to Quit

patient smobs
Advise patient to quit Assess wiDingness ID quit Asllist in quit lllt8mpt Arnnge follow-lip
Aui.t Patilnl in Developmg Duit l'llln
STAR
Set quit date TID family and frilllds {for support) Anticipate challenges {e.g. willldlliWIII) lamoveiDblcco products {e.g.
Toronto Notes 2011

Table 9. Types of Nicotine Replacement Therapy
Family Medicine FM9
Type
Niclllina Gum IOTC)
Daslge 2mg if <25 cigfd 4mg if >25 cigfd 1piece q1-2h for 1-3 mos (max. 24 piecetld)
Use for 8weeks 21 mgldx4weeks 14 mg/d x 2 weeks 7mg/d x 2weeks
Camment Chew until taste then "park" between gum and cheek to facilitate absorption Continue to chew-park inll!rmittently for30 mil
Stllrt
Side Eflects
Mouth stra1ess
Hiccups Dyspepsia Jaw ache Most SFs are1ransient Skin irritation nomnia Palpitations
Codnnellllflbllsed_.RMws 2008; IIU1 This s,stlmltic fiViM rl132lltldani!ld 1rilll MIT111 piiCIIbo or n 1Jullmart or o dillarantlfiT d-.
e-n.
lillalill ........ lBiprfar Sniali"
Nicutina Patch [OTC)
lower dose if < 10 cigfd Change patch q24h and albmate sides
llllilwln' Cllllibml: AI c:o11111111dlti Millbll fum rllfiT (gum. trndlnnll pn:ll, 1'DIIIJIIIIY, im*rllllsubqulllllbi!Q'
krzangBIII118 aflwctMt 1111 pill ci111r11BQy bl promote smoking ceslllion. Theyiacaue1he llbl cl quilling lrf 50 111 raQIIdlew oheUing IIIII indlplndlnt 111 tt.IMI allddilioniiiUppart pravided 111 hlrnolrlir. C..lllll 11111ingll bm al NRT, combining I nicolila IIIIth witli I liPid delwly loan of NRT lillY be mm effective.
AnxiBty
Nicllline inhaled through mouth, absorbed in mouth and throat but not in lungs Not Milable in Canada
Niclllina lnhiiIOTC)
6-16 cartridgSIOI'day
for up to 12 weeks
Local irritation Coughing
Nicutine Naill Sp11y !Rxl
Tabla 1D. Bupropion as Treatment for Smoking Casution Clllllnlindicatian Inhibits re-uptake of 1. 150 mg qAM x 3 days 1. Decide on a quit date dopamile ancllor 2. Then 150 mg bidx 7-12 wks 2. Continue to smoke for first 1-2 wks Ill norepinephrine 3. For maintenance consider treabnent and then completely stop **Side alhlcts: insomnia, 150 mg bid lor up to (therapeutic lewis 11111ched in 1wk) dry mouth 6 months Seizure disorder Eating disorder MAOI use in past 14 days Simulllrleous use ol bupropion !Wallbutrin41 ) for depression
'lOO'l; IIU1 This systandc review rl&& 11ndolriled 1rilll llllidrlpre-' mediclliln1o pllcebo llf lbmltiw ph11111ICOII!apy lol11110king Cllllli111 IIIII wll11111 fvlaw-up -111m &ll1llllhl.
Ad....... far Smali" Cllluliln
llllilwln' Cllllibml:
-mn1111 biVIalimimllliclcybl f.IIT.
Tabla 1I. Varaniclina 11 Treatment for Smoking Cessation
Colnpl!1d 111 Yftllicline 1huwed higher 11181. SilactMI-ain . . . inhibm
Mechanilm
Daslge
Prescribing
Clllllnlindicatian
(e.g. illllllinel GrveDIIildne lid not hM I lignificlnt 8ll1ct
Partial nicotinic receptor 1. 0.5mg qAMx3 days agonist, llld partial 2. Then 0.5 mg bid x 4 days competitive antagonist 3. Continue 1mg BID x 12 nicotinic receptor weeks plus additional **Side effects: nausea, 12 weeks as maintenance vomiting, constipation, headache, dream disorder, insomnia. increased risk Ill psychosis
Mry be used in cariinlltion with nicotine replarnenttlunpy
Begin 1reatment 1week before quit date, Caution with pr&-existing then stop smokilg as planned psychiabic
....
1IHI 2-3 httwlrn !If SmDidng CNIIon Onset of withdnrwal is 2-3 hours after last cigarette twk withdnrwal is at 2-3 days Expect improvement of ayrnplllms at 2-3 waekl Resolution of withd111W1IIt 2-3 months Highest rellpte 111111 willli'1 2-3 months
unwilling to quit motivational intervention (5 Rs) (see sidebar): 1. Risks of smoking short-term: SOB, asthma exacerbation, impotence, infertility, pregnancy complications, heartburn, URTI long-term: MI, stroke, COPD,lung CA, other cancers environmental: higher risk in spouse/children for lung CA, SIDS, asthma, respiratory infections 2. Rewards: benefits improved health, save money, food tastes better, good example to children 3. Road blocks: obstacles fear of withdrawal, weight gain, failure, lack of support 4. Repetition reassure unsuccessful patients that most people try many times before successfully quitting (average number of attempts before success is 7} recent quitter highest relapse rate within 3 months of quitting minimal practice: congratulate on success, encourage ongoing abstinence, review benefits,
problems
1111 5 Rs for l'ltients Unwilling tD Quit Relewnce to patient {tlelllth concerns,

family/locialsitullli0111)
Risks
Rewatds of quitting
ROidblocks to quitting Rapstilion of motivlllional inlllrvanlion

at IIICh
prescriptive interventions: address problems ofweight gain, negative mood, withdrawal. lack of support
FM10 Family Medicine

Allltinence
Toronto Notes 2011
Law Riek Drinking <2 drinkr/day
< 9 drilktlwk for women < 14 drinkf/wk for men

At llilk Drinking Consumption above low-risk laval but no alcohol-nlllllld phyJical or social problems AlcehoiAb Physical or social problems Contiluad usa daspite consequancas Inability to fulfill life roles Legal problems, no avidence of dependence Alcohol DllpendBnce
Figura 3. Continuum of Alcohol Usa
Alcohol
see Psychiatry. PS20 Definition diagnostic categories occur along a continuum (see Figure 3) Epidemiology 10-15% of patients in family practice are problem drinkers 20-50% of hospital admissions, 10% of premature deaths, 30% of suicides, and 50% of fatal traffic accidents in Canada are alcohol-related more likely to miss diagnosis in women, elderly, patients with high socioeconomic status Assessment screen for alcohol dependence with CAGE questionnaire (see sidebar) if CAGE positive, explore with further questions for alcohol abuse assess drinking profile setting, time, place, occasion, with whom impact on: family, work. social quantity-frequency history how many drinks per day? how many days per week? maximum number of drinks on any one day in the past month? if identified positive for alcohol problem screen for other drug use identify medical/psychiatric complications ask about drinking and driving ask about past recovery attempts and current readiness for change Investigations GGT and MCV for baseline and follow-up monitoring AST, ALT (usually AST:ALT approaches 2:1 in an alcoholic) CBC {anemia, thrombocytopenia), INR (decreased clotting factors production by liver) Management intervention should be consistent with patient's motivation for change regular follow-up is crucial 10% of patients in alcohol withdrawal will have seizures or delirium tremens Alcoholics Anonymous/12-step program outpatient/day programs for those with chronic, resistant problems family treatment {Al-Anon. Alateen, screen for spouse/child abuse) in-patient program if dangerous or highly unstable home environment severe medical/psychiatric problem addiction to drug that may require in-patient detoxification refractory to other treatment programs pharmacologic diazepam for withdrawal disulfiram (Antabuse): impairs metabolism of alcohol by blocking conversion of acetaldehyde to acetic acid, leading to flushing, headache, nausea/vomiting, hypotension if alcohol is ingested naltrexone: competitive opioid antagonist that reduces cravings and pleasurable effects of drinking may trigger withdrawal in opioid-dependent patients Prognosis relapse is common and should not be viewed as failure monitor regularly for signs of relapse 25-30% of abusers exhibit spontaneous improvement over 1 year 60-70% of individuals with jobs and families have an improved quality of life 1 year post-treatment
.....
', ..
Standrlrd Drink Equinltm One standn drink = 14 g of pure alcohol Beer (5'J. alcohol) = 12 oz
Wine (12-17% alcohDI) = 5 oz Fortified wine = 3 oz Hard liquor [80 proof) = 1.5 oz
C HIIV8 you avarfelt the nead to CUT dawn on your drinking? A HIIV8 you aver fall ANN DYED at critici&m of your drinking? G HIIV8 you IYir flit GUILTY about your drinking? E HIIV8 you aver had a drink first thing i1 the morning to Sllllldy your nerves or get rid of a hangover? [EYE OPENER) :<!2 for man or :<!1 for women tUUQ8SIS possibility of problem drinking [sensitivity 85'J., specificity 89'J.)
CAGE Qulllionnah
.....
', .Jr-----------------,
Alcohol Metallolized pw Haur Alcohol metabolism is constant [zero

order kinetics) rvgardless of blood alcohol laval [BAL) Avaraga metabolism rangas betwnn 13-25 m!VdL blood/hour or 100-200 mg,t!Vhaur Equivalent to metabolizing 0.5-1 sllndanl drink per hour or BAL deCIIllse of 0.01% par hour Metabolism mara rapid in chronic alcoholics
.....
', .}------------------,
c--..ncee
Some Adftrel Medical of Prablllll Drinkinl Gl: gastritis, dyspepsia. pencraatitis, li-diaiiOSII, bleed&, diarrhea, oral/ esophageal cancer Cardiac: hypartsnsian, alcoholic cardiomyopethy Naurolagic: Wamicka-Klnakoll syndrome, peripharal nauropethy Hematologic: anemia, coaglJapathies Other: trauma. insomnia, flmily
violence, anxiety/depression, dysfunction, sexual dysfunction, fatal damage
Toronto Notes 2011
Fam.lly Medicine FMll

Abdominal Pain
see Gastroenterology, G2 and GS4
Epidemiology
20% ofindividuals have experienced abdominal pain within the last 6-12 months 90% resolve in 2-3 weeks only 10% are referred to specialists, <10% admitted to hospital
Etiology
most common diagnosis is "nonspecific abdominal pain," which has no identiii.able cause and is usually self-limited GI disorders (e.g. PUD, pancreatitis, IBD, appendicitis, gastroenteritis, ms, diverticular disease, biliary tract disease) urinary tract disorders (e.g. UTI, renal calculi) gynecological disorders (e.g. PID, ectopic pregnancy, endometriosis) cardiovascular disorders (e.g. CAD, AAA, ischemic bowel) other: toxic ingestion, foreign body, psychogenic
Pathophysiology
type of pain somatic pain - sharp, localized pain visceral pain - dull, generalized pain location of pain epigastric (foregut) - distal esophagus, stomach, proximal duodenum, biliary tree, pancreas, liver periumbilical (midgut) - distal duodenum to proximal2/3 of transverse colon hypogastric (hindgut) - distall/3 oftransverse colon to rectosigmoid region
In plllient >50 yen Did, keep a high indax of &U&pic:ion for AAA - ib
pmentltion may mimic renal colic or diverticulili-
Investigations guided by findings on history and physical

possible bloodwork: CBC, electrolytes, BUN, Cr, amylase, lipase, AST, ALT, ALP, bilirubin, glucose, INR/PTT, tox screen, beta-hCG imaging abdominal x-ray (gas pattern, free air) ultrasound (gallbladder disease, gynecological problems) CT scan (AAA, appendicitis) other tests urinalysis endoscopy (for peptic ulcers, gastritis, tumours, etc.) H. pylori testing (urea breath test, serology)
rt,
II pain precedes nause.tvomiting. cause
of abdominal pain is more likaly to ba surgical.
Allergic Rhinitis
see Otolat:ynjWlou. OT23
Definition
inflammation of the nasal mucosa that is triggered by an allergic reaction classification: seasonal symptoms during a specific time of the year common allergens: trees, grass and weed pollens, airborne moulds perennial symptoms throughout the year with variation in severity common allergens: dust mites, animal dander, moulds
Etiology
increased IgE levels to certain allergens -+ excessive degranulation of mast cells -+ release of inflammatory mediators (e.g. histamine) and cytokines-+ local inflammatory reaction
Toronto Notes 2011
Difr.rtnlilll Dillgnollis
Acum vinll rn.ction Vasomotor rflinitis Deviated septum N1581 polyps Acum/chnmic sinusitis Drug-i11luced rhinitis
Epidemiology affects approximately 40% of children and 20-30% of adults prevalence has increased in developed countries, particularly in the past two decades associated with asthma, sinusitis, and otitis media Assessment identify allergens take an environmental/occupational history ask about related conditions (e.g. atopic dermatitis, asthma, sinusitis, and family history) Management conservative minimize exposure to allergens most important aspect of management, often sufficient (may take months) maintain hygiene, saline nasal rinses pharmacologic agents oral antihistamines - fust line therapy for mild symptoms e.g. cetirizine (Reactine), fex.ofenadine (Allegra),loratadine (Claritin) intranasal corticosteroids for moderate/severe or persistent symptoms (> 1 month of consistent use to see results) intranasal decongestants (use must be limited to <5 days to avoid rhinitis medicamentosa) allergy skin testing for patients with chronic rhinitis symptoms not controlled by allergen avoidance, pharmacological therapy may identify allergens to include in immunotherapy treatment immunotherapy (allergy shots) reserved for severe cases unresponsive to pharmacologic agents consists of periodic (usually weekly) subcutaneous injections of custom prepared solutions of one or more antigens to which the patient is allergic
Pregnancy
r-t,
lllliniliiiMdicamllntDN - Rebound
11811111 cangellion. Occurs with prolonged use !>57 days} of vQOCOII$Irictive medications. Patient may btcome requirinv mar. frequent dosing 111 achieve the same dlconuestant lfflct.
Amenorrhea
see Gynecology. G12 Definition and Etiology classified as primary or secondary primary absence of menstruation by age 14 in women without secondary sexual characteristics, or absence of menstruation by age 16 in women with secondary sexual characteristics causes: Turner's syndrome, constitutional delay of growth and puberty, Kallmann syndrome, androgen insensitivity syndrome, Mullerian agenesis, imperforate hymen, transverse vaginal septum, also include differential of secondary amenorrhea secondary absence of menstruation for 3 months in women with previously normal menstruation, or absence of menstruation for 9 months in women with previous oligomenorrhea causes: pregnancy, hypothyroidism, hyperprolactinemia, medications, premature ovarian failure, anorexia or bulimia nervosa, CNS tumour, chronic illness, PCOS Assessment history menarche and menstrual history, sexual activity. exercise, weight loss, current or previous chronic illness, prescription/illicit drug use, previous CNS chemo or radiation, previous pelvic radiation, psychosocial stressors family history of genetic defects, infertility, menarche and menstrual history, pubertal history physical growth chart, BMI, Tanner staging, dysmorphic features (e.g. webbed neck, short stature), signs of Cushing's disease, thyroid exam, hirsutism or acne, pubic hair pattern, imperforate hymen, absent uterus Investigations based on clinical picture consider beta-hCG, prolactin, TSH, progesterone challenge test, FSH and LH levels, head MRI,
karyotype
Toronto Notes 2011
Famlly Medicine FM13
Anxiety
see Psychiatr:y. PS12
Epidemiology 25-30% of patients in primary care settings have psychiatric disorders many are undiagnosed or untreated; hence the need for good screening high rate of coexistence of anxiety disorders and depression Screening screening questions Do you tend to be an anxious or nervous person? Have you felt unusually worried about things recently? Has this worrying affected your life? How? if positive response, follow up with symptom-specific questions (see Figure 4) Assessment associated symptoms risk factors family history of anxiety or depression, past history of anxiety, stressful life event, social isolation, gender (women), co-morbid psychiatric diagnosis assess substance abuse, co-morbid depression, suicidal ideations/self-harm to differentiate anxiety disorders, consider symptoms and their duration (see Figure 4)
....
,,
Di"-rentill o...-11 (saa FigUI'I 4} Panic disorder
GAD
PTSD OCD Social phobia Specific phobia anxisty (children} Other: GMC, mood disorder, psycllotic
dilordar
......
,.Jr------------------, ,
Rule Out
Cardiac (port MI. armythmias) Endocrine {hyperthyroidism, diabetes, pheochromoc:yliJma} Respinrtory {asthma, CDPD} Mood di&Oiders (depnlliliian, bipol111)
Somatoform disordn Psychotic disordtirs

Per1onality disorder {OCPD) Drugs (amphetamines, thyroid preparations, cllffme, DTC for colcWdecongestants, alcohoV benllldiazepinu withdlliWIII}
No
Ate they accompanied by a repetitive behaviour mearrt to neutralizB the anxiety?

Yeo
AdllptBd from: Anxiaty lilviaw Pinal &Ins M. Bradwajn J, D.mn L(lils) (21DJ]. Prin!Brct0n!D,pp.41.
Figura 4. Differentiating Anxi.ty Dilardars
lilltmeiJraiAIIr!e!yllim*nil PrilwyCI!e. T11111111D: au.-s
Management patient education: emphasize prevalence, good recovery rate of anxiety conditions lifestyle advice: decrease caffeine and alcohol intake, exercise, relaxation techniques self-help materials, community resources (e.g. support groups) cognitive behavioural therapy: cognitive interventions, exposure therapy, etc. pharmacotherapy forGAD lot line - escitalopram, paroxetine, sertraline, venlafaxine XR - antidepressants better for depression and ruminative worry than benzodiazepines 2nd line - benzodiazepines, buproprion XL, buspirone, imipramine, pregabalin 3rd. line - mirtazapine, citalopram, trazodone, hydroxyzine, adjunctive olanzapine, risperidone - 3rd line therapy may be used as an adjunct or used for those patients who fail I ot and 2nd line therapy alone or combined
Toronto Notes 2011
benzodiazepines can be used at any time for severe agitation/anxiety - due to side effects, dependence and withdrawal issues, benzodiazepines are best used on a short-term basis (i.e. 1-2 months) beta-blockers are not recommended therapy should continue for at least 1 year after relief of symptoms for pharmacotherapy specific to other types of anxiety, see Psychiatry, PS13
.....
', ..
SOCIAL PHOBIA
Commonly fslf8d situlltions include: pLJ!Iic aatilg, drinking, writing in fnlnt of others, using public mtrooms, on the IBiephone and social gatheringt.
a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others Epidemiology lifetime prevalence rate of up to 16%; F:M = 1.5:1 often begins in early childhood and adolescence can lead to significant psychiatric comorbidity including depression, other anxiety disorders, alcohol and substance abuse and eating disorders History fear of being humiliated or embarrassed in one or more social or performance situations fear is recognized as excessive or unreasonable avoidance, anticipation and distress of the social situation interferes significantly with social and occupational functioning can often present with somatic complaints of insomnia, fatigue, palpitations, chest pain, shortness of breath, dizziness, trembling hands, sweating, blushing and GI complaints Physical symptoms of hyperhidrosis, tremor, blushing, stuttering, hypertension and tachycardia thorough mental status examination Management cognitive behavioural therapy exposure therapy, cognitive restructuring and social skills training to decrease anxiety and weaken the tendency to avoid social situations exposure therapy is the most well established therapeutic technique pharmacotherapy effective treatments include SSRis, MAOis and anxiolytics; no TCAs SSRis are preferred because of effectiveness and lack of significant side effects beta-blocker or benzodiazepine in acute social situations
Asthma/CO PO
see Respirolog)T, R7 Definition asthma chronic but reversible airway inflammation characterized by periodic attacks of wheezing, shortness of breath, chest tightness, and coughing airways hyper-responsive to triggers/antigens leading to acute obstructive symptoms by bronchoconstriction, mucous plugs and increased inflammation cannot be diagnosed at first presentation pulmonary function tests can be done from age 6 peak flow meters are useful in the office for monitoring called Reactive Airway Disease until recurrent presentations chronic obstructive pulmonary disease (COPD) a group of chronic, progressive, expiratory lung diseases characterized by limited airflow with variable degrees of air sac enlargement and lung tissue destruction emphysema and chronic bronchitis are the most common forms of COPD
---"{,
Dltr.rendill Dlllgnolls of AslltrM Chronic obstructive pulmonlll'( dileue
Cystic fibrosis Vocal cord dysfu1clion Congestive heart failure Mechanical obstruction of airw8yl {e.g. tumours)
Toronto Notes 2011

Table 1Z. Differentiating COPD from Asthma
Fam.lly Medicine FM15
COPD
AgaofOnllt
llole of Smoking
lllmnibility of Airflow Obltluction
Evalutian
Astlln
Usually in 6th decade Directly rellll!d Airflow obstruction is dnric and persistent Slow, cumulative disabling pattern lnlrequenl Enviranmenllll initants (air pollution), cigarette smoking, antilflllease deficiency, viral ilfection, occupational exposure {firslighta11, dusty jabs) Chronic cough, sputum ancVar dyspnea
Any age (but 511% at cases diagnosed in children <1 Dyo)

Kn0111111 trigger
out for signs of hypokalemia: lelharvv,

irritability. p11111111111sias, myalgia, weakness, palpitations. IIIUSH. vomiting, polyuria.
When prescribing Ventolin, wetch
Airflow obstruction is episodic and usually reversible with 1helllpy Episodic, less than 511% will outgrow Over 511% patients Environmental irritants (dust, pollen), furry animals, cold ait exercise, URTis, cigarette smoke, use at bebl-blocke"'ASA
Hhdary of Allargy PrecipillltDII
\,,
Sips Df Puorty Controlled Althml 88ta-2agonist use >41(/wk
Asthm.rallllld absiii!Ca from

school
Wheaze dyspnea, chast tightness, cough which is worse in cold, Bl night, and nearly AM prolonged expiration Normal (far pure asttma) Not usually p18Sant Episodic with 811V818 attacks bronchodilator& or staroids
Exarcise induced asthma Night-tine symptoms > hc/wk
DeCIIIIISad (more so in purelllq)hysema) Chronic in advancad stagas Spil'llllllllry
May haw
but not universally seen
with bronchodilator& Markad
N-
BodyJC8p Colour
light blu/nevy
rw.z..ganim
Ventolin
ChlllX-fty
Often no111111l Increased bronchial markings {chronic bronchitis) and chronic hyperinllation {lllq)hysama) often co-uisl: Fim line: ipratropium bromide Others: salbutamal (Venlalin8 ), tiotropium bromide (Spirivallt), fluticasone Dllll prednisone. oxygen, salml!ll!rol (SI!n!lll!llt) Bl bedtime Gat flu shot and Pneumovaxllt
Ofl8n nannal or episodic hyperinllation

Hyperinllatian during asthma attack
s.reveme
BriciiiiYjl& ICS
tea1 bluafwhite
Fla,.me Combination at rescue medications {SABAs) taken on pm besis and maintenance medications (see sidebar) taken an a regular basis to achiava control of asttma symptoms Maillanance medications: Step 1: Low-dose ICS Step 2: Medimigh-dose ICS or low-dose ICS plus either LARA, LT modifier, or long-acting 1heophytlina Step 3: Medimigh-dasa ICS plus either LABA, LT modifier, or theophylline Step 4: As above plus immunotherapy Dllll glucocorlicosteroids + flu shot and PneUJ'flD'I8x4D
Managamant
l'ulmic:o....
Camllinllll
AdVIIi..
orange/peach whitalbrown purple discus
Symbica...Other
red/white
clellr/Qn18n clllllr/orang
Atrovantl& Combivent4'
Spiriva
Benign Prostatic Hyperplasia (BPH)
----------------------
Definition
hyperplasia of the stroma and epithelium in the periurethral transition zone
History and Physical

include aJirent/past health, surgeries, trauma, current and OTC meds {see Table 13} physical exam must include DRE for size, symmetry, nodularity, and texture of prostate {prostate is symmetrically enlarged, smooth and rubbery in BPH}
....
,,
Prosteta cancar Urethral obstJuction

Bladder neck obslruction
Investigations
urinalysis for microscopic hematuria {common sign) serum PSA: protein produced by prostatic tissue increased PSA in a younger man is more often due to cancer than other causes an abnormality on DRE or PSA should trigger further assessment discuss test with men at increased risk of prostate cancer {FHx. African ancestry) or who are concerned about development of prostate cancer considered normal when <4.0 ng/mL; but must take into account patienfs age and rate of PSA increase (PSA velocity) ifbetween 4-10 ng/mL: consider measuring free/total PSA if> 10 ng!mL, can diagnose prostate pathology PSA testing is inappropriate in men with a life expectancy less than 10 years PSA should not be measured in patients with an acute UTI
Neurogenic bladder
Cy&litia
Prostatitis

other Cr,BUN post-void residual volume by ultrasound uroflow patient voiding diary, International Prostate Symptom Score tests NOT recommended as part of routine initial evaluation include: cystourethroscopy cytology prostate ultrasound or biopsy
Toronto Notes 2011
IVP
Table 13. Symptoms of BPH
Obstnu:tiva Sympta111
Hesitancy (difficulty stlrting urine flow) Diminution in size force of urinary stream Stnlam (double widing) Urinary retention (bladder does not feel Post-void Overflow incontinence
Irritative
Urgency Fre(Jiency Nocturia Urge incontinence Dysuria
Hydroneptrosis
Loss of renal concentrating

Sy&temic acido&is
Renal failure
Management referral to urologist if moderate to severe symptoms conservative: for patients with mild symptoms or moderate/severe symptoms considered by the patient to be non-bothersome fluid restriction (avoid alcohol and caffeine) avoidance/monitoring of certain medications (e.g. antihistamines, diuretics, antidepressants, decongestants) pelvic floor exercises bladder retraining - organized voiding pharmacological: for moderate/severe symptoms alpha receptor antagonists [e.g. terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomu-), alfuzosin (Xatrai)] relaxation of smooth muscle around the prostate and bladder neck 5-alpha reductase inhibitor [e.g. finasteride (Proscar)] only for patients with demonstrated prostatic enlargement due to BPH inhibits enzyme responsible for conversion oftestosterone into DHT thus reducing growth of prostate phytotherapy (e.g. saw palmetto berry extract, P;ygeum africanum) more studies required before being recommended as standard therapy considered safe surgical: TURP: transurethral resection of the prostate absolute indications: failed medical therapy, intractable urinary retention, benign prostatic obstruction leading to renal insufficiency complications include: impotence, incontinence, ejaculatory difficulties (retrograde ejaculation), decreased libido TUIP: transurethral incision of the prostate - for prostates <30 g other invasive procedures: TUVP (transurethral electrovaporization of prostate}, laser prostatectomy, open prostatectomy minimally invasive surgical therapies (MIS}: TUMT: transurethral microwave therapy TIJNA: transurethral needle ablation stents: for severe urinary obstruction in non-surgical candidate
!'('
Bronchitis (Acute)
----------------------------------------
Differential Diagnosis URTI Asthma

Al:ute Ullcerbiltion of ct.onic bnmchitia
Definition acute infection of the tracheobronchial tree causing inflammation leading to bronchial edema and mucus formation Epidemiology 5th most common diagnosis in family medicine, most common is URTI Etiology 80% viral: rhinovirus, coronavirus, adenovirus, influenza, parainfluenza, RSV 20% bacterial: M. pneumoniae, C. pneumoniae, S. pneumoniae
Pneumonia Bronchiolitis l'8rtuHil EnvirorrnentaVoccupational exposures Post-IIUIIII drip Otllers: reflux esoph&gitis, CHF, bnmchogenic CA. aspiration syndromes, CF, foreign body
Toronto Notes 2011
Investigations acute bronchitis is typic:ally a clinical diagnosis sputum culture/Gram stain is not very informative CXR if suspect pneumonia (cough >3 weeks, abnormal vital signs, localized chest findings) or CHF pulmonary function tests with methacholine challenge if suspect asthma Management primary prevention: frequent hand washing, smoking cessation, avoid irritant exposure symptomatic relief: rest, fluids (3-4 Uday when febrile), humidity, analgesics and antitussives as required bronchodilators may offer improvement of symptoms (e.g. albuterol) current literature does not support routine antibiotic treatment for the management of acute bronchitis because it is most likely to be caused by a viral infection antibiotics may be useful if elderly; comorbidities, pneumonia is suspected, or ifthe patient is toxic (refer to Antimicrobial Quick Reference, FMSO) antibiotics in children show no benefit
r-t,
How w reu if V"al or a.eterial'l Bacterial infections mnd to give a higher fever, excessive amounts of purulent sputum production, and may be associated concomitant COPD. Noll: pLmllllt sputum is not bacterial.
Chest Pain
see Cardiolo!D" and Cardiovascular
C4 and Emerienc.y Medicine. ER22
.....
Differential Diagnosis
Tabla , 4. Diffarantial Diagnosis of Chait Pain
MSK/Neuro
Angina* Ml* Pericarditis* Myocarditis Aortic dissection* &ldocarditis
PraJmonia PraJmo1horax"
Rillk facto,. for Coronary An.ry DiMMI

Mior 1. Smoking 2. Diabetes 3. Hypertension 4. Hyperlipidemia 5. Flllllily hislllry Minor 1. Obesity
2. Slldenbry
GBlD
PUD
Pe!forated viscus Esophageal spasm
Cholecystitis
Costochondritis Intercostal sbllin
Anxiety Panic
PE"
NmorayHTN
LungCA
Arthritis Rib fractures Helpes zoster
Depression
Hepatitis
J.AQe
Investigations ECG, CXR, and others if indicated (cardiac enzymes, D-dimers, LFI's, etc.) refer to Emergency Department if suspect serious etiology (e.g. aortic dissection, MI) Management of Common Causes of Chest Pain angina/ischemic heart disease acute: nitroglycerin (NTG) (wait 5 minutes between sprays and if no effect after 3 sprays, send toER) if inferior Ml, NTG will cause patient to become hypotensive long term: see Figure 5 myocardial infarction (MI) chew ASA STAT, to ER for "MONA" (Morphine, Oxygen, NTG, ASA) reperfusion therapy with tPA or streptokinase if within 6 hours (Note: can only use SK once in lifetime) start beta-blocker (e.g. metoprolol starting dose 12.5 mg PO OD, increase gradually to 50 mg PO bid) endocarditis: IV penicillin G 20 million units OD or IV ampicillin 12 gOD GERD: antacids, H2 blockers, PPis costochondritis: NSAIDs
Higll-lisk SympiDIM 1nd Si. . af Ch..t Pmlndllde:
Severa pain
Pain for > 2D min

New -81 pain at 1811
Seven SOB
l..olll of comsci01151111H
Hypotension
Tachycardia
llnldycanlia Cyanosis
Ml in Eldllly Wamen Bd811y women can oftan preaent will1 dizziness, lightlleadedness or weakness, in 1he absence of chast pain.
Toronto Notes 2011
SIBbie IICbamic Heart Disaa

Lif&.style modifiCIJiion (addi"IJS$ diet, smoking. 8XBrcise) Menaga concomilllnt disortln (a.g. hypartllnsion, diablllls, hyperthyroidism, anamia) Arm-plllllluttharapy fur all patian!J (upirin 81 mg PO 00 unlau conlniindica!Bd orfBilad) fl-blocbr for all post-MI patients or 1hosa with haart fliluna ACE inhllitor for patients >55 years or with any coincident indiCIJiion Stati11harapy for pllliants with coronary diseasa
Start a p-bloclalr not already using it){swi1ch ID p-1 selective blocker Sublingual nitrata for prophylaxis end acute symptnm relief
Add long-acting (onll or1ransdarmal) nilrall calcium channal blocksr
Ass111
suilllbility for coronary artllry nMISCLHrization
Figure 5. Treatment Algorithm for Stable Ischemic Heart Disease
llalanmcas: Onllrio 1NJ Thllllpy Gi.idalinls lschmlic lllan Di- in l'limuy C.. {2000).0n!Mo Propn frr Op/inl/ 111etrpeuta. Toroii1D: ban's l'rillllr of0n11rio, pp. 10. Gi.idalines an '6ia1111111Q81T1111 ofsllbll paclllris..Recommelldl!io of file 1i.!kForce offile EIIO/Iflll Sociefyof ClnfiDiologr. 2006. p63.
Common Cold (Acute Rhinitis)

c - Cold EtiDiogy
PRIMA
lhinoviruses lnfiU811lll virus Myxoviruus Adanoviruses
Definition
viral upper respiratory tract infection (URTI) with inflammation
Epidemiology
most common diagnosis in family medicine; peaks in winter months incidence: adults= 2-4/year, children= 6-10/year organisms mainly rhinoviru.ses (30-35% of all colds) others: coronavirus, adenovirus, RSV, influenza, parainfluenza, echovirus, coxsackie virus incubation: 1-5 days transmission: person-person contact via secretions on skin/objects and by aerosol droplets
..... ,
......
Fevtr
lnlhlllllz vs. Colds: A Gllide Ill
SympiDms
Onsetr/Hnea
... Sudden
e.ld
Slow None
Risk Factors
psychological stress, excessive fatigue, allergic nasopharyngeal disorders, smoking, sick contacts
Higii!Mr
Exhaustion IMI Smra Dry IIMII CCIIIIIb orhlckilg File Tlloll Dry 11d cleu Nose Achy lle1d Appel ita D8CIIIS8d Musclll Achy
Mid
Clinical Features
symptoms local- nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough general- malaise, headache, myalgias, mild fever signs boggy and erythematous nasal/oropharyngeal mucosa, enlarged lymph nodes normal chest exam complications secondary bacterial infection: otitis media, sinusitis, bronchitis, pneumonia asthm.a/COPD c:xacerbation
Sore RllmY
Cb.
Y81
lleedec:ht-free Normal Fine No
laiw:llfor ........ lllll ,..... dill

CIJdnll Dllllllst II Sjtmmlfi: lllMilws 2tlD&; luull This i'/lflmlltic nMIIW Df 16 triali11181111d thl rl Echiul il IIIII trellillll c:ompll8d c:orDililg Echinlc with pilclllo. no 11111mlllll. 111 11brnatiw camnan cold lr8IIJna. vntin il p1pmtims and IJIIIty rl Edlinlcel mtda matlJut in reds suggeslld 11111"1 J11F1111ians rl Echillcae nwy Ill blllll thin pllcebll. c..:.- Echil8CBI plllpllllioni VI!YwidllrSome prepations l'lidl nwy be . . ueilconsinnt.
allergic rhinitis, pharyngitis, influenza, laryngitis, croup, sinusitis, bacterial infections
Management
patient education symptoms peak at 1-3 days and usually subside within 1 week cough may persist for days to weeks after other symptoms disappear no antibiotics indicated because of viral etiology secondary bacterial infection can present within 3-10 days after onset of cold symptoms prevention frequent hand washing, avoidance of hand to mucous membrane contact, use of surface disinfectant
E."""""
Toronto Notes 2011
Fam.lly Medicine FMHI
symptomatic relief rest, hydration, gargling wann salt water, steam analgesics and antipyretics: acetaminophen, ASA {not in children because risk of Rc:yc:'s syndrome) cough suppression: dc:xtromethorphan or codeine if necessary decongestants, antihistamines zinc gluconatc: lozenge use is controversial patients with reactive airway disease will require increased use ofbronchodilators and inhaled
steroids
"' .... eo....... Cold lllviiM CJnne llllllllse flfSyl/rlmllic

INuu 3; t.t IIITIIIIdmant: 19119
1M!
eftecls al lin!; lolenges far cold (laD UIJPII rnpitlbJiy tJ1c1 irllclimj TiMI trills the lallloges Wlll1l ullactiw in rming -aymttlntila al
TJ-.I'/SIIIIlltit miuw ol71111111onUad C8111181
Contraception
see
GY18
111e lllliages lid not IPPIII1D be eft\Jr:M. .........._lhlll'idlnclfarzinc 1rlllillllhe t:QIII111111 coil ii inc:ancllliw,llld 1hanJ ill potantiellor lidelllflcts.
Tabla 15. Methods of Contraception CombmlldOCP

Efhlctiveness: 99.!1% with perfect use, 97-9!1% with typical use, 111'811ulilr bleeding, systarnic hormonal side eff8cts (breast tendarness, lliiUSiil, mood cycle co1111'DI, II; dysmenorrhea, II; menstrual flow, II; ovarian cancar, changes), no Sll protection, slightly increased risk of venous 111'ambaerdlolism II; endometrial cancer, II; risk af fibroids, II; acne, II; hirsutism (VTE), Ml, and stroke, decreased quantity af breast milk pos1partwn
Progestin Only Pill
(e.g. Pllb:h
(e.g.
At least 95% effective with pelfect use, II; mensl!ual flow, >If cramping, no 1' risk af VTE, Ml or &troke, 5Uitable for postp.tum
Same as OCP, easy to use, changed weekly, 99% elfactive with correct use Same as OCP, easy to use (in for 3weeks. out far 1). less systemic hormonal side affects, 99% ellactive with correct use 99.7% effective agai1st pregnancy, infrequent closing,
II; mensbual flaw or amenarmea, .J; risk of endometrial cancer
Irregular bleeding, no STI protection, contraceptive reliability requires taking pill at the 5arne time each day (within 3 haul$), no pill free intarval Same as OCP, skin irritation Same as OCP, vaginitis, some women may be uncomfortable with IITl!llular bleeding, delayed return of fertiity, no STI protection, systemic hormonal side effects (most common is headache), weight gain .J; bone mineral density (check ahl!r 5yean)
NuvaRig (inserted by patient)
DMPA
IM prog11518rone injection q12 wlcs (e.g. DepoProvere")
MllaCDOdom
97% effec1ive against preiJlancy and STis when used properly. 'IJhen used properly WITH spermicide 1heyIll! close to 99.9% elfactive, no Rx rvquired 92-96% effective with perfect use, non-hormonal, female-controlled method !i contraception, decreased risk af cervical cancer
Latex allergy, irritation, only effec1ive before the expiry date, must be applied properly, can only be used once
Must be left in for 6h after intercourse, must be used with spermicide, incomplete STI protection, latex allergy, must be fitted by health care worker, increased risk of UTI, risk of toxic shack syndrome
Sponga
One-size-fi!HII barrier method, does nat rvquire fitting by MD, available in pharmacies, 90% effective without a condom, 98% effec1ive with a condom 99% effec1ive against preiJlancy, effective for 5yrs, no daily regimen required, can be easily removed, ideal in post-partum women
II; mensbual flaw, less systemic hormonal side effects than OCP
Relatively expensive, only -60% eff8ctive in parous women, incomplete S1l protection, risk of toxic shock syndrome
No STI protection, increased relative risk af PID in first month, must be inserted by MD, risk of post-insertion vaso-vagal response, risk of uterine rupture is 0.6-1.6 per 1DDD, 2-10% expulsion rate Hormonal side effects (see combined OCP), expensive (-$400) 111'811ular bleeding or 1' menstrual flaw, 6-211% women discontinue use in first 5yrs because af pail or '1' bleedi"cl Hilt! probability of flliiWll nat used consistently and corractly, no STI protection
lntl'llllllri1111 Dnic:e (IUD} Llvonorgtiiii'IIIUD
(e.g.
Copper IUD (e.g. Nave
>If risk of endometrial cancar,less expensive (-$170)
typical use, Fartility A'NIImiW/ Efhlctiveness: 95-98% with perfect use, Natural Family ilcr811S8d awaraness of gynecological health, 11111Sanable for couples Plannilg for wham an unplanned pregnancy would be acceplable
(e.g. symptothennal method)

Llc:talilllll
IR11101rhll
Very effective in breastfeeding women nat returned, fully or nearly fully breastfeeding baby and baby is under 6months old
Nat infant receives any food supplementary to breastfeeding Must treastfeed regularly, even through the night (at least q6h)
Emergency Contraception (EC) hormonal EC {Yuzpe or Plan B, usually 2 doses taken 12 hrs apart) or post-coital run insertion hormonal EC is effective if taken within 72 hrs of unprotected intercourse {reduces chance of pregnancy by 75-85%), most effective if taken within 24 hrs, does not affect an established pregnancy post-coital IUDs inserted within 5 days of unprotected intercourse are significantly more effective than hormonal EC {reduces chance of pregnancy by -99%) pregnancy test should be performed if no menstrual bleeding within 21 days of either treatment advance provision ofhormonal emergency contraception increases the use of emergency contraception without dc:crc:asing the use of regular contraception pharmacists across Canada can now dispense Plan B without a doctor's prescription (as of April2005)
AhohQ Contraindicmons tu Combi1111d0CP
IAldiagnosad abnormal V1Qi111 bleeding Thromboembolic disorda11 Carabi'OVIICLJir or coronary ertay

diseue Es!rogln dlp1ndlnt llmOUill (brlllll. Ullrus) lmpllirld livlrfunction with III:W livlr diAII88 Congenital hyper1riglyceridemia
KnowMuspected pregnancy
Smoker >35 yen old Migraines with focal neurological

syJ11)10ms
lklcontrollecl hypertension
Toronto Notes 2011
it' Differtntial
Common eau
Althml
Cough
History and Physical duration (chronic >3 months), onset, frequency, quality (dryvs. productive), sputum characteristics, provoking/relieving factors, recent changes associated symptoms: fever, dyspnea, hemoptysis, wheezing, chest pain, orthopnea, PND, rhinitis constitutional symptoms: fever, chills, fatigue, night sweats risk factors: smoking, occupation, exposure, family history of lung CA or other CA, TB status, recent travel medications (ACE inhibitors), allergies PMH: lung (asthma, COPD, CF), heart (CHF, MI, arrhythmias), chronic illness vitals including 0 2 saturation, respiratory exam, HEENT and precordial exam Investigations guided by findings on history and physical consider throat swab, CXR, sputum culture, test for acid-fast bacilli refer to respirology for PFfs as appropriate
Upper airway cough syndrome
(postnasal drip)
GERD
Non-lllhmatic eosinophilic
OlhlrC..p ACE inhibitnrs Aspiration Bronchietasis Cyllic fibrosis
Pertussis
Chronic interstitial king disease

Psychogenic Restrictive lq disease TB, atypical mycobacterium. and otl!lr chronic lung infiC!ions
Dementia
see &)rchiatcy. PS18
Epidemiology 10% in patients over the age of 65, 25% in patients over the age of 85, 50% in patients over the ageof90 prevalence increases with age, Down syndrome and head trauma differential diagnosis: Alzheimer's dementia, vascular dementia, Lewy-Body dementia, frontotemporal dementia Investigations history, physical. MMSE investigations are completed to exclude reversible causes of dementia and should be selected based on the clinical circumstances CBC, liver, thyroid, renal function tests, serum electrolytes, serum glucose, vitamin B12, folate, VDRL, IllY, SPECT, head CT, EEG Management treat and prevent reversible causes provide orientation cues (e.g. calendars, clocks) and optimize vision and hearing family education, counselling and support (respite programs, group homes) pharmacologic therapy: NMDA receptor antagonists and cholinesterase inhibitors slow rate of cognitive decline; low-dose neuroleptics and anti-depressants can be used to treat behavioral and emotional symptoms 20% of patients develop clinical depression, most commonly seen in vascular dementia
Depression
------------------------------------------------
..._.
..
see Psychiatry. PS7

Etiology often presents as non-specific complaints (e.g. chronic fatigue, pain) depression is a clinical diagnosis and tests are done in order to rule out other causes of symptoms 2/3 of depressed persons may not receive appropriate treatment for their depression identification and early treatment improve outcomes Screening Questions
Are you depressed? (high specificity and sensitivity)
Differtntial Di11nosi1 Ottm- psychilltric disonlm (1.g. IIIXiety, personllity, bipollt', schizoallec:tiw, SAD, substllrn:e lbuselwilhdlliWII) Early damentil. Endocm {hyparJhypolhyroidilrn. OM) Liv8r failure, nmlll failure Chronic fatigue syndrome Villmin deficiency (pernicious 1U18111ill, pallllgra) Medication side elfecb
banms)
Have you lost interest or pleasure in the things you usually like to do? (anhedonia) Do you have problems sleeping? (for those not willing to admit depression)
Assessment risk factors personal or family history of depression medications and potential substance abuse problems suicidality/homicidality fill out Form 1 (in Ontario): application by physician to hospitalize a patient against his/her will for psychiatric assessment (up to 72 hours)
Infections (mononucleosis)
Menopause
Clncr
before the dilgnosis at cancer is rna)
of palilllts rumours, of brain, lung and pencraes, develop symptoms of dapnsuion
Toronto Notes 2011
functional impairment (e.g. work, relationships} at least 5 out of 9 criteria including anhedonia or depressed mood weeks for actual diagnosis to be met (see sidebar} validated depression rating scales: Beck's depression inventory, Zung's self-rating depression scale, Children's depression inventory routine medical workup (physical examination, CBC, TSH, electrolytes, urinalysis, glucose, etc.)
Crtt.illhr .,.,_.,.. M DIPIUud Mood

S I G E C A Increased/decreased Sleep lntemt G uilt
Treatment goal: full remission of symptoms and return to baseline psychosocial function phases of treatment acute phase (8-12 weeks): relieve symptoms and improve quality of life
maintenance phase (6-12 months after symptom resolution}: prevent relapse/recurrence, must stress importance of continuing medication treatment for full duration to patients treatment can consist of pharmacotherapy alone or psychotherapy alone combination of antidepressant drug therapy and psychotherapy results in synergistic effects
Tabla , &. Common Madiclltions
Clas
DecreaMd Energy
Concentnrtion lnc11111118d/dBCnlllsed Appetite
P Psychomotor agitationfretardation S Suicidal ideation
Must Ask Abold/Rule Ollt Bipol/ma'liclhypomanic episodes
Psychosis
Anxiety
Exallpl
paroxstine (PaxiP), fluoxetine (Prozac8 ), sertraline (Zolaft), citalopram (Celexu"), fluvoxamine venlafaxine bupropion (Wellbutrin) amitriptyline (EiaviP)
Actian Block sl!l'lllanin reuptake
Side Effects Sexual dysfunction (impotl!nce, decreased libido, delayed ejaculation, anorgasmia), headache, Gl upset, weight loss, tremon, insormia. fatigue Insomnia, trlmors, lllchycardia, sweating Headache, insomnia, nijrtmares, seizures, less sexual dysflrlction 1han SSRis Sexual dysfin:tion, weight gain, 1remors, lllchycardia, sweating
Natal
First line 1herapy for teens is
BIIIIIIMIII1ent
Sllbstance IISWabuse/Withdrllwal
SSRI
SllicidaVhomicidal ideation
ft.loxeti1e; paroxetine is not

recoll'ITI8nded for teens (conlnlVlnial)
Common Dosing
llilrliltO. .....
Block sBIIIIanin and NE reuptake Block dopamine and NE ll!llplllke Blocksl!l'lllonin and NE reuptake
SNRI SDRI TCA
....
Nlm!W thel!lpeutic wildow, lethal in overdose
Prognosis
up to 40% resolve spontaneously within 6-12 months risks of recurrence: 50% after 1 episode; 70% after 2 episodes; 90% after 3 episodes
Diabetes Mellitus (DM)

see Endocrinolon. E6
... l'lrdlallliCII ,..._........:A,_.IIir:..,._
Epidemiology
major health concern, affecting up to 10% of Canadians Type 1 Diabetes (DM1): 10-15% ofDM, peak incidence age 10-15 Type 2 Diabetes (DM2): 85-90% ofDM, peak incidence age 50-55, up to 60,000 new cases in Canada per year gestational diabetes mellitus (GDM): 2-4% of all pregnancies incidence of Type 2 DM is rising dramatically as a result of an aging population, rising rates of obesity, and sedentary lifestyles leading cause of new-onset blindness and renal dysfunction Canadian adults with diabetes are twice as likely to die prematurely, compared to persons without diabetes
1rillls.
lludr. $yllalllllie miew rmbrimd clinicll
..._: 1142plllienls. llllmdaft: Antidlplamtll'llli!Wit alone VI. c:omlimlln al intmwntion lf1CI llllidapmanttllmpy. Mlil llllall: Elicacy a! IIIII adherence ID
lllerlpy.
11116: IMrlll c:ombined tlmpysigniic:antly 1111111 &tiw ttu llllidupl8111rt 1llerlpy alone (OR 1.86; M a I.38-2.52L '-er u.n-110 Item. al drgpoul$and 11011-mpondn illilhlr llll1mlnt arm. .. lbJdill > IZ weeks, corrlliled 111nPV iiiiiWid 1 IICllclion in dJII)OUIS ClllfiiiiiCI to 1111nofiii)Onden (OR 0.59; M Cl D.39D.881
Risk Factors
Type 1 DM personal or family history of autoimmune disease Type2DM first degree relative with DM age years obesity (especially abdominal}, hypertension, hyperlipidemia, coronary artery disease, vascular disease prior GDM, macrosomic baby (>4 kg) PCOS history of IGT or IFG presence of complications associated with diabetes both member of a high risk population (e.g. Aboriginal, Hispanic, Asian or African descent)
Toronto Notes 2011
Diagnosis persistent hyperglycemia is the hallmark of all forms of diabetes

DM lltlm.d Symptoms
Hypeqtycemia: polyphagia, polydipsia, poi'(IN. weight change, blull'f vision, yeast infections
D1abe11c IIIIIMcldosll (DICAI: fruity breath, anoruill, fatigue, llbdo pain, Kussmaul breathing. dehydration Hypoglrl:emia: IJinger, amdety,
Tabla17. Diagnosis of Insulin Allocillted Disorder&

Canditi111
Dilbca Milito
Dillgnosdc Criteria
One of the folowing on 2occasions: Random BG <!1 1.1 mmoVL (200 mlfdl] with sympiDms of OM (fatigue. polyuria. polydipsia, unexplained weight loss) OR Fasting BG <!7.0 rrrncAA. (126 mgjdL) OR BG 2 hours post 75 g DGTT <!1 1.1 mmoVL (200 mgJdl] DR HbA1c<!6.5% Fasting BG 6.Hi.9 mmDIA. (110-124 mgJdL) BG 2 hours post 75 g OGTT = 7.8-11.0 mmDI/L (141-198 mgJdL)
tramOIS, palpitations, -ling, coma

headache, fatigue, confusion, seizures,
Impaired Futing Glu1:01e (IFGI Impaired GlucoH Toleruca (IGT}
DKA can bl1riggmd bv infection, isc:l1emia, infarction, intoxication, madimion non-compliance.
Screening Type2DM FBG in everyone q3 yrs more frequent and/or earlier testing ifpresence
1 risk factor (as previously listed) GDM (see Obstetrics. OB13) all pregnant women between 24-28 weeks gestation non-fasting 1 hr SO g OGCT ;?:10.3 mmol/L (186 mgldL) is diagnostic if between 7.8-10.2 mmol/L (141-184 mgldL), do confirmatory fasting 2 hr 7S g OGTT if develop GDM, have a SO% chance of developing Type 2 DM over 20 years
Goals of Therapy
,,.. ,
Long T- Complic:lltio... .t Diablbl
Microvascular: naphropathy, rulinopllthy, naurupetlly Mocrovucular. CAD, CVD, PVD
Tabla 18. Goals of Therapy in DiaHtas Mallitus

Avoid complications (e.g. ketoacidosis, hyperglycemia. infection) Prevent long-tenn complications (micllMiscular and macrovascLJw) Minimize negative saqualaa associated with therapies (e.g. hypoglycemia,
Fas&Jg or Prepranclial Glucose
gain)
Ideal: 47 mmoVL 172126 mgjdl) Suboptimal: 7.1-10 rrrncAA. {1281 80 mgjdl); action may bera!Jiirad > 10.0 rrrncAA. {180 mgJdl); action is required :S0.07 or :S0.065 in some typa 2 OM patients at risk lor nephropathy Suboptimal: 0.070.084 Inadequate: >0.084 5-10 mmoVL (9G-180 mgJdl) HbA1ctargetmet 58 mmoVL (9G-144 mgJdL) HbA1ctargetnot met
HbA1c
Blood Pressure Lipids
< 13QIBD in adults (OM and HTN guidelines) LDL <2.0 mmoVL (36 mgjdl) Triltft;erides <1.5 mmoVL (27 mgJdl) Total cholesterol/HOL ratio <4.0 mmolll (72 mg/dl)
Assessment and Monitoring

Tabla 19. Assessment and Monitoring
Initial Altesunent
Hislary
q2-4months Oiabetasdiractad history Screen lor awareness 111d frequency of hypoglycemia and OKA Glucose monitoring Use of ilsuli1111d oral agents
Anllldy
Diabstes-directad histurv Screen for ewareness and frequency of hypoglycemia and OKA Glucose monitoring Use of insulin llld oral agents Sexual function COW\Selling Psychosocial issues
SympiDms ol hyperglycemia. ketoacidosis, hypoglycemia Past medical history Functional inquiry Family history Risk facton Medications Sexual function Lifestyle
General: Ht, WI. BMI, BP Wt, BP, BMI, WC Completa niiUI'D axam for Head and neck: fundoscopy, thyroid IIXIIII Foot axam for sensation, ulcers, paripheralnauropathy Cardiovascular exam: signs of CHF or infection Rernailder of exam as per PHE pulses, Abdominal exam {e.g. for organomegaly)
HamVIo!Mkin IIXIIII
Neurological exam
Toronto Notes 2011

Table 19. Assessment and Monitoring (continued)
lnilill Assessmllnt lnnlligllionl FBG. HbA1c, fasting lipids, microab11rin:creatine ratio
q2-4months
HbA1c q3 manths FBG as needed
Annually Fasting lipid prafile Resting or exercise ECG if age >35 Dipstick analysis for gl'tlSS prolllinuria; negative: annual rricroalbumiooria screening with random allUmiu:rl!lliline ratio for Type 2and Type 1 (5 yrs post
t...-
LGa Alii.. wtlll'nlllllllll
m;
ECG
puberty) If positive: 24-flr urine for endogenous

creatinile cleann:e rate and microalbuminuria qS.12months Management riltritional and physical education Consider rafarral to diabetes education fllliiJIIm if available Monitoring BG: explain methods and Assess progress IDwards Calibrate heme glucose monitor long-term complications Arrange ophthalmology followo(Jp anooaly Adjust traatmant plan lor Type 1 and q2yaan; for Type 2 necessary Influenza vaccination annually
lsu2 Ameta-tllltilis. 9s111dies CCIIJ1IIisi1g 51 68l)llii!D, invls1igdld 11111111c:tMr.a al dill canbd. pbysicaiiCtM!y, behlvicml weight prgQIIII'II11111 Wligllt I:QIIiaf ilfiMnlin in lltJb wilh wlysiswas lni1ed Wwt.n Mth U!Uil en. Migld ian2.8 k;ad 1M d8CIIliiiiWR1.3 ta'm111t111u
unv
glyl;enic canbd. BP 11111 blood iPd wn l'llllld. SIIDI wilh al U VIlli illawed I significlnt deaRie iJ dilbefls amel wlw1 compnl wilh contnR.
freiJiency
Medication counselling: oral hypoglycemiC& an4/or insulin, mathad of administration, dosage adjusbnents Ophthalmology consult Type 1 within 5 yrs Typa 2at diagnosis
IJi8y Uvi:lflr.._.allfpl ZDM il Mllll
Nonpharmacologic Management diet all diabetics should see a registered dietician strive to attain healthy body weight decrease oombined saturated fats and trans-fatty acids to < 10% of calories avoid simple sugars, encourage complex carbohydrates, choose low glycemic-index foods physical activity and exercise encourage 30-45 minutes of moderate exercise 4-7 days/week promote cardiovascular fitness: increases insulin sensitivity, lowers BP and improves lipid profile if insulin treated. may require alterations of diet, insulin regimen, injection sites and self-monitoring Self-monitoring of Blood Glucose Type 1 DM: 3 or more self-tests/day is associated with a 1% reduction in HbA1c Type 2 DM: optimum frequency of self-tests remains unclear ifFBG >14 mmol!L, perform ketone testing to rule out DKA if bedtime level is <7 mmol!L, have bedtime snack to reduce risk of nocturnal hypoglycemia
Codnne ilmlllse IIM'M 2007; laa3 A111111-nlyU. Lllilg 3S arti:lls r11parting 1111111 al 18 llillllalowilg , 467 pri:ipiiiiJ. lhow8d u.tthn is on1111 afticlcy al lietaly11111tment of type 2 . Alter 611111 12 rmnlhl. ..... allllltill irnpnMd gljatld
lanoglobil
g1ulisine, aspart. lispro
.....
J
18
0:::
Clllculml Totallllllllin llalpliNd: Type 1: 0.50.7 uniWkclfday Type 2: 0.3 L61its/kclfdly
qlwgine, detemir
"'
N
24
Hours After Injection Figure 6. Types of Insulin Preparation
..
Oral Hypoglycemics (DM2) available agents biguanide: metformin (Glucophage) thiazolidinedione: troglitazone (Rezulin), rosiglitazone (Avandia) alpha glucosidase inhibitor: acarbose (Precose) nonsulfonylureas: nateglinide (Starlix), repaglinide (Gluconorm) sulfonylureas: glyburide (DiaBeta), glimepiride (Amaryl), gliclazide (Diamicron) DPP-4 inhibitor: sitagliptin (Januvia)
Toronto Notes 2011
11,
IIAith Ca1111dA RtlciiiiiiHIIdllti- on M-v-mm of llaaigliblmn U.. in DM2 Rolliglitazonl il indic.-.d for.
Uu as monotlllnpy, in patiants nat conlrullad by diet lllld uxerci&e alone For patients inldequallly conlroDed on metfonnin or sulfonylurea, rosiglilllmn shoW! tJ. addld to,
Other Medications Used in DM

ACE inhibitors for: all hypertensive DM patients elevated microalbuminuria (30-300 mg albumin in 24 h) overt nephropathy (>300 mg albumin in urine in 24 h) ARBs are second line for these conditions ASAfor: all diabetics, unless contraindicated statins as required to attain target lipid profile
nat substituted lor, metfonnin or

sulfvnykne
In Canada, rosiglitllzone is not
for use:
wi1h insulin 1Mrapy with tile combilllltion of metforrnin AND sulfonyluraa in patients Contraindicatld in patiiiTis with NYHA Class Ill .,d IV cardiac status Should ba used with caution in any patient with NYHA Class llllld u cardiac stBIIJs l'lltilnllshould b1 monitorad for signs lllld symptoms of fluid retantion, ldlma. and rapid Wlight gain Maximum daily dose used in combination with sulfvnyluraa should nat exceed 4 mg
Clinical Ass111mant
Uleslyle inl2rvention (iritiation of nutrition therapy and physical activity)
A1C <9.0%
.
l
I
I
I
A1C 0!:9.0%
lllllfllnnin
Initiate
lniliata immediately without waiting for llffiCI from lifestyle interventions: Consider iltiating lllllforrnin concurrently will1 another agantfrom a dillennt class; or initiate insullin
ISymptomatic metabolic
. .
I
I
with
mlthlnnm
:1:
....
lttnututaruu 1
Add an agiiTt bill: suilld Ia thl i..tvidull 111111111 an th advantagwldiladnntagliltad bllaw Cl Alpha.tluc:osidasl lnhlbhor ll*llinagenl:
DPN illlllilor
MllflnlinMonotnpyt.Twflllllilllll CIJdnll Dllllllst II Sjtmmlfi: lllMilws 2tl05;
luul3 ACac:lnna RavirN rJ 2ll trU willl17 llllli {S259 JllllicipiiD) cCJmPII'IIIIIIAillnnin wMh INI'onlJ1815, plalo, diet, thia2Qiidinecion81,
indn.nw9tili-lllll gUco!idllll inlibibn The IIUIIn canclided lhBt matfannin may fiiMIII soma Vllat complicltions snd m:Mtlllily in MMeiglt and obete 11.12 PB1ientJ IIIII u Kh may bl Cllllidllld irst inllblllfll'. Thill is liD evidence lhlll the l1lded fllllmlliw thenPes lllve 1111111 benafit far 1J1c1111i1 bolt;' waiglt, Of lpids 111111 does metlomia.
AIC
Hypaglyclmill
Other AdviiUgll
Ott. IIi. . . . .
Gl side affect$
Rare Rare
Y8i
WBVIt niUtral
mprMCI postprandial contnll mprMCI poslprandill contnll

No dosB Cliling types. flaxible reginens
WeVrt: neutral
New agent (urinown lonlf"lerrn Slfely)

Weight gain
lulin lulin _..81111111 Maglililill
-1-
Yes
Y8i
mpmoect poslprandill contnll

NUWIII" &Dylurvas (glicllllidu, {imepiride) n IISSOCialed with IUS$ th111 Qlyburide
Durable manothnpy
til to qid Weight gain
1IIZ
Rare
RIICJiiras 6-12 -ks for llllllimal ellect Weight gain EdBma, rara CHF. nn fnlcturas illlmaiBs Gl side affect$ {orlistat) lncreaed '-! nd:a'1!P {libutnlmins)
WliaM .... aglnt
Nona
WBV!tlass
1 " nat .. target 1

Add another drug 1nlm a difhnnt class; ar Add bedtime biSII insulin to ather agent(s); or Intensify in111lin regimen
lliiiiiiJadjusn.ttsto allll{aradditianoflnlihyplrglvl:lmic ...... llllldl bll mad1toattail tlrgii:A1Cwilhi16-1Z months

AIC - glyclttd hemogllti1 DPP-4 - djMptidyl peplid11H -<1.01.dlc:,..llinAIC BP -bloodPIIISUrt Gl - gosl!ailtMti1111 -1.11-2.01d8CIIIIeinAIC CHF hWI flilure T2D -lhilllllidinedime ->2.01.decr81seinAIC Less hypogycemia in the context ol ll'issed me lis Nolo: Physicionslh.Ud rerum the most recent ocition olthe Co.....,.ti11111 of ,_nniCalticals ord Specialties !C.,IIdia"l Pt.nnacisb Auocillion, 0t1aw1, Onbrio, c,..da) far pmm.cl monotJ111hs ord far de11is presailing ilfmmllion
Figura 1. Management of Hyperglycemia in Type 2 Diabebls
C11111dian llabells Aaaciltion Cinical Practice Guidlln11 Expert Cammitt&a. Callllliln liabBtBS Aslociltion ZDOBiilical Plldics guidlln11 for the Jll1'l8l11ian and m-;ement al dillletes i1 Canida. Cln J CJilllete$ 2008; 32{suppl 1 (used Mth penrission).
Toronto Notes 2011
Diarrhea
see Gastroenterology, Gl4
Definition passage of frequent unfonned stools (>200 g ofstool/24 hours) can be acute (<14 days duration) or chronic (>14 days duration) Etiology and Clinical Features acute diarrhea: majority of cases are self-limiting most commonly caused by viral infection (e.g. rotavirus) fever and bloody stools increase probability of bacterial infection consider C. difficile infection if recent hospitalization, recent antibiotic use, age >65, immunosuppression chronic diarrhea: most commonly of non-infectious etiology common causes include drugs (laxatives, antibiotics), infection (bacteria. parasites), inflammation {IBD, diverticulitis), neoplasia {colon cancer), malabsorption, maldigestion, IBS, and idiopathic Treatment chronic diarrhea; nonspecific treatment often required before workup is complete antidiarrheal opiates (e.g. loperamide) - most effective nonspecific treatment should be used on a scheduled basis before meals rather than PRN fibre (e.g. psyllium) - commonly used as adjunctive treatment oral rehydration solution - offset electrolyte imbalances lifestyle and diet changes
Dizziness
see Otolacyngology, OT6
Epidemiology 70% see general practitioners initially; 4% referred to specialists frequency proportional to age; commonest complaint of ambulatory patients age >75 Differential Diagnosis
Vertigo (vastibular) Objective (axlamal world seams to revolva around individual) or subjective [individual revolvas in space)
Dizziness
I
...
II
Centnll [15,) Brainstem Cerebellar
...
...
lll'llripheral (15%) Inner ear Vestibular nerve
Nonvartiginous (nonvastibular) Fealing ,ightheadad." "giddy," "dazed," mentally confused, or "disoriented"
..
...
11
l'llychagenic: Diagnasis Df exclusion
V.C:ulu
I
I
...
Ocular
I
I
I
Biology
Biology
Tumour Stroke Drugs Multiple sclerosis
ldioplllhic M1111illru's BPPV Acoustic neuroma Trauma Drugs

Labyrinthitis
VBI Bllsilar migraine TIA Orthostatic hypDIIInsion Stokas Adams Arrhythmia CHF Aortic stenosis Vasovagal episodes Mllllbolic causes
Dacruue:cJ vi&Ual
IICUity
Figura 8. DiHarantial Diagnosis of Dizziness
History
clarify type of dizziness: vertigo, pre-syncope, dysequilibrium, light-headedness

onset, precipitating/alleviating factors, preceding infections and activities, associated symptoms, previous experiences of dizziness duration (seconds to minutes vs. hours vs. days to weeks vs. persistent) exacerbations worse with head movement or eye closure {vestibular) no change with head movement and eye closure (nonvestibular) worse with exercise (cardiac/pulmonary causes)
Toronto Notes 2011
associated symptoms neurologic (central) transient diplopia. dysphagia. dysarthria, ataxia (TIA, VBI, migraine} persistent sensory and/or motor deficits (CNS) audiologic (peripheral) hearing loss, tinnitus, otalgia, aural fullness, recruitment others nausea, vomiting (peripheral vestibular disorders) SOB, palpitations (hyperventilation, cardiac problem) general medical history HTN, diabetes, heart disease, fainting spells, seizures, cerebrovascular disease, migraines ototoxic drugs: aminoglycosides (gentamicin, streptomycin, tobram.ycin}, erythromycin, ASA, antimalarials hypotension (secondary to diuresis): furosemide, caffeine, alcohol
.....
', .1------------------,
Diltfllllpia Tea Have 1he p111ient seated with leg5 extended and head at 45" robdion Rapidly lhift patient to $Upine position wi1l1 head fullv supported in slight
extension (for 45 ObMM for rutatory n'fllllllmus and ask about sensation of vertigo
.....
,,
1. In ganllllll how would you dncriM your l'llalionlhip?
Physical Exam/Investigations syncopal cardiac, peripheral vascular, and neurologic exams bloodwork, ECG, 24-hr Holter, treadmill stress test. loop ECG, tilt table testing, carotid and vertebral doppler, EEG vertiginous ENT and neurologic exams Dix-Hallpike, consider audiometry and MRI if indicated non-syncopal, non-vertiginous cardiac and neurologic exams 3-minute hyperventilation trial, ECG, EEG Treatment guided by history, physical and investigations include education, lifestyle modification, physical maneuvers (e.g. Epley for BPPV), symptomatic management (e.g. antiernetics}, pharmacotherapy and surgery refer when significant central disease suspected, vertigo of peripheral origin is persistent (lasting >2-4 weeks), or if atypical presentation
Scrwning lnlllrument. far Do.-tic
Violence
AJ WASTSHOIT
a. Lot of tension b. Soma llnsion c. No tension
z. Do you and your partner WOik out

IIQilrnanlll with .. .1
a. Gnaat difficulty b. Soma difficulty c. No difficulty

Endoning either question 1 ("a lot of llnsion") or question 2 ("great difficulty") makes intimal8 p11rtnar Ymt.nCIIlq!DIIIn libly
Domestic Violence/Elder Abuse

INTIMATE PARTNER VIOLENCE Definition includes physical, sexual, emotional, psychological and financial abuse (see EmeJi,Cllcy Medicine, ER28) Epidemiology lifetime prevalence of intimate partner violence against women is between 25% to 30% women who experience abuse have increased rates of injury, death and health consequences including 50-70% increase in gynecological, central nervous system, stress-related problems occurs in all socioeconomic, educational and cultural groups with increased incidence in pregnancy, disabled women, and 18-24 age group 25-50% chance of child abuse or neglect in families where abuse occurs physician recognition rates as low as 5% Presentation multiple visits with vague, ill-defined complaints such as: headaches, gastrointestinal symptoms, insomnia, chronic pain, hyperventilation may also present with injuries inconsistent with history Management screen ALL patients always have a high index of suspicion physician is often first person to get disclosure health care visits are an important opportunity for physicians to address intimate partner violence asking about abuse is the strongest predictor of disclosure several screening tools (see sidebar) exist to identify victims of partner violence make sure to determine the victim's level of immediate and long term danger and ask if there are weapons in the house
Bl HITS
Haw often does your p11rtner: 1. Physically Hurt you? 2.1nsultyou? 3. Threetan you with hann? 4. Scream or curse at you?
Each question an HITS to be answered on a 5 poirt scale ranging from 1 navt1rj to 5 fnquandy) A total scare of 10.5 is significant
---"\.
.,
H-ID Documant Abule Take photographs (wi111 permission) of known or suspected injuries Use an injury location chart or "body when documenting physical findings Document any investigations ordered {e.g.x-r.y) Writa legibly or uu a camputsr Ricard the patilnt's awn wards in quotation ITIIrlai Avoid phrases that imply doubt about lha patient's r&liability (a.g. "plllient claims that.. .") lllcord 1he patient's dama11110r {e.g. upset. agitated)
Record the lime of day the patient is IIXIImi'llll and haw much time has
elapsed since the abuse occuned
Toronto Notes 2011
ensure patient safety victim most at risk for homicide when attempting to leave home or following separation provide community resources safety planning includes ensuring that there is access to an exit in the home, establishing a safe place to go and having money, clothes, keys, medications, important documents and other emergency items prepared should the patient need to leave quickly shelter or helpline number with legal advocacy and counselling services involve social workers or domestic violence advocates marital counselling inappropriate until safety is established and violence under control appointment for follow-up to assess whether condition is better or worse reassure patient she/he is not to blame and that the assault is a crime goal is to convey the message that "As your doctor, I am concerned for your safety" and "Your partner has a problem that he/she needs help and "I want to help you" reporting suspected or known child abuse is mandatory (see Emergency Medicine, ER60) spousal abuse is a criminal act, but not reportable without the woman's!man's permission DOCUMENT all evidence of abuse related visits for medico-legal purposes
ELDER ABUSE Definition

mistreatment of older people by those in a position of trust, power, or responsibilty for their care types of abuse: psychological (e.g. threatening, intimidating, insulting. demeaning, withholding information that may be important to them, ignoring) financial (e.g. stealing, pressuring to sell or share home, misusing power of attorney) physical (e.g. hitting, burning, locking in room, inappropriate use of physical restraints, withholding or misusing medication) sexual neglect
....
,,
Rillk facto,. flllllllla Older 11g11 [BIJ8 80 ud olderl
Physicel and mental fraity
Epidemiology
7% of adults in Canada age >65 reported experiences of emotional or financial abuse older adults who live with someone are more likely to be abused than those who live alone 2/3 of reported abuse cases involved family members, most often adult children followed by spouses older females are more likely to be abused than older males men are more likely than women to be victimized by an adult child (45% vs. 35%) women are more likely than men to experience violence at the hands of a spouse (30% w. 19%) (Statistics Canada, 2004) reasons for under-reporting: fear, shame, cognitive impairment, language/cultural barriers, and social and geographic isolation
Screening
insufficient evidence to include or exclude as part of the periodic health examination, but recommended that physicians be alert for indicators of abuse and institute measures to prevent further abuse general questions such as "Do you feel safe at home?" and move into more specific questions about different kinds of abuse
Presentation
signs that an older adult is being abused may include: depression, fear, anxiety, passivity, unexplained injuries, dehydration, malnutrition. poor hygiene, rashes, pressure sores, and over-sedation/inappropriate medication use
Management
gather information from all sources (e.g. family members, health care providers, neighbours) perform a thorough physical examination ensure immediate safety and devise a plan for follow-up additional steps depend on whether the patient accepts intervention and whether they are capable of making decisions about their care interventions may include use of protective and legal services, senior resource nurses, elder abuse intervention teams and senior support groups
Toronto Notes 2011
Dyspepsia
see G6
Definition and Clinic:al Features

defined as epigastric pain or discomfort can be associated with fullness, belching, bloating. heartburn, food intolerance, nausea or vomiting
Epidemiology
annual incidence 1-2%, prevalence 20-40%
Etiology
common: functional, peptic ulcer disease, gastroesophageal reflux disease, gastritis others: cholelithiasis, irritable bowel disease, esophageal or gastric cancer, pancreatitis, pancreatic cancer, Zollinger-Ellison syndrome, and abdominal angina
History
symptoms may not be useful in finding cause association with food, anorexia, nausea, vomiting. NSAID use symptoms suggestive of underlying pathology: weight loss, dysphagia, persistent vomiting, gastrointestinal bleeding (hematemesis, hematochezia)
Investigations and Management

empiric therapy: H 2 receptor blockers, proton pump inhibitors testing for H. pylori: serology, urea breath test upper endoscopy (preferred), upper GI series
Dyspnea
....
',
see
R2 and Emergency Medicine, ER27
History and Physical

cough, sputum, hemoptysis, wheezing. chest pain, palpitations, dizziness, edema asthma, allergy, eczema, ASA/NSAID sensitivity, nasal polyps constitutional symptoms smoking. recreational drugs, medications occupational exposure, environmental exposure (e.g. pets, allergens, smoke) travel and birth place FHx of atopy previous CXR or PFIS exam: vitals, respiratory, precordial, HEENT, signs of anemia/liver failure/heart failure
DDXufDppnR
Pulmonary embolism Oecondilioning ForaV! body aspiration DKA Anemia Asthma

Pneumothorax
Investigations
CXR,ECG PF'IS, ABG acutely if indicated
Management ABC's: send to Emergency Department if in severe respiratory distress

depends on cause
Dysuria
see 1liQlQgy, U4
....
',
Definition
the sensation of pain, burning or discomfort on urination
llilk FactDr. fur Complicatad Urinary
Tract lnr.ctian
Malesex Pragnancy
Epidemiology
in adulthood, more common in women than men approximately 25% of women report one episode of acute dysuria per year most common in women 25-54 years of age and in those who are sexually active in men, dysuria becomes more prevalent with increasing age
Rei:ent urinary 1rllct in&lrumenflltion Functional or anatomic abnormality of the urinatY 1r11ct
Chronic r.nlll disa111
Diabelel
lmmuno&Uppreuion
Etiology
infectious most common cause presents as cystitis, urethritis, pyelonephritis, vaginitis or prostatitis non-infectious hormonal conditions (postmenopausal hypoestrogenism), obstruction (BPH, urethral strictures), neoplasms, allergic reactions, chemicals, foreign bodies, trauma
Indwelling catheter
Toronto Notes 2011
Table 20. Etiology, Signs and Symptoms of Dysuria

lnflctian U11/Cyllitil Etiolagy
Signs and Symplllms

Intimal dysuria 1hraughaut micturition, urgency, incontinence, hematuria, nocturia, back pain, suprapubic discomfort. low grade fever (rare)
0... . . . _
u_..lcQt
E aJii, S. siiJIIIlllhytil: Proteu5 minlbilis, Entenlllacter, Klebsiella, Pseudomonas
JAAM 2002; Z81:Z701-Z710 To IIView tt. acancy IIIII precisiln
"'-e;
Urdritis
Vaginilil
strophic. hetpes. lichen sclerosis
C. tnlr:/Jom6tis, N. gononfJee. Ttidromonas, Initial dysuria, uretlnVvaginal discharge, histury of Sll CandKJa. herpes CandKJa. Ganfnelela, Ttichomonas.. c. tnJchomatis, External dysurill/pain, vaginal discharge, irritation,
dyspareunia. abnormal vaginal bleeding Dysuria, fever, chills, urgency, frequency, tender prostate Intimal dysuria. fever, chils. flllnk pain radiating to groin. rNA tendemess, nausea or vomililg
liT1 in Study Chnctllilliz Systemltic mriew 1'19 IWR laokiJu lithe ICCUICY ar pi!Cilill(i listory or phy!ical mrrinrion in ...compli;Qd UTI.
l'lrlil:i!IBI: Hlllthy chik11111 oradoillll:8nll, pragl1llll wumun. hln pllilnts, ll1d patients willl compli;Qd UTI-
E aJii, C. trachomalis, S. saprophyticus. Proteus mir&biis, Enlllrobaci!IJ; Kltbsi8118, PseudomontJs
PyeloniPhritia E aJii, S. siiJIIIlllhytil: Proteu5 minlbilis, Enterobect8J; Klebsiellt. Ps811domontJs
Investigations no investigations necessary when history and physical consistent with uncomplicated UTI treat empirically (urinalysis can be performed when indicated by dipstick or microscopy) radiologic studies and other diagnostic tests if atypical presentation urinalysis/urine R&M: pyuria, bacteriuria, hematuria urine C&S if vaginal/urethral discharge present: wet mount, Gram stain, KOH test, vaginal pH, culture for yeast and Trichomonas endocervical or urethral swab for N. gonorrheae and C. tTachomatis renal U/S voiding cystourethrogram (VCUG) in children with recurrent UTI Management UTI/cystitis pregnant women with bacteriuria (2-7%) must be treated even if asymptomatic, due to risk of preterm labour; need to follow with monthly urine cultures and retreat if still infected patients with recurrent UTis (>3 per year), should be considered for prophylactic antibiotics if complicated UTI, patients require longer courses of broader spectrum antibiotics urethritis when swab is positive for chlamydia or gonorrhea must report to Public Health all patients should return 4-7 days after completion of therapy for clinical evaluation
el!CIIded. . . llllllara: l'rlcilian llld ICCIIIICY rllli!lory 11kilg ml physicll 01111. bltdll: No sbldies axamilld precisian as n M:ome. llld one sign illl:lllllld 1ha problbiily lll/Tl: dyuil. hlmlnlil,lill:k (llin,llld CVA llndlmla. Four sympiDmS and one lign siglliic11111y dacl'8llld lb!anca ablnca II blc:k plil, a history of vagillll c1sc1wve. a listory Vl(lillll irrilllian, ml . . . dilcbltgt 111 mminltioa. Clncbiul:\\lnnanwhoprasartwitli 1or
inlllciim. Addili011ll hnricll......,lllri!ical IIIIITinl!ion, llld llilllysil illlllbil fD lowlr the post-las1 alliT1 fD aiMlwlwt kc111 be ruled cU. Addili011ll testing, sud! as We, lillllld hi (IIIUid.
....
,,
Pnlnntion of UTI o Mainlllin good hydmion with crllflbeny juiceI WIPe urelhra from front to back to
avoid contamination of the urethra

o
Epistaxis
see Otolar_yngology, OT27
Table 21. Characteristics of Anterior n. Posterior Bleeds Anterior 190%)
,_.ior{IO%)
with t.cn from raCIUm Avoid feminine hvuiene sprays 1nd scented douc:hes Empty blldder immediately before and lifter inlll!course
m.
l.ocltiDIV Origin Little's Aret,IKiesselbach's Plexus

Age 2-10,50-80 Common Cause Trauma (digital, fracture, foreign body), dry air, coal clinate. past URTl, nasal dryness. chamical (nasal sprays, cocaine), tumour Traatmant
Woodruff's Plexus/Sphenopalatine Artery
Usualy >50
Syrlamic: hepatic disease, primary/secondary bleeding disorder, medications (ASA, NSAIDs, warfain), HTN, a1herosclerosis
Conservative: Emergerx:y: ENTlER consult for posterior packing o Position: upright leaning forward direct digital with an intranasal balloon/Foley ca1heter Embalimtiol\"surgery pressure over soft part of nostril for >10 min ("pinch" up to cartilage) o Humidiier in bedroom, nasal saline sprays, bacibiacin or Vaseline3 application to Utile's area Silver nitrate GelfoamiHemosllrt o Nasal packing with Vaselineat gauze, nasal catheter or sponge o Cotton soaked in vasoconstrictor (oxymetazoline 0.5%) and topical anesthetic (4% lidocaine) placed in anterior nasal cavity with direct pressure for >10 min Investigations: CBC, Hct, cross & type, INR, PTT (only if severe), CT/nasapharyngoscopy if suspected tumour Usually with > 10 min of pressure to nose Copious bleed, aflm swallowed and vomited May lead to hypovolemic shack if nat treated
Prognlllil
Toronto Notes 2011
Erectile Dysfunction (ED)

see Urolo!D'" U30
Definition
-------------------------------------
consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual performance of <?:3 months duration
Epidemiology -20% of men aged 40; -50% of men aged 70 Etiology

organic: vascular (90%) (arterial insufficiency, atherosclerosis), endocrine (low testosterone, diabetes), anatomic (structural abnormality e.g. Peyronie's), neurologic (post-op, DM), medications (clonidine, antihypertensives, psychotropics) psychogenic (10%) Tabla 22. Diffarantiation Blrtwaan Organic and Psychogenic Erac:tila Dysfunction
Onset Gradual Global
Acute
Situational
Caune
Nan-caitalerec:ti111 PlychDIIXUII prablam Partner prublem Anxiety and fear
Constant Poor
Secondary Secondary Secondary
V!rying
Rigid
Long history
At on5et Primary
History
comprehensive sexual, medical and psychosocial history time course last satisfactory erection gradual or sudden onset attempts at sexual activity quantify presence of morning or night time erections stiffness (scale of 1-10) ability to initiate and maintain an erection with sexual stimulation erection stiffness during sex (scale of 1-10) qualify partner or situation specific loss of erection before penetration or climax degree of concentration required to maintain an erection percentage of sexual attempts satisfactory to patient and/or his partner significant bends in penis or pain with erection difficulty with specific positions impact on quality oflife and relationship
Mid....
t F.-. ...Chi. . ..., lilt? Eldll C.liflllojll
l.tOOgy 2lnl; 56:302-3)6
Sl.dr. APIOIIIICtiw cohort study designed Ill
11JQ1111ile Mlether chilloes il1111oking. llelvy lllcohal canllqliln, lldmty illlytl, 11'111 obelij;y 1re IIOClltld will the risk of ED in 111111
Investigations
hypothalamic-pituitary-gonadal axis evaluation: testosterone (free + total), prolactin, LH risk factor evaluation: fasting glucose, HbA1c, lipid profile others: TSH, CBC, urinalysis specialized testing psychological and/or psychiatric consultation in-depth psychosexual and relationship evaluation nocturnal penile tumescence and rigidity (NPTR) assessment vascular diagnostics (e.g. doppler studies, angiography)
llglld41HO. "--Il: Obesity WISISSOCial. al IP=D.OO&L ollelily hp risk rllllblllpnt Wligltt lass.IMI rl pifflicllldivityWII..alud Mil Bl (P=0.01(: 111011 ili1illing lli!YiicaiiCiiYily or Nmlirilg ICIM hid IIDWel risk Df ED, wflile those wbo remlined dlnllly hid aliglllr rilll AI carnpmd ID lllair sedmry lllose wbo iililted mam:ise il midliflhlda70'follllllcedED1118.a.... il !lrUkilg or ak:ohol inllke were not associlll!d will! Bl(P>0.3I. Can-....: Mlloogh making lflllytl chlngls in mn lTIIf be 1DO 11111 lllTIMII'IIIIII lffim r1 lnllkilg, *'j;y, and llaJhol 011 Ell, inililli'G physicalactMiy il midife nay in IJct raib:t Bl rall1ivi!D J111r1 wbo r.Mirllldlruy. 1 helllhy lifest1e ellty il lilenybethe belt approecii1D raGicilg IIIII riat al davekfing ED in lll!rye111.
with._
conr.mv
Management
Tabla 23. Managamant of Eractila Dysfunction
Pluullllculagic
l..if85tyle changBii (alcohol, smoking, exercise)
Relatiooshi(isexual counselling
Surgical
Implant&
VBSCular repair
Oral agm
Suppository (MUSE: male urettnl suppository for erection)
Realignment
Vacuum devicBii
l!lections
Toronto Notes 2011
pharmacologic treatment phosphodiesterase type 5 inhibitozs (see Table 24) alpha adrenergic blockers (e.g. yohimbine) serotonin antagonist and reuptake inhibitor (e.g. trazodone) testosterone - currently only indicated in patients presenting with hypogonadism and testosterone deficiency (note: breast/prostate cancer are absolute contraindications)
Table 24. Phosphodiesterase Type 5 Inhibitors

Exlmples sildenafi (V.agra<el tedelafii(Cialisl menafil (Levilra) D01ing(l dDIIW'dlyj
Specifics
Sida Eff8c:ls
Centrlildicllions
251DO !rWdose
Taka 0.5-411' prior111 inllrtoursa Rushing. headache, Not to ba used in patienbi May lest 24 hours ildigestion teking Eflects may last 36 hours Take 1hr prior ID intercourse
5-20 m!lfdose 2.520 mgfdose
As above As above
As above
As above
Fatigue
Epidemiology
25% of office visits to family physicians peaks in ages 20-40 women 3-4x >men 50% have associated psychological complaints/problems, especially if <6 month duration
'hdg1111 Rid Rags

Fever
Waight loss
Night swell!$ Neurological dalicils
Tabla ZS. Differential Diagnosis of Fatigue: PS VINDICATE
P
S Psydlagenic Sedentary Depreaian, sleep dilonler,life strenes. anxisty disorder, chronic fatigue syndroma. fibromyalgia UnhiB!hy/sadentary
V
N
Vascular Infectious
Naoplallic
Nutrition Neurogenic
Stroke V"nl (e.g. mononucleosis, hepatitisI. bacterial (e.g. lBI. fungal, parasitic, HIV
Airt malignancy
Anamil (Fe deficiency, B deficiency! 12
Myasthenia pis, multiple sclerosis, Parkinson's Disease
D
1
Drup
Idiopathic Chronic illnesses Autoimmune Toxin Endocrine
Beta-blockers, antihistemines. anticholinergics. benzodiazepines. antiepieptics CHF, lung diseases (e.g. COPD, sarcoidosis), renal faiure, chronic liver disease
SLE. RA. mixed connective tissue disease, polymyalgia rheurnatica
Sullstlnce abuse (e.g. alcohol), heavy melal
Hyplllllyraidism, dilbates, Cushing's
insufficiency, Jlll!llnancv
C
A
T
Common causss aru in bold.
Investigations
psychosocial causes are common, so usually minimal investigation is warranted physical causes of fatigue usually have associated symptoms/signs that can be elicited from a focused history and physical examination investigations should be guided by history and physical and may include: CBC + differential, electrolytes, BUN, Cr, ESR, glucose, TSH, ferritin, vit B1z, total protein, albumin, AST, ALT, ALP, bilirubin, calcium, phosphate, ANA, beta-hCG urinalysis, CXR, ECG additional tests: serologies (Lyme disease, hepatitis B and C screen, HIY, ANA) and PPD skin tests
Treatment
treat the cause if etiology undetermined (underlying cause cannot be identified in 1/3 of patients) reassurance and follow-up, especially with fatigue of psychogenic etiology supportive counselling, behavioural, or group therapy encourage patient to stay physically active to maximize function review all medications, OTC, and herbal remedies for drug-drug interactions and side effects prognosis: after 1 year, 40% are no longer fatigued
Toronto Notes 2011
CHRONIC FATIGUE SYNDROME (CFS) Definition (CDC 2006) - must meet both criteria l.new or definite onset of unexplained. clinically evaluated. persistent or relapsing chronic fatigue, not relieved by rest, which results in occupational, educational, social, or personal dysfunction 2.concurrent presence of at least 4 of the following symptoms for a minimum of 6 months: impairment of short-term memory or concentration, severe enough to cause significant decline in function sore throat tender cervical or axillary lymph nodes muscle pain multi-joint pain with no swelling or redness new headache unrefreshing sleep post-exertion malaise lasting >24 hours exclusion criteria: medical conditions that may explain the fatigue, certain psychiatric disorders (depression with psychotic or melancholic features, schizophrenia, eating disorders), substance abuse, severe obesity (BMI >45)
CIJdJtla DlltJbae oJS)'ll!mlfi: IIIMilws 21104; Issue 3 .......:To damila 1ba lllac:tiwrl8ll riiiXBllRe 1llerlpy Ia! Chronic htip (CFSI. ......_.: IVVirN rl 5RCTwi1b 336 piliiiD Ill with aclirical dilgnasis Ill CR. lllllrnnlianl: Exun:ile lhullpy alune Wll compnd wi1b trmnant u IIIUII (or llllmion llld flrllibiilyj, 01 phii11111C01h1Apy Of pltilllllll!CIIim. 11116: P4 12 pltilnll undllgailg llllll:iie 1llerlpy were less fa1ipd 1ban conlrols (Sr.ll .0.77; MCI. 1.2511:1.0.281. Pilyli:IIUiclionirG - butlhnwm 1110111 dlopW Mil - 1barapv. >Mill fjJOXIIiie, pllianiJ IIC8iiilg llllll:iie liiiiiVt'
eoctnne De!msioll. Araiety,and Newun llloup.
blrcile ....,. fir Clnnlc Flligle
Epidemiology FM, Caucasians> other groups, majority in their 30s CFS found in <5% of patients presenting with fatigue Etiology unknown, likely multifactorial may include infectious agents, immunological factors, neurohormonal factors, and/or nutritional deficiency Investigations no specific laboratory tests diagnose CFS Treatment promote sleep hygiene provide support and reassurance that most patients improve over time non-pharmacological regular physical activity optimal diet psychotherapy (e.g. CBT), family therapy, support groups pharmacological to relieve symptoms: e.g. antidepressants, arudolytics, NSAIDs, antimicrobials, antiallergy therapy, antihypotensive therapy (increase dietary sodium, fludrocortisone)
-u.
were less flligued (WD -1.24; 9S!I. Cl, -5.311o 2.831. PllilrD fiCiiving corililllion 1iiiiii'Y Mdl earcise111ef111JY 11111 li1her butine 01 pltillt adUCIIion. did belhlr 1ban 11101& on monotllllfi!IY. l'llienl$rn11'benefilfqmexercise 1barlpy. Cadillllian lilmpywilll lilbar fjJOXIIiia Of llb:llian IIIII' . . addilillllll illnllit. Fllu. lliglllfllily lrilllata naadad.
Fever
T1ble 26. Differenti1l Di1gnosis of Fever

Infection Bacterial Viral
Cancer
Leukemia Lymphoma Oth11r MaliiJiancius
Medications
1B
Allopurinol Captopril Cimlllidina Heparin INH Meperidine
Nifidepine Phenytoin Diuretics Barbiturates Anlihisbrnines
lnilable Bowel Disease Collagen-vascular disease DVT
Definition mean oral temperature = 36.8"C, unadjusted TM temperature is 0.4"C lower, rectal temperature usually 0.4"C higher diurnal variation: usually 0.5"C higher at 4PM vs. 6AM fever= oral temperature >37.2"C (AM), 37.7"C (PM) History fever peak temperature, thermometer, route time of day response to antipyretics systemic symptoms weight loss, fatigue. rash, arthralgia
Toronto Notes 2011
symptoms of possible source UTI/pyelonephritis: dysuria, foul-smelling urine, incontinence, frequency, hematuria, flank pain pneumonia: cough, pleuritic chest pain URTI: cough, coryza. ear pain meningitis: headache, confusion, stiff neck, rash osteomyelitis: bone pain skin: purulent discharge PID: discharge, dyspareunia gastroenteritis: abdominal pain, diarrhea, blood per rectum, vomit medications DVT: swollen legs, pain in calf, shortness of breath, pleuritic chest pain history of cancer/family history of cancer infectious contacts travd history, camping, daycare, contact with TB, foodbome, animals
Investigations CBC & differential, blood culture, urine culture, urinalysis stool O&P, Gram stain, culture CXR, TB skin test, sputum culture
LP
Management general: sponge bath, light clothing acetaminophen/ibuprofen as needed treat underlying cause
Joint Pain
see RbeumatoloflY. RH3
Table 27. Differential Diagnosis of Joint Pain

Non-Articular Gennized
Bursitis Tendonitis Capsulitis
Fibromyalgia Polymyalgia rhaumatica
lnftunmlllny
Seropositive Rhaumalllid Primary
milial Hebarden's node

lnllammlllory ostaoarthritis RB!Jonal hip or knee
Systemic klpus erythematosus

Scleroderma Polymyositis Sjogran's syrd'ome Seronegative Ankylosing spondyitis ln115l'flllltory bowel di5eil58 Psariatic arthritis Reactive arthritis Crystal Gout
Secondary
Metabolic H111110philiac Neuropathic

Tll!Umatic
Pseudogout Milwlluba shoulder, calcific periarthritis

Infectious Gonococcal Non-gonococcal
History number of joints involved - monoarticular, oligoarticular, polyarticular pattern of joints involved- symmetrical vs. asymmetrical, large vs. small joints, axial skeleton relation to activity (inflammatory better with activity, degenerative worse) relation to rest (inflammatory worse with rest, degenerative better) morning stiffness >30 minutes (inflammatory) soft tissue swelling, erythema (inflammatory) onset- acute vs. chronic (>6 weeks) trauma, infection, medications (steroids, diuretics) FHx of arthritis co-morbidities: diabetes mellitus (carpal tunnel syndrome), renal insufficiency (gout), psoriasis (psoriatic arthritis), myeloma (low back pain), osteoporosis (fracture), obesity (OA) constitutional symptoms {neoplasm)
Common Presenting Problems systemic features fever (SLE, infection) rash (SLE, psoriatic arthritis) nail abnormalities (psoriatic, reactive arthritis) myalgias (fibromyagia. myopathy) weakness (polymyositis, neuropathy) GI symptoms (scleroderma. IBD) GU symptoms (reactive arthritis, gonoccocemia)
Toronto Notes 2011
Physical Exam
vitals specific joint exams systemic features {skin, nails, eyes, hands)
Investigations
CBC +differential, ESR, CRP, RF, ANA, HLA-B27, serum uric acid, calcium urinalysis tissue: cultures
x-ray
joint aspirate for cell count + differential, culture, Gram stain, microscopy
Headache
see Neurology. N39
Primary Headaches
Table Zl. Primary Headachas
Migraile EpidBmiolagy 12% of adulll F>M 80% without aura S.72 hrs Tensillftotype 311"11. of adulll, can be episodic or chronic
< 0.1% of aclllts, M F
-50% of people drinking
Duration
Pain
llellll.cbl Rid Rllp Sudden 011set of seven headache Worst tlaadache evw New headache alter age 50 Headache prwent an aWllkening lmpilired mental sllltus f81111r Neck stiffness
Classically unilateral and but 40% are bilalerlll, moderat&-severe inl1111sity, nausllil/vomiting. photQiliJonophobia
<3 hrs a1 same time of day May occur as isolated ilcidanl or daily, dullllion is variable Mild to moderate pain, Sudden. unilateral, severe, bilalerlll, or usually centered around eye, generalized pain, frequently awakens patient pain. conlraclld neckf scalp muscles. associated little disability
Stressful events, NOT aggravated by physical activity Often alcohol
Begins 12-24 hrs after last caif8ile intake, can last-1 wk Severe, throbbing, associated with drowsiness, anxiety, muscle stiftn85&, nausea, waves of hot or cold sensations Disconlinuing caffeine
Seizurn FOCIII neural011ic deficitl

Jaw claudicllli011
Scalp tenderness
Worse
VllsalVll
exercise, sexual activity ar
Numerous (e.g. food, sleep di&turbanca, stra5&, hormo111l, fatigue, weelher, highaltibJde) Aggravated by physical activity Traabnantrl 1"1ine: acatamino!iJen. ASA. caffeine Acute 2"4 1ine: NSAIDs he :fliline: SHT agonist! anliematic 1"1ine: beta-blockers 2"'1ine: TCAs :flilina: anticonwlsants
Triggers
Rest and relaxation NSAIDs
Surnatriplall Dihydroergollmine lrrtranasallidocaine
Caffaine Acataminoph1111 or I-SA caffeine
Rest and relaxation. physical activity,
carbonate, prednisone, methysargide
Cut down on caffeine
biofeedback
Secondary Headaches
caused by underlying organic disease account for <10% of all headaches, may be life-threatening etiology space-occupying lesion systemic infection (meningitis, encephalitis)
stroke
subarachnoid hemorrhage systemic disorders (thyroid disease, hypertension, pheochromocytoma. etc.) temporal arteritis traumatic head injuries TMJ or C-spine pathology serious ophthalmological and otolaryngological causes of headache
Toronto Notes 2011
treatment based on underlying disorder analgesics may provide symptomatic relief
Investigations indicated only when red flags are present and may include: CBC for suspected systemic or intracranial infection ESR for suspected temporal arteritis neuroimaging (CT or MRI) to rule out intracranial pathology CSF analysis for suspected hemorrhage, infection. tumour or disorders related to CSF
Hearing Impairment
-------------------------------------
see OtolaryniQlogy. OT9
Definition hearing impairment: a raised hearing threshold measured as decibels of hearing loss relative to the normal population at specific frequencies hearing disability: hearing impairment that interferes with performing daily tasks Epidemiology 10% ofthe population is hard ofhearing or deaf 90% of age-related hearing loss (presbycusis) is sensorineural hearing loss detectable by audiology is present in greater than 1/3 of people over 65 associated with significant physical, functional and mental health consequences Classification conductive (sound does not reach cochlea) sensorineural (sound is not converted or transmitted via neural signals)
mixed
ao.llill'llillllhnl ..... .w.tA 2006; 295:416-4211 evUII bedsidet:iliclllTIIIIIIIMn Ul8d 1D MllltS 1118 pmanc8 ti impaimt Sbldr. EWianoHald r1Nilw allludi1111111111ining
,..,_To
CaltcMII: Bdlltt PlllianiJ MID tamg hauilv irnpMmanl ilwll be allnl lllliamaby, whii&U..Mioda nat llllould und&'ga
lhiiiCCUIKY II' 11'111 IBill. 24 Ada& Wlll8 ilc:Uiad il thii 1111tjiis.
nvf1ilpnckai:8111t n-wlloha1118 wtilpnd voice no llrthlr l8llilg. wllia those wf1o do IIIII 111diometr{. The Wehel 11'111 Rinra tlllln nat IJI8U in lor
Assessment infants universal newborn hearing screening program elderly whispered-voice test whisper six test words 6 inches to 2 feet away from the patient's ear out of the visual field, ask patient to repeat the words (with non-test ear distraction) tuning fork test Rinne and Weber (not for general screening) audioscope delivers pure tone frequencies to obtain thresholds for frequencies of 250-8000 Hz Management counsel about noise control and hearing protection programs (grade A evidence) refer patients with hearing loss for a complete audiological examination hearing amplification (e.g. hearing aids), assistive listening devices, and cochlear implants can dramatically improve quality oflife
Hypertension
Epidemiology 20-25% of Canadian adults have HTN (and up to 50% undiagnosed) 16% have adequate BP control approximately 50% of adult Canadians are hypertensive by age 60 3rd leading risk factor associated with death risk factor for CAD, CHF, cerebrovascular disease, renal failure, peripheral vascular disease Definition hypertension
BP :<:140/90 mmHg (see Figure 9) isolated systolic hypertension sBP::<:l40 anddBP <90 associated with protf.:.ssive reduction in vascular compliance usually begins in 5 decade; up to 11% of 75 year olds
',..,
Symptoms of hypertension are usually NOT PRESENT (this is why it is called h "sillnt kin."l.
May haw occipital headache upon awabning or organ specific complaints I advanced dis8U8.
Toronto Notes 2011
llyperblin Emlfllllnc-.
1. Al:c.larat8d IUiignant IITN with
paplledernll
Z. CINIIroviiCular: Hypenansive encephalopathy CVA with severe hypertension lntrac1r.bnl hlmorrhavSAH 3. C.rdiiC:
Acute aortic dissection Acute rafracmry LV fllilura AciD Ml with pnistant isch1111ic pain altar CABG
4.Rinal:
accelerated hypertension significant recent increase in BP over previous hypertensive levels associated with evidence of vascular damage on fundoscopy but without papilledema malignant hypertension sufficient elevation in BP to cause papilledema and other manifestations ofvascular damage (retinal hemorrhages, bulging discs, mental status changes, increasing creatinine} not defined by absolute level ofBP, but often requires BP of>200/140 develops in about 1% ofhypertensive patients hypertensive urgency sBP >210 or dBP >120 with minimal or no target-organ damage hypertensive emergency high BP +acute target-organ damage Etiology essential (primary) hypertension (>90%) undetermined cause secondary hypertension (10%) watch for labile, white coat" hypertension (office-induced elevated BP) Predisposing Factors family history obesity (especially abdominal) alcohol consumption stress sedentary lifestyle smoking male gender age >30 excessive salt intake/fatty diet African American ancestry dyslipidemia
Table 29. Causes of Secondary Hypertension
Acute glomerulonephritis R-1 cri- from collagen vascular di1i811&81 Severa hypertension following ranal
lllltwhal........:
s. U.uiwl circull.lilll
Pheochromocytoma Tyramine contailing foods or drug
interactions with MAOis Sympathomimetic drug use (e.g.
1nlnsplanllltion
cocH1a)
Rebound HTll altar CGSSition of hypertensive drugs (e.g. clonidine) &. Eclampsiro
1. Surgillllt
lines I. HTW fallawlnt- bums 9. S.V.ra 111istusis
Severe HTN prior to surgery Severe post-op HTN Post-op bleeding from IIIISCular suture
Obltnu:tin SIIIP Apnea

CluHI of S-nduy Hypert8nsion
ABCDE
Ca11m111 cau
Renawscular HTN Renal parenchymal disease, glom1111lonephritis, pyelonephritis, polycystic kidney
Renal Endocrina
Apnaa, Aldostaronilm
Bruib, Bad kidneys Coan:tation, Cushing's, cmcholamina,
1 hyperaldosteronism
Pheochromocytoma Cushing's syndrome Hyplrlhyroidisrnlhyparparathyroidism Hypercalcemia of any cause
Calcemia
Drugs Endocrine disease
Coan:tation of 1he aorta Renal artery stenosis Estrogens MAOis Cocaine Steroids AlllJhataminas
NSAIDs
Decongestants Alcohol
....
.. ,
}------------------,
bp til Gr of RecammendW.. t. Hypartenalon Dillgnallis end
Trellmlnt
Grade A High levels of intamal validity and siBiistical precision
arc
D
Lawar levels of intamal validity and siBiistical prvcision

Elcpert opinion
Investigations for all patients with hypertension (D) CBC, electrolytes, Cr, fasting glucose and lipid profile, 12-lead ECG, urinalysis for specific patient subgroups (D) DM or renal disease: urinary protein excretion increasing Cr OR history of renal disease or proteinuria OR HTN resistant to 3 meds OR presence of abdominal bruit renal ultrasound. captopril renal scan, MRA/CTA (B) if suspected endocrine cause: plasma aldosterone, plasma renin (D) if suspected pheochromocytoma: 24h urine for metanephrines and creatinine (C) echocardiogram for left ventricular dysfunction assessment if indicated (C)
Toronto Notes 2011
Diagnosis
HYPERTENSION VISIT 1
Hypertensive Urgency/Emergency
+
+
Wliflt, l'llpical FiiiBSS IIIII B d ,.,_... ..
t.dnl.
_....:.V.=----+ Diagnolialll' HTN
I'IEIIIEICIIUcntivl lllllelrch ' Mil ilfem Med ZOO&; 4;1-"171:127 .....11: To aiZIIIIyll
,.._..hi'-' ..... Iran..
sBP "'140 and/or dBP :!90

2 mora mdings during sama visit
1RCIIIicltian iiDMmlioni llOI1'fll'8d 1o lllvice hyperllnsilm . . . Jjood p18AUR1,1111d lleslyle chlnoes. Study: WlicerU8. 1llldomiz8d bill ...... 810 will!
S..n:h far tarvat arpn da..age
Global CardiovuciAr Risk Age Mala gander Pollmanopausll Smoking High cholesterol Dtl\llmJIIIillld gluco.a mle11111ce Family history <55 i1 men, < 65 in women] Obesity
.A.k
Hx Hx TIIVStrolat Hxof PVD (i.e. claudicalionl Hx nmal disease
Raview MadiCllll Record and
Exami.. CanliOVIIIcular exam NaurologiCllllaxarn for focal nauro signs Fundoscopy for retinopathy YIISCUiar exam (pul11s, bruit, AAA)
lnvasligalians CBC K. Na. creatinine Fasting glucose Fasting mtal choiNterol HDL. LDL. TGs Urinalysis Standard 12-laad ECG
IIIIMnlilu: imlmnlion using elllblished rllllhlilllllfl ,_,.. .,....,. pkls tie Dnly Approaches ID SIDp Jlpeitension IIIASHI rllllblllied +llASH1 11111, anc1 lilviceOitfmn.
. . ....... lialtytllillibilllld hllod
Wilt i1CliCid flil boeh iiillrVInlion 1111111 CGII1IIild
lllidll: At II i1liiMhl, alisalda liiDDd pr8IIIRS
tu ldvi:e only hut diflelences -IICII-significllll.

18mllllfiiMII
TW.Icedfar balh1rellment nns tu 1i1vice Oltf. S1ltilticaly aOifant waigli lois. llll irDIIe and SOiblilllke- nolal flll bolfl
traiibiWtllliil.
HYPERTENSION VISIT 2
Wrthin I month Target organ or diabetes or Yes chronic kidney disease or BP :!I 8111110 mmHg
Di..nosis of Hnl
Clinic liP Monitoring HYPEmNSION VISIT 3 sBP :!160 mmHg and/or dBP :!1 DO mmHg Or HYPEmNSION VISIT 4-5 sBP :!140 mmHg dBP :.90mmHg
BP: 14G-17919G-I 09 mmHg
OR
OR
Ambulltory Blood Prauura Monitoring

Mean Awake: sBP :!135 mmHgandlor dBP :!85 mmHg Dr Mean 24hour: sBP :!130 mmHg dBP :!80mmHg
Salf/llo..e Blood Praaura ManitDring sBP :!135 mmHg and/or dBP:!85 mmHg
lllillb;IIJiudrWtigM:Iar ea.tdlg H,pnllloninM*I Codnne iJiflbaN Rflliews 11118: IID4 A sys11mltic: l'l!lliew of eigiDen 1rills liiawed hi waiQht-111cU:iig dills in IMIWiligli liyplrtansiva can lffect modest weiiJid loss il the range fl 3-3 rJ bodrWiiglt lll1d lit publbJv IIHOCillld l'liGI modest blood pmue llilc.- of i!liiglilv 3 nrnHg l'flldic li1d di.tulic. W&ijit-Riducing dills meydlc:l.-
111uidaa .lAMA 21)02; 288:2881-1'7 Study: Rllidomized. ddkl-lilnd. dw-IXIIIIniled t:iaicll trill Mh 1111111 lalbwiip 4.1 yam. 1'1111111: 33,357 (mlln IIIII 61y, 53\
llillllllnl,.okCHDrisli.IICIIir. .......: tu IICIM cl'lartlielidonl (12.W5n'G'dl.lllllldi>ila (2.S.IIlmll"dL Drhiiopril (10-40mll"dl. Tuget BP - <I WI) mmHg.ICiiiiMid bytibalirJ llil ISSigned stilly drug.llllldling open-lllieiiiQIII!s wliln nacaay. IMcaiiiC n. prinwy OUII:oml Will carliinld lllliil CliO or .-filii Nl. Seconduy IU!:om111 snkl. cariliild CHD. IIIII t:Gitined 00
-ALIMT
Oiagnaei of Hllil
Continue to Follow
Figure 9. Approach to Hypertension

Adlpllld from: 11ltc-fln ..bllllldCinilllgyliXI;22(11:571.
Treatment
target BP is <140/90 mmHg, <130/80 ifDM or chronic kidney disease lifestyle modification (in all H1N patients) maybe sufficient in patients with stage 1 HTN (140-159/90-99) diet follow Canada's Guide to Healthy Eating (see Nutrition, FM4) and DASH (reduced cholesterol and saturated fats) (B) limit daily sodium intake to 65-100 mmol (1.5-2.3 g) (B) potassium/magnesium/calcium supplementations are NOT recommended fur H1N (B) moderate intensity dynamic exercise: 30-60 minutes, 4-7 x/week (D); higher intensity exercise is no more effective (D) smoking cessation low-risk alcohol consumption (see Alcohol, FMlO) (B) achieve and maintain a healthy BMI (18.5-24.9) and waist circumference (< 102 em for men, <88 em for women) (C); BP will decrease by 4.0/2.8 mmHg for each 4.4 kg of weight loss; use multidisciplinary approach to weight loss (B) individualized cognitive behavioural interventions for stress management (B)
llnlll: ThnWIII 110 signilcll'ltdir- in eitber the prinllly GUtcome or III-111C1111ily hltwalll traiibiWt fJ111411. For llliidipina 111. t:Noitllllililie, S8l:alidliy were .-.r uceptlan higher s.,.,.i'llli of 118utlaita with .nodipine (10.2\vs. 7.7'/o; p<O.OOJI. Forisilopril
VI. clilortlilidCIII, iinapriiiMid IMglilllr.,miiiBI II CIIIIDn.. CV1l (33.3\w. 30.9'1; p<0.001], 11nib {6.3\w. 5.6% 1wt llilull (8.7\ VI. 7.7'/o; p<O.OOI ). CancbiP: lliUdt-typa .,.., ... superior to CCSIIIII ACB flil p!MIIIing 11118 or millllllljor fliln. CVD, willi limilu . . . dlltti li1d mfllalMI.
Toronto Notes 2011
Calcillm Chllnntl Blockers Dihydropyridine CCBs amlodipine nifadipine felodipine Non-<lihyllropyridine CCBs
dillillam
verapamil
pharmacological indications regardless of age:, be c:autious with frail c:lderly patients mmHg with target organ damage or independent cardiovascular risk factors (A) dBP mmHg (A) or sBP mmHg (A) without target organ damage or dBP cardiovascular risk factors with target organ damage sBP if partial response to standard dose monotherapy, add another first-line drug (C) caution with combination of non-DHP CCB and beta-bloc:ker (D) combination of ACE inhibitor and ARB is not recommended (A) if still not c:ontrolled or adverse effects, can add other classes of anti-hypertensives (D) choice of therapy in patients with unique conditions (see Table 30) most patients will require c:ombination therapy for optimal control
11;1
H- to Comline Antihypert.IIIM
Mldicllli-
ACEI
Beta-blocker Diuratic
CCB
1><1
Follow-Up assess and encourage adherence to pharmacological and non-pharmacological therapy at every visit lifestyle modification -+ q3-6 months pharmacological q 1-2 months until BP under target for 2 consecutive visits more often for symptomatic: HTN, severe HTN, antihypertensive drug intoleranc:e, target organ damage q3-6 months once at target BP referral is indkated for c:ases of refrac:tory hypertension, suspec:ted sec:ondary c:ause or worsening renal failure hospitalization is indicated for malignant hypertension
Tabla 30. Pharmacologic Tralltmant of Hypertanlion in Patients with Unique Conditions

Canditi111 or llilk FICIDr
lsalltBd llintali: HTN
Recammanded Drup
Thiazide diuretic Monotherapy with law dose diuretics
Ahnativa Drup
(age < 60) ACEI or ARB or CCB Lang actilg dihydropyridine CCB or ARB or long-acting CCB ff stable angila ARB (if intolerant Ia ACEI) CCB if P-blocksr is conlnldindicated or ineffective
Nat Recannded
a-blacksr, P-blacksr monotlunpy {age >60) a-blocker, manotherapy with Short-acting CCB (nifl!dipine) ACEI + ARB if no co-existing systolic hllll't failura CCB if evidence crf heart faiure
Ischemic Heart Disease (IHDI
ACEI
Recent STEM I or NSTEMI P,.blocker + ACEI
Left Ventri:ullr
Hyplll:roplly
(stroke/fiA)
LaniJ-ICiing CCB, or thiazide diuretic
Direct arterial vasodilators: hydralazine, minoxidil ACEI + ARB aftur astroke ARB (if intolerant to ACEII Hydralazine + isasorbide dinitrate (ff ACEI +ARB contraindicated) CCB
Cerebravuc:ulllr Disease ACEI + diuretic
Systolic llyslunctian
ACEI + (diuretics as therapy! Aldosterone antagonists for NYHA Clan 111/lV or po&tMI ACEI + ARB (uncontrolled HTN)
Carefully monitor for s/e if using ACEI +ARB
Dyslipidemias
Paipheral Vascular
k for uncomplicated IHD P,.blockers (if severe disease)

ACEI or ARB m{r'd) ARB, DHP CCB, or thiazide
k for
k for
Add other
IHD IHD
without ISA
As for uncorrpicated IHD

a-blocksr
Dileue
Dilbnla M.ita
with Neplnpllhy
(urinary albumin
Dilbnla M.ibas without Nephropathy (ACR<Z.O mglmmol for men. <2.8 for Wlll!lell) Nan-41ii1Hdic Chronic ICidiiiYDi181U RenCIVIICUI D i Asthma Gout
Cardioselective If creatinine >150 jiiiiOVl, use loop or CCB duretic instead of thiazide diuretic Can add Dlherfirst-line agents ACEI +ARB if normal urine albumin Can add thiazide diuretic Loop diuretics if volume ACEI +ARB
ACEI (thiazide diuretics as therapy) Same as HTN without Diller indications K-splling + thiazide diuretics for patienls an salbutamol
Caution with ACEI or ARB due Ia risk of ARF
unless specific indications like angina or post-MI

Thiazidas, but asymptamlllic hyperuricemia is ncrt a contraindication
Toronto Notes 2011
T1ble 30. Pllmcolagic Treltment of Hypertension in Patients with Unique Conditions (continued) Condition or Risk Factor
Smoking
Recommended Drug
Low dose thiazides
Altemative DIU(II
Not Recommded
P-blockers
ACB
Pragnucy
Methyldopa Hydralazine
l..abetolol Nifedipine
ACB
ji-blocbrs not recommended as first line tnllllment
Eldalfv'
(>&OJ
Emergency
If >3
As for uncomplicated IHD,

lll(C8pt for Ule of p.blocbrs
(BP >169/90} = labetolol,

rifadipina
RF or eltilblilhed llh-larotic: diiiiH

fGiallim I'IDpn llewnlnendllitm.
Caution with use of ASA i1 patients with uncontrolled BP

I r1C8P1 blockm, ACB = angiotlnlil conwrting IIIIYilll inhili!Dr C111
ISA = syr1111thoninatc ICIMty, ARB = Adap18dfrom: JCinfo/, 18(6[:625-641. ANl The 2010
Low Back Pain

see Orthopaedics. OR23 Definition acute: <6 weeks subacute: 6-12 weeks chronic: >12 weeks Epidemiology 5th most common reason for visiting a physician lifetime prevalence: 90% peak prevalence: age 45-60 largest WSIB category most common cause of chronic disability for persons <45 years old 90% resolve in 6 weeks, <5% become chronic Etiology source of pain can be local, radicular, referred, or related to a psychiatric illness 98% mechanical cause ligamentous/muscle strain, facet joint degeneration, disc injury, spondylosis, spondylolisthesis, compression fracture, spinal stenosis, pregnancy worse with movement. improved with rest 2% non-mechanical cause most concerning when pain is worse at rest and does not change with position surgical emergencies cauda equina syndrome: low back pain, areflexia, lower extremity weakness, fecal incontinence, urinary retention, saddle anesthesia, decreased anal tone abdominal aortic aneurysm: pulsatile abdominal mass medical conditions neoplastic (primary, metastatic, multiple myeloma) infectious (osteomyelitis, TB) metabolic (osteoporosis, osteomalacia, Paget's disease) rheumatologic (ankylosing spondylitis, polymyalgia rheumatica) referred pain (perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, herpes zoster), no change with position
Physical Exam neurologic exam for 14, L5, Sl helps determine level of spinal involvement {muscle strength, sensation, reflexes) peripheral pulses
'Red Flq1 far Bilek hin

BOWIII or bladder dy5function Anesthesia (saddle)
Con$1itutional symplomf/malillfiiiiiC'( IChronic disUN Parllllhuaiu AQe >50 and mild trauma IV drug use ruuromator dlflcitl
special tests straight leg raise (positive if pain at <70 degrees, aggravated by dorsiflexion of ankle), positive test is indicative of sciatica crossed straight leg raise (more specific; raising of uninvolved leg elicits pain in leg with sciatica) femoral stretch test (patient prone, knee flexed, examiner extends hip) to diagnose L4 radiculopathy
Toronto Notes 2011
............ n..,bt..illl:lll'lil
Cadnnelllfllllseli_,.lle.WS 2004;
Investigations
plain films not recommended in initial evaluation indications for lumbar spine x-ray no improvement after 1 month fever >38C unexplained weight loss prolonged corticosteroid use significant trauma progressive neuromotor deficit suspicion of ankylosing spondylitis history of cancer (rule out metastases) alcohoVdrug abuse (increased risk of osteomyelitis, trauma, fracture) CBC, ESR, urinalysis (infection, cancer) bone scan (infection, tumour, occult fracture), EMG if indicated consider CT or MRI (worsening neurologic deficits, infection, tumour)
lssue1 IWIIIIII: Syametit miaw oi3911CTslllll

lhql: Far
low blck plin. clmic low blck plin.

111111111' was iUplriar anlv to
liln tii!IIPI" 111 tllqias iudilld 1D be inefteciM 111 MR hurnlli ft hill no IIDsticelllf l:hcal
IMnflciIMr mlglm.
mn:ises, back sdiJal or physil:iln en
eancwa.: Far acullllld chronic low-lleck

J)lil.lhse is no evidmce lhll
....... law lllct l'lil CGdrn lllalllst
lilll1iiM" 21111;
Treatment
reassurance and education if no underlying serious condition 70% improve in 2 weeks, 90% in 6 weeks recommend comfort measures/conservative limited bed rest (>2-4 days bed rest has potentially debilitating effects and no proven efficacy) staying active (within limits of pain) leads to more rapid recovery and less chronic disability activity modification (temporarily avoid activities that stress spine:, e.g. heavy lifting, prolonged unsupported sitting) heat or cold therapies notes for work or WSIB to endorse modified, appropriate work" vs. time off encourage early return to work or activities short course of massage may be beneficial NO proven efficacy of spinal traction, TENS, biofeedback, injections (trigger-point, facet joint) or spinal manipulation; some evidence that acupuncture may be a hdpful adjunct to other therapies pharmacological acetaminophen NSAIDs muscle relaxants sometimes hdpful but may cause drowsiness and are no better than NSAIDs; short term muscle relaxant use <7 days may be hdpful NOT narcotics if no improvement after one month of conservative therapy, consider further investigations x-rays and appropriate labs in presence of any red flags surgical evaluation if suspected cauda equina syndrome worsening neurologic deficit intractable pain not responding to conservative therapy
Tabla 31. Approach to Non-traumatic Low Back Pain
llale 4
111&1111 al nusiQIIhlllpyfar nan-specific kMr blck plin CIJII1IIf8d 111 atlllr lleiM or sham 1Nitmanll. ....... t:ancbia: Farllllllli palierawilh lllhmlll or clmlnic low blck plil, naage miiYbe benelic:illl-lllpeciltf Mil lldui:Dan and lllllln:ilas. SGmell'idlmce1111J18111 II1ISSIQe mi!V be 111111t 6ctNe 1llln cllssic rr-ue bli mont fiiPred 11:1 canfinn ... lids.
Gf
.......
No!HIIroiiiiAIM!Iwi... , llnlgl fur Llw

Clldrlne OiiiiJise ri S}'llllmlfir: llale 1
21111;
This lylllmllic miaw IIIII ibible-hild cmrolled triell IIStell8d fie lfleciJ of NSAill rn!plciic IIWI blckplin md whitt. ane tp al NSAID- more elllctive. ......,., tancuia: lndclnnic low blck pail Mdiwtscillica. NSAIDs 1ft slightly Thert -no ciflfiJIIcl NSA11111nd pllclbo il ]lltiem wilh IICUIIIICillica. specific type Gf 1D be betlar.
'*'
Clldrlne llltllllae ri S}'llllmlfir: lleMiM" 21m; llale 1
Back daminlllt
{Pain glllleal fold)
This S'fSiemllic leview
Llg do11inant {Pain g11!81est below gluteal fold) Pltlam3 Pain ch111ges with back movement/position Cumrrtly/praviously consblnt
Qldlal
lrilll inwlligllBd lbe eftaclivanlll aiiCUJIIIct!Jr& an lcMr bact peilllBPI-
Hillary
Pittam 1
Worse with flexion Constant/intennittant
Pltlsn Z Worse with extension

Naver WOI19 with flexion Always intermittent Nonnal neuro I!Xlllll improves with flexion
Plttam4
Worse activity
CIIdui- lfectivena oiiCIIpuncUII for IICUII LBP Till hi _ . 4it1D poor sUlly da!ign llld kMr HcMIMI!, ICUplllC1In ill fiiiJIIIfllclivlfllrplin llhfmd flllctillllll Lll' then no1nlalment or llilm 11111ment. Allllough ICIIpuncbn is not men lllllctivetllen oilier tillllpies, IIIII' be UIIM 11 en adjunct. Higlw-lrilk 1ra natdad.
lf1111'DV8S with I'8St and postura chqe

Intermittent/short duration No irritative findings conductive loss
Exam
Nonnal neuro exam Fast responder Improves with IDrten&ion Slow respom!er No change ar IDrten&ion
Leg pain can improve but not disappear Positive straight leg raise conlllction IO&&
East respond!![
Improves with specific back position Slow responder Not better with position
clwiges
Ubfv' Pathalogy Arising from interverl!bral discs or adjacent ligaments Scheduled !!XI!nsion Lumbar roll Night lumbar roll MBdication as required
Adapmdfnlm: American
Posbrior joint complex {associated ligaments and capsular sbucllll!S) Scheduled flexion Limited extension Night luntar rol Medication as required
Sciatica
NeLrDganic clilldication
Prone extension Supine T lie

Lumbar roll Night h111bar roll Medication as required
Abdominal exercises
Night lumbar roll Sustained flexion Medicstion as required
AaniCare: rbibaume1ic Low Btct
1.tJck
153-Ui&
Toronto Notes 2011
Family Medicine FM41
Menopause/HRT
see Gynecolog_)( GY32
Epidemiology mean age of menopause = 51.4 years a woman will spend over 1/3 of her life in menopause Clinical Features urogenital tract: atrophy, vaginal dryness, incontinence blood vessels and heart: vasomotor instability, hot flashes, increased risk of heart disease bones: bone loss, fractures, loss of height brain: depression, mood swings, memory loss Management encourage physical exercise, smoking cessation, and a balanced diet with adequate intake/ supplementation of calcium/vitamin D (1500 mg/800 IU OD) hormone replacement therapy (HRT) routine use of HRT is no longer recommended regimens: cyclic estrogen + progesterone, continuous estrogen + progesterone, estrogen only (no uterus), estrogen ring, estrogen gel helps with symptomatic relief of estrogen deprivation decreases risk of osteoporotic fractures, colorectal cancer increases risk of breast cancer, coronary heart disease, stroke, and pulmonary embolism initiation ofHRT requires a thorough discussion of each patient's history, symptoms and risk factors, and of the overall short and long-term benefits and risks consider venlafaxine, SSRI, gabapentin to ease vasomotor instability
Estrogen Plus Progestin and the Risk of Coronary Heart Disease NEJM 2003; 349(6):523-34 Study: Randomized controlled trial after amean follow-up of 5.2 years. Planned duration was 8.5 years but the data and safety monitoring board recommended tenninating the trial because the overall risks exceeded the benefits. Patients: 16,608 postmenopausal women, age 50 to 79 years at base line. lntarvantion: Conjugated equine estrogens (0.625 mg per day) plus medroxyprogesterone acetate (2.5 mg per day) or placebo. Purpose: Final results with regard to estrogen plus progestin and CHD from the Women's (WHI). Main Outcomes: Nonfatal Ml or death due to coronary heart disease. Results: Combined HRT was associated with a hazard ratio for coronary artery disease of 1.24. The elevation in risk was most apparent at one year (hazard ratio 1.81). Conc..sioos: Estrogen plus progestin does not confer cardiac protection and may increase the risk of CHD among generally postmenopausal women, especially during the first year after the initiation of honnone use. This treatment should not be prescribed for the prevention of cardiovascular disease.
Osteoarthritis
see Rheumatology. RH4
Epidemiology most common form of arthritis seen in primary care prevalence: 10-12%, increases with age results in long-term disability in 2-3% of patients with OA almost everyone over the age of 65 shows signs of OA on x-ray, but only 33% of these will be symptomatic Clinical Features pain with weight bearing, improved with rest morning stiffness or gelling <30 min deformity, bony enlargement, crepitus, limitation of movement usually affects distal joints of hands, spine, hips, and knees Investigations no laboratory tests for the diagnosis of OA radiographic features: joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes Management goals: relieve pain, preserve joint motion and function, prevent further injury conservative patient education, weight loss, exercise (OT/PT), assistive devices (canes, orthotics, raised toilet seats) pharmacological keep in mind co-morbid conditions such as HTN, peptic ulcer disease, renal disease medications do not alter natural course of OA 1st line: acetaminophen 325-1000 mg qid prn (OA is not an inflammatory disorder) 2nd line: NSAIDs [COX-2 selective NSAIDs (Celebrex'", Mobicox'") recommended if long-term therapy or if high risk for serious GI problems] combination analgesics (e.g. acetaminophen and codeine) intra-articular corticosteroid injections (not more than 3-4x/yr) may be helpful in acute flares (benefits last 4-6 wks, can be up to 6 mo) intra-articular hyaluronic acid injections topical NSAID (Pennsaid'") capsaicin cream (Zostrix'") surgery consider if persistent significant pain and functional impairment despite optimal pharmacotherapy (e.g. debridement, osteotomy, total joint arthroplasty)
Hand (DIP, PIP, 1st CMC) Hip Knee 1st MTP L-spine (L4-L5, L5-S1) C-spine Uncommon: ankle, shoulder, elbow, MCP. rest of wrist
Figure 10. Common Sites of Involvement in OA

Glucosamila Tharapy for Treating Ostaoarthritis Cochrane Database of Systematic Reviews 2005; Issue 2 This meta-analysis of 25 single- and double-blinded randomized controlled trials 4963 patients compared glucosamine treatment administered by any route, against placebo or another treatment Revians Conclusions: Glucosamine can decrease pain and functional impainnent from OA and is not associated with any side effects compared to placebo. Differences in the effectiveness of Rolla and non-Rolla preparations highlight between glucosamine preparations and patients should be made aware of this.
Toronto Notes 2011
Osteoporosis
see EndocrinoloK)'. E43
age-related disease characterized by decreased bone mass and increased susceptibility to fractures affects 1 in 4 Canadian women and 1 in 8 Canadian men
T1ble 32. Risk Factors for Osteoporosis

Mljor Risk Facton
Age >65 years Vertebral CDII1llession fracture
Minor Risk Factors Rheumatoid Past history of clinical hyperthyroidism Chronic anticonvulsalt therapy Low dietary calcium intake Smoker Excessive alcohol intake Excessive caffeine intake
Fragility fracture after age 40

Fsnily history of osteoporatic fracture (especially maternal hip fracturel Systemic glucocorticoid therapy of >3 months duration Malabsorption syndrome Primary hyperparalhyroidism
Propensity to fall
Osteopenia apparent on x-ray film l+r'Pollonadism Early (befor& age 45)
Weight <571qj Weight loss > 1II% of weight at age 25

Chronic heperin therapy
,,.. ,
Calcium Content of So11111 CDIIIIIIGn Fllld 1 cup milk - 300 mg *cup yogurt- 295 mg 'h can salmon w.ibona - 240 mg * cup cooksd broccoli - 50 mg 1 medium orange - 50 mg
Diagnosis defined in terms of a bone mineral density (BMD) T-score < -2.5 SD osteopenia: BMD T-score between -1.0 SD and -2.5 SD mass BMD screening is not recommended measure BMD in all patients >65 years of age all patients with one major or two minor risk factors for osteoporosis (see Table 32) measure BMD using dual x-ray absorptiometry (DEXA) suspect osteoporosis in women with back pain, a decrease in height or thoracic kyphosis Management institute a fall prevention program for those at risk; optimize eyesight lifestyle weight bearing exercise, smoking cessation, decrease alcohol intake diet for women without documented osteoporosis, calcium and vitamin D supplementation alone prevents osteoporotic fractures (grade B recommendation) calcium (1500 mg/day) and vitamin D (800 IU/day) intake in diet or supplements pharmacological women with osteoporosis: bisphosphonates (e.g. risedronate, alendronate) or Selective Estrogen Receptor Modulators (e.g. raloxifene) prevent osteoporotic fractures (grade A to B recommendation) women with severe osteoporosis (osteoporosis plus at least 1 fragility fracture): alendronate, risedronate, parathyroid hormone (limited duration), raloxifene, etidronate and oral pamidronate therapy (grade A to B recommendation) if none of these drugs is tolerated, hormone replacement therapy (HRT) or calcitonin can be considered severe esophagitis is the major side effect ofbisphosphonate use HRT, calcitonin there is fair evidence that combined estrogen-progestin therapy decreases the incidence of total, hip and nonvertebral fractures; however, for most women the risks may outweigh the benefits (grade D recommendation), see GY33
Osteoporosis Society of Cenlldl. www.osteoporosis.ee
.....
', .l------------------,
Rash
see D4
DDxDflllllb Clllltllct dlrml!tilis
Herpes mmr
Ecama
Erythema nodosum Lichen pl1111111 Psoriasis
Lupus arythamatous Drug reaction
History age duration oflesions associated symptoms: itching, fever, pain travel history sick contacts past medical history, medications, sexual history vaccinations
Toronto Notes 2011
Physical Exam vitals describe lesion (SCALD) Size Colour (e.g. hyperpigmented, hypopigmented, erythematous) Arrangement (e.g. solitary, linear, reticulated, grouped, herpetiform) Lesion morphology Distribution (e.g. dermatomal, intertriginous, symmetricallasymmetrical, follicular) Investigations depends on history; may include swab oflesion, biopsy Management depends on symptoms and cause of rash refer to dermatologist as needed
r-t,
c - DDx crf Pruritic

Ecz111111
ln:sact bites
Scabies
Urticaria
Contact dermatitis
PUPPP (dumg pregnancy) Drug reaction
Rhinorrhea
see Otolaryngology, OT23
Differential Diagnosis common cold, sinusitis, influenza, strep pharyngitis, ear infections, vasomotor rhinitis allergies, contact with substances/tearing foreign body opioid withdrawal basilar skull fracture Investigations CBC, throat swab, nasopharyngeal swab, x-ray if injury, allergy testing Management saline nasal rinse consider medications: antihistamines, decongestants, cortkosteroid nasal spray
Sexually Transmitted Infections (STis)

see Gptecology, GY26
Definition diverse group of infections caused by multiple microbial pathogens transmitted by either secretions or fluids from mucosal surfaces Epidemiology high incidence rates worldwide Canadian prevalence rates in clinical practice common: chlamydia, gonorrhea, PID, genital warts, genital herpes (increasing incidence) less common: hepatitis B, HN & syphilis (both increasing in incidence), trichomoniasis rare: chancroid, lymphogranuloma venereum, granuloma inguinale genital tract infections (NOT sexually transmitted): vulvovaginal candidiasis (VVC), bacterial vaginosis (BV) three most common infections associated with vaginal discharge in adult women are BV, VVC, and trichomoniasis History sexual history level of sexual activity and type (oral, anal and/or vaginal intercourse) age of first intercourse, sexual orientation, sexual activity during travel total number of partners in the past year/month/week and duration of involvement with each
....
',
Iiiii Factor.
S8XIIIlly active males and females <25yam old Early IIIJB af 151 inlan:oum Straet involwd ancVor substance use, men who have sex with men
Unprolllctlld IIIIX. previous STI, contact with known cue of STI New partner in put 2 monthl, > 2 partners i1 past 12 months
When I STI is detected in 8 praplJ!ertBI
child, avlllualion for SBliLB llbun is
prudent.
Toronto Notes 2011
...............udm..ilw-:
A.,...._llllilwlf........Ut.nnllll IIIII CMAJ '11111; 177!5):48479. ,.,.._ To MUll prop/lyactic HPV wccilltian il higll-1nd c:mi:lllleslans, 1*J0ut HPV inlwc:tion, ullmlll Qllilllllllin, adverse MIIIJ, llld dellh usiJJ mellfilysis.
,.......'llcr:illlion.-......
STI history STI awareness, previous STh and testing, partners with previous STis contraception history, last Pap test and results local symptoms such as genital burning, itching, discharge, sores, vesicles associated symptoms such as fever, arthralgia, lymphadenopathy partner communication with regards to STis
lnvastigations/Scraaning
individuals at increased risk, even those who are asymptomatic, should be screened for chlamydia, gonorrhea, HIY, hepatitis B, and syphilis Pap test if none performed in the preceding 12 months
40 323 ]ll1ilnls Mil ilckldld 111d Ill Wlils Mil Tlnlllluill Ul8d IIIII twoul8dllle biwlent,111d one used aiiiiiiiiMIIIIIL The lmgest l!llliiiUdioa rlfollaw-!lp-4111101ths. 1116: l'nJpllylatic HPV WICCilltion deawsed the freq!MIIcy rl higl\.gl'lde C*\'iclllasions caused by 'IICCint-type HPV slrli1s compnltD tie oWiJI (I'IID Dddlmo0.14 (IMCIO.Dlll.21). Vlcl:illliorl also pi'MIIIId pnilllnl HPV illei:tiln.lowpelllions and Q11i111 WII1S 111d 1111N1)0111d ldvlne MniiWII'I mO!IIy minor. pacebo,lhere WISRO diflerence in
ri liuh mal1odokJvi:
Management
primary prevention is vastly more effective than treating STis and their sequelae
offer hepatitis B vaccine if not immune, offer Gardasil to women under age of26 discuss STI risk factors (e.g. decreasing the number of sexual partners) direct advice to ALWAYS use condoms or to abstain from intercourse condoms not 100% effective against HPV, herpes, genital warts a STI patient is not considered treated until the management of his/her partner(s) is ensured (contact tracing by Public Health) patients should abstain from sexual activity until treatment completion mandatory reporting: chlamydia, gonorrhea, hepatitis B, HIY, syphilis
. . . . . . . Mnlllllldlllh. c:.duiln: Prophylllic II'V is highly eliclciaus
disease ii-IIQed 1HSwho not p!Muly blan irilclad Mil wccr.lypiii'V ltrlins.
Tabla 33. Diagnosis and Treatment of Common Sll Sig.. and Symptoma
IIIVIIIIigldiDII
M: urine PCR, urethral swabs for stain and culture F: endocervical swab lor culture, vaginal swab for wet mount 111d Gram stain
T11111mant
CBiixi1118 400 mg PO, single dose + nan-ganacocca( urethritis/cervicitis Rx* FlU in 2 wks far test af cure if symptoms pnist
Camplicltillls
Arthritis, inCillllsed risk of acquiring and transmitting HIV M: ul'lllnl stricturas, epididymitis, irlartility F: PID, infertility, ectopic pregnancy, perinatal infection,. chronic pelvic pain Same as above
Ganococ:cll UrelllritiW Cervicitis (NeissetitJ gonotTfreu)
M: burning, irritation, unexplained pyuria, urethral discharge F: roocapurulent endocervical discharge, dysuria, pelvic pain, vaginal bleeding M111d F: often asymptomatic, can involve rectal symptoms in cases af U1'9rolactad anal sex
Nan-Gonoc:DCCII
UrelhriliiJCerviciti1 (Usually Ch/6mydia tradronr8tis**)
-711% asymptomatic S1111e as above If $YIIIp\am5 appear (U5WI!Iy wits after infection) then similll' to gonococcal symptoms (see above)
Mast n asymptomatic M: lesions acuminata) an skin/mucosa af anal area F: cauliflower lasion& AND/OR pr&neoplastic/neOJ.Rstic lesions an cervix, vagina, or wlva 1 episode: painful vesicoulcerative genital lesions, tender fvn1lhadenopathy and fever, protractad course Recunent episodes: less extensive lesions, shmer course, may have "1rigger factors" None needed if condylomata Potential biopsy af suspicious lesions F: &creening far cervical dysplasia tlrough Pap smears
Azithromycin 1 g PO. single dose + ganacocca( urethritis/carviciti& Rx* Same follow up as above Far condy1arna1ll: cryotherapy, electrocaulllry, topical therapy (podophyllotoxin) For cervical dysplasia: colposcopy llld possible excision, dependent on grade af lesion
Humiln Pilpillalllill Virus (gerital Wllb)
M + F: anal cancer F: cervical/VIIginaVvulvar cancer M who have sex: w/ M + F who havu IIICeplivu anal sex: rectal CA Genital pain, urethritis. aseptic meningitis, cervicitis, increased risk a! ac(Jiirilg and transmitting HIV
(HSV-1111d -2)
GaniiiiiHIIP
Swab of vesicular content for 1" episode: culture, serologic Acydovir 200 mg PO S'x/da'f for 5-1 Od, OR testing for HSV-1 and HSV-2 Famciclovi' 250 mg PO lid far 5d, OR antibodiBS Valacyclovir 1000 mg PO bid for 1Dd Recurrent EPisodes: Valacyclovi' 500 mg PO bid OR 1g qd far 3d, OR Famciclovi' 125 mg PO bid for 5d, OR Acydovir 200 mg PO S'x/d for Sd, or 800 mg PO tid for 2d Specinen collection from 1 and z lesions; screen high risk individuals with serologic swflilis tasting; uniVIII'SIII sCillllni"cl of pregnant women Benmthina penicillin GIM (dose depends an stage) Notify partners (last 3-12 mths) Continuous follow-up 111d tasting until patienb are seronegBtive
Infectious Syphilis {TI8fJOil8fTJ8 pallidum)
1": painless sora 2": rash 111d ftu-like symptoms Latent Phase: asymptomatic 3: nauroi01Jic, miovascular, and tissue complications
lnC1811sed risk of acquiring and transmitting HIV Chronic neurologic and cardiovasculll' sequlllee
M= Miles; F= Females *N.B. ilnllritirlcervicitii upllCI8d. aiNI'jltraatw both QIIIICoccllld llOII-gonOCOCI:IItypal (i.e. CafixirneANDAzilfllmrt:inl Most common reporllhle STI in Canld1
Toronto Notes 2011
Sinusitis
see Otolaryngology, OT25
Definition inflammation of the mucous membranes ofthe nasal cavity and paranasal sinuses, fluid within these cavities, and/or the underlying bone Etiology classifications: acute: <4 weeks recurrent 4 or more episodes per year, each lasting at least 10 days, with an absence of symptoms in between chronic: 12 weeks common pathogens: rhinovirus, influenza, parainfluenza. S. pneumoniae, H. injluenzae, M. catarrhalis Risk Factors medical conditions: respiratory infections, allergic rhinitis, cystic fibrosis, immunodeficiency anatomic: deviated septum, polyps, adenoid hypertrophy, tumour irritants: environmental. tobacco smoke, air pollution, chlorine iatrogenic: topical decongestant overuse, cocaine, trauma Investigations radiography is warranted only when the diagnosis of sinusitis is in doubt all patients with pronounced frontal headaches should have a radiograph performed to rule out frontal sinusitis CT scans are not cost-effective and should not be used routinely to diagnose sinusitis Management acute sinusitis 70% of patients will resolve without antibiotics oral analgesics/antipyretics for pain/fever nasal saline rinse and humidification may be beneficial short-term use of topical or systemic decongestants may be useful adjuncts antihistamines are contraindicated antibiotics limited to those diagnosed with acute bacterial sinusitis through history and physical 1st line: amoxicillin x 10 days (TMP-SMX or doxycycline if penicillin allergic) 2nd line: amoxicillin+clavulanate, clarithromycin, azithromycin, cefuroxime referral to ENT if failure of second-line therapy episodes per year development of complications (mucocele, orbital extension, meningitis, intracranial abscess, venous sinus thrombosis)
linualll Sco..
MlxiiiiiV t00111acha [1 I Hi$10ry of coloured nll$8l discharge [ 1)

No improV11118nt with acongntants
(1)
Abnormal transilh.mination [1 I Purulent secretion on exam (1} Other signs: 1111111 congestion, facial
ProiUilty llf 5mulitia lly Sc. . 0-9%
1-21% 2-40%
3-63'K.
4-81%
5-92'Kt
1111( MH.
cn:.lprr6r:liolll!iw. 2001.
Sleep Disorders
see also ResWroloiD!. R32
Definition most often characterized by one of three complaints:

insomnia
difficulty falling asleep, difficulty maintaining sleep, early-morning wakening, non-refreshing sleep parasomnias night terrors, nightmares, restless leg syndrome, somnambulism (performing complex behaviour during sleep with eyes open but without memory of event) excessive daytime sleepiness
Epidemiology 1/3 of patients in primary care setting have occasional sleep problems 10% have chronic sleep problems more common in women and with increasing age Etiology
primary sleep disorders primary insomnia, obstructive sleep apnea, restless legs syndrome, narcolepsy, periodic limb
movements of sleep
Common Presenting Problems secondary causes medical: COPD, asthma, CHF, hyperthyroidism, chronic pain, BPH drugs: alcohol, caffeine, nicotine, beta-agonists, antidepressants, steroids psyclliatric disorders: especially mood and anxiety disorders lifestyle factors: shift work
Toronto Notes 2011
Investigations complete sleep diary every morning for 1-2 wks record bedtime, sleep latency, total sleep time, awakenings, quality of sleep rule out specific medical problems (CBC +differential, TSH) sleep study referral if suspect periodic leg movements of sleep or sleep apnea night time polysomnogram or daytime multiple sleep latency test Treatment treat any suspected medical or psychiatric cause psychologic treatment sleep hygiene: avoid caffeine, nicotine, alcohol; exercise regularly; comfortable sleep environment; regular sleep schedule; no napping relaxation therapy: deep breathing. meditation, biofeedback stimulus control therapy: re-association ofbed/bedroom with sleep; re-establishment of a consistent sleep-wake schedule; reduce activities that cue staying awake sleep restriction therapy: total time in bed should closely match the total sleep time of the patient (improves sleep efficacy) pharmacologic treatment short-acting benzodiazepines: e.g.lorazepam, oxazepam, temazepam, should be used <7 consecutive nights to break cycle of chronic insomnia Specific Problems primary insomnia majority of cases person reacts to insomnia with fear or anxiety around bedtime or with a change in sleep hygiene; can progress to a chronic disorder (psychophysiological insomnia) snoring results from soft tissue vibration at the back of the nose and throat due to turbulent airflow through narrowed air passages risk factors: male gender, obesity, alcohol consumption, ingestion oftranquilizers or muscle relaxants, and smoking PE: obesity, nasal polyps, septal deviation, hypertrophy of the nasal turbinates, and enlarged uvula and tonsils investigations (only if severely symptomatic): nocturnal polysomnography and airway assessment (CT/MRI) treatment sleep on side (position therapy}, weight loss nasal dilators (noninvasive external dilator made with elastic adhesive backing applied over nasal bridge), tongue-retaining devices, mandibular advancement devices at risk of developing obstructive sleep apnea obstructive sleep apnea (OSA) apnea resulting from upper airway obstruction due to collapse of the base of the tongue, soft palate with uvula, and epiglottis respiratory effort is present leads to a distinctive snorting. choking. awakening type pattern as body rouses itself to open airway = resuscitative breath apneic episodes can last from 20 sec to 3 min; can have 100-600 episodes/night diagnosis based on nocturnal polysomnography: >15 apneic episodes per hour of sleep with arousal recorded consequences daytime somnolence, non-restorative sleep poor social and work performance mood changes: anxiety, irritability, depression sexual dysfunction: poor libido, impotence morning headache (due to hypercapnia) HTN (2x increased risk), CAD (3x increased risk), stroke (4x increased risk), arrhythmias pulmonary hypertension, RV dysfunction, cor pulmonale (due to chronic hypoxemia) memory loss, decreased concentration, confusion investigations blood gas not helpful, TSH if clinically indicated evaluate BP, inspect nose, oropharynx (i.e. for enlarged adenoids or tonsils) nocturnal polysomnography (sleep lab)
Aillk fclll,. fur Oblllruclivll SIMP ApnH 2% wamen, men between ages
4"'
Obesity causing upper airwav 1111rrnwing: BMI >28 kWJn2 prasent in 6090"' Df C8SII Childran: commonly tonsils, ad-ids Aging which caUSII muscle toni l'llrsisUnt URlls, alergies, nasal tumours, hypothyroidism (due 1D
Family history
Toronto Notes 2011
treatment modifying factors: avoid sleeping supine, lose weight, avoid alcohol sedatives, narcotics, inhaled steroids if nasal swelling present primary treatment of OSA is CPAP: maintains patent airway in 95% of OSA cases dental appliances to modify mandibular position surgery: somnoplasty, tonsillectomy and adenoidectomy (in children), uvulopalatopharyngoplasty (UPPP) report patient to Ministry of Transportation if OSA is not controlled by CPAP central sleep apnea definition brain fails to send appropriate signals to the breathing muscles to initiate respirations defining feature is absent respiratory effort often secondary to CNS diseases: brainstem infarction, infection, neuromuscular disease investigations: PFTs, nocturnal polysomnography, MRI treatment: CPAP or mechanical ventilation (ifbrainstem origin) prognosis: poor
Sora Throat (Pharyngitis)

Definition
inflammation of the oropharynx may be caused by a wide range of infectious organisms, most of which produce a self-limited infection with no significant sequelae
Etiology
viral adenovirus, rhinovirus, influenza virus, RSY, EBV, coxsackie virus, herpes simplex virus, CMY,HIV bacterial group A beta-hemolytic Streptococcus (GABHS) group C and G beta-hemolytic Streptococcus, Neisseria gono"heae, Chlamydia pneumoniae,
Red Flqs In l'ltillllll with "So.. Tbrllllt" l.l'lrsistence of symp!Dmslonp- than 1 week without improvement
Z. Respinrtory difficulty, particulll1y stridor 3. Difficulty in handling 1111C1111iona (l*ilcnsilllr ablc111) 4. Difficulty in awalluwing o.udwig"s angina) 5. Severe pain in the absence of lfYihlma (suprwgloUitill'piglllllitis) 6. A palplble mass [neoplasm) 7. Blood in the pharynx or ear UraL.IIIa)
'
Mycoplasma pneumoniae, Corynebacterium diphtheriae

Epidemiology
viral most common cause, occurs year round bacterial Group A beta-hemolytic Streptococcus most common bacterial cause 5-15% of adult cases and up to 50% of all pediatric cases of acute pharyngitis most prevalent between 5-17 years old occurs most often in winter months
Clinical Features
viral pharyngitis, conjunctivitis, rhinorrhea, hoarseness, cough nonspecific flu-like symptoms such as fever, malaise, and myalgia often mimics bacterial infection coxsackie virus (hand, foot and mouth disease) primarily late summer, early fall sudden onset of fever, pharyngitis, headache, abdominal pain and vomiting appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharynx ulcers are pale gray, several mm in diameter, have surrounding erythema, may appear on hands and feet herpes simplex virus like coxsackie virus but ulcers are fewer and huger EBV (infectious mononucleosis) pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash bacterial symptoms: sore throat, absence of cough, fever, malaise, headache, abdominal pain signs: fever, tonsillar or pharyngeal erythema/exudate, swollen/tender anterior cervical nodes complications rheumatic fever glomerulonephritis suppurative complications (abscess, sinusitis, otitis media, pneumonia, cervical adenitis) meningitis impetigo
Common Presenting Problems Investigations
Toronto Notes 2011
suspected GABHS see Table 34 for approach to diagnosis and management of GABHS gold standard for diagnosis is throat culture rapid test for streptococcal antigen: high specificity (95%), low sensitivity (50-90%) if rapid test positive, treat patient if rapid test negative, take culture and call patient if culture positive to start antibiotics suspected EBV (infectious mononucleosis) peripheral blood smear, heterophile antibody test (ie. the latex agglutination assay, or umonospot")
Table 34. Sora Throat Score: Approach to Diagnosis and Management of GABHS
POINTS
Cough absent?
History of fever >38"C?

Tonsillar exudate? Swollen, tender anterior nodes? Age 3-1 4years?
1
Age 15-44 years?

Age >45 years?
0
-1
4
In commurities willl moderate levels of strep infection (1 [}-20% of sore throats): Score 0 1 2 3
Chance petiant h8s slnlp
SuggiiSIBd action
2-3%
J-7%
8-lli%
19-34%
Cuhura aiL trelll will1 antibiotics on
NO cuhura or antibiotic
Cullllra aiL treat only cuhure is positive
clinicai!Jllunds1
ilcUIIai"VIr-or allllr inllca1ms thltlill Pllilnl ilclinicallyUIIWIIIIIId in Ilia ccma allilllns. Umilltions: "His sa11e is not applicable Ill pllilll151ess lhan 3yen rJ age. w an outbralll: or epidamie of ilms ceusad hy GAS is in lilY C011111U1ity, 1iii1C018 is inwlid and shotJid not be ullld. CelltorRM et II.Medill!cis Mllilg 1981; 1:239-46. MclswWI, WhiteD, T11111111blun D, 1.atl DE. CAW 1998; 15811):75-83.
Management
GABHS (see Table 34) no increased incidence of rheumatic fever with 48-hour delay in treatment incidence ofglomerulonephritis is not decreased with antibiotic treatment antibiotic treatment: see Antimicrobial Quick Reference, FMSO routine follow-up and/or post-treatment throat cultures are not required for most patients follow-up throat culture recommended only for: patients with history of rheumatic fever, patients whose family member has history of acute rheumatic fever, suspected strep carrier viral pharyngitis antibiotics NOT indicated symptomatic therapy: acetaminophenJNSAIDs for fever and muscle aches, decongestants infectious mononucleosis (EBV) antibiotics NOT indicated; administering ampicillin produces rash self-limiting course; rest during acute phase is beneficial if acute airway obstruction, give corticosteroids, consult ENT supportive care, ie. acetaminophen or NSAIDS for fever, sore throat, malaise avoid heavy physical activity and contact sports for at least one month or until splenomegaly resolves because of risk of splenic rupture
Toronto Notes 2011
Complementary and Alternative Medicine (CAM)
Complementary and Alternative Medicine (CAM)

Epidemiology 50-75% of Canadians report some use of CAM over their lifetime, and only half will disclose this use to their physidan use is highest in Western provinces, lowest in Atlantic provinces more likely to be used by younger patients, those with higher education and income examples: chiropractic, acupuncture, massage, naturopathy, homeopathy, traditional Chinese medicine, craniosacral therapy, osteopathy most commonly used for: back/neck problems, gynecological problems, anxiety, headaches, digestive problems and chronic fatigue syndromes Herbal Products over 50% of Canadians use natural health products most commonly used include echinacea, ginseng, ginkgo, garlic, StJohn's Wort, and soy relatively few herbal products have been shown to be effective in clinical trials many patients believe herbal products are inherently safe and are unaware ofpotential side effects and interactions with conventional medicines all natural health products (NHPs) must be regulated under The Natural Health Products Regulations as of January 1, 2004, including herbal remedies, homeopathic medicines, vitamins, minerals, traditional medicines, probiotics, amino adds and essential fatty adds (e.g. omega-3) always ask patients whether they are taking any herbal product, herbal supplement or other natural remedy. Further questions may include: Are you taking any prescription or non-prescription medications for the same purpose as the herbal product? Are you allergic to any plant products? Are you pregnant or breastfeeding? information resources: National Centre for CAM (www.nccam.nih.gov), Health Canada website
T1ble 35. Common Herhal Products
CommonN1111e BliCk callosh
RepolledUses
Menopausal symptoms, PMS, labour induction, artlvitis Mild sedilliw, anxiolytic, Gl complaints, common cold Comnon cold, flu, wound treatment. urinary 1n1ct infections. cencer
Ponible Adwellll Eflec:ls Hepatitis, liver failure, headaches, Gl discomfort, heaviness in legs, waight problems Alsrgi!icontact dermatitis, anaphylaxis Hypersensitivity, hepiiiDIDxicity with prolonged use, avoid use if iiTilllnOSUplf88Sed H!llldache, restlessness, nau-. diarrhllil. may decrsa&s seiZll8 threshold
Possible Druglntei'IC!ions None reported
Chimurni11
Edlinacea
Anxiolytics, sedatives
Potentiates warfaril
Evening prim1111e llysmenorrhee, menopaU8818X,

inflammation, allsrgie&, eCZBIIlil, arthritis, MS
Anticoagulanll,
Foarfww
Migraine prevention. rheumatoid arthritis, anti-inflammetory
resh. misciiTiage
Diarrhea
Anxiety, upset stomach, skin
Anticoagulanll, Do not 11llre with other medications as fibre content cen bind drugs Anticoagulanll, potentiates antihypertEnsives Noneknovlln Anticoagulanll, thiazide diuretics, MAO inhibitors Stimulant medicetions, antihypertensives, hormonal therapies Cilltion shellfish allergy AlphHdrenergics, finasteride CNS depressants, Cll with indinavir CNS depressants, antihistamines
FIIXIWdal
Gillie Gina Ginkgobloba
L.axalive, menopausal sx. source of omega-3 flrtty acids

BIIVlllad lipids, hyperllnsion, antimicrobial anti-inflammetory
lt.Jn'ew.ta.,.._
m;
Gl irritation, conlact danna1itis, may increase post-op bleeding Nausea, motion sickness, dyspepsia, Hes'lbum, not to be used for
moming sickness Headache, cramping, bleeding, mild digestive problems; reports of intracranial hemorrhage Hypertension, nervousness, insomnia, breakthrough bleeding, palpitations Gl distress, headllche, drowsiness, palpitations Mild Gl distress Photosensitivity, increased liver Bf1ZY11188, chwainess, dizzin888, nausea, headaches Drowsiness, headache, digestive problems, paradoxical insomnia
Gi-.g
ncreases peripheral circulation (AD, dementia, i'llermittent claudication), premenstrual syndrome, vertigo Energy enhancer, decreases stress, adjunct support for chemotherapy/ radiation
Osteoarthritis BPH, adjunct to finasteride Mild to moderate depression
llu2 Amllll-tllllv!il rl31lrilll. including 2li wlich Sl JDim'l Wart>Mth piiiCibo 11111114 wlicll compuad St Jolin's Wort willllllndlld llllidlpr..nll. Thellllilu:.na-111elllio rii"'JDDIders 1D non-185ponderf. nd 1be l1'llil D:omii!IIU.IIfor IIMna llllactsWII 111ellrilr !If patilabi dluppilg aut ilJe 1D ldwml axpan- Signliclnt hllllllgalllily Wll nalld -; trills, lui trills were
FGII!IIjlr
depwiion, t:ampllld wilh plica, 1he OR fur
nilftrills, 2.1li85\CI Us-2.581. Compered
GlucDMmiiB (Chondroitin)
-1.151S a 1.02-1.291and 5
Saw palmiiiiD St Jahn"s Wart
Sedative, anxiolytic, muscle relaxMI, PMS
llftlnces: mt T. Clllllin J.lllrllll '111elth"JIU!lm: Wt.tflrnilyphysicilns1'118d1D Colr!Jiemenbiry lllld Allllnlli'le Medi:ine welilill (hUpi/ncclm.rih.aaWI
1998; 58(51:11331140.; Nit Nlltiolllll Clatarfor
Mil SSRlslnd lJic:ojclicl, 1fw llljiDIIII IIIII Will 0.18IMCIDJ5.1.12]1111d 1.03IMCI0.931.14I, "-pltieriSon Sl JaM's Wart dropped DLK due 1D ldwne etlecll CDfnlllll!d 1D1hrlll-lricyl:lcaj0110.25; l!ii.CI0.14lllluimillr lilt IIDil-tiQiiicld trend18111 Min compnd wilh SSRII lOR O.ll; 1M Cl 0.31-1.15]. Dftlwin; sold concUions il dillic:Ut given 1lle dearve of Aldy h.,...ily 111111rurilel ltllies.
FMSO Family Medicine
Primary Care Models/Antimicrobial Quick Reference
Toronto Notes 2011
Primary Care Models

Table 36. Primary Care Models
Camplllhanlliva Cua MDIIII Model for GPs in solo practice with limited after-hours IMiilllbility Groups of health en professionals (e.g. GPs, RNs, NPs, dieticians, social workers) Wider range of services (e.g. rehabilita1ion, palliative care), with increased after-llours IMiilability Receives provincial Mding for allied health Group of GPs, with some alter-llours IMiilability as wei as on-call to telephone health advisory services Payment model: fe&.for-servica premiums Group of GPs; can utiize nurse practitioners, with telephone health advisoiY services to provide around the clock primaiY care coverage Payment model: salary-basad Groups of GPs working with allied health, with after-hours clinics and 24h telephone health advisory services Paymllll model: fe&.for-servica premiums
hmiy Health Team
hmiy H111th Group
hmiy H1111h Netwalt
hmiy Health
Antimicrobial Quick Reference*

Canditian
RESPIRATORYlENT
Antimicraliill
Viral: Rhinovirus, Adenovirus, RSV, Influenza, stc. Viral: Adenovirus, Rhinovirus A beta-Hemolytic St!ep None None Pediltric: pan V2550 m\ll1qJ/d PO div. q6h x 1Od llliOX/dav 45 m\ll1qJ/d PO div. q12h x 10d darithromycin 15 mll'1qfd PO div. bid x 1Cd azithroll1'r'l:in 12 m\ll1qJ/d PO x 5d
Al:uta Rhinitis (common cold)

P ryngitis .. (sore throat}
Strap Pharyngitis
AtAtlts:
pan V501ng PO bid or 250 mg qid x 1Od cefuruxime 250 mg PO bid x 4d darithromycin 250 mg PO bid x 1Od azithroll1'r'l:in 500 mg PO once. 1hen 250 mg daily x4d Panicillin allergy: ll'fllnll1'r'l:in
Sinusitis
H. intluenzae M. Cllllin1Jelis
Anaerobes S.IIURIU3
s. pneumoniae
1st line: amoxicillin 1gPO tid x 10d (H penicillin allergy: TMPJSMX DS 11Bb PO bid} 2nd line: llliOX/davulin 2000/125 mg PO bidx 10d 3rd line: clarithroll1'r'l:in XL 1DOD mg PO 00 x 1Dd
Al:uta Otitis Medii
Viral
H. inftuerrzH M. Cllllin1Jelis
s. pneumoniae
treat
lrlder 24 mon1hs old for 7d. H>24 months old, after 4S.72h <10y.o.: 1st line: amoxicillin 75-90 mg.1qfd PO tid x 5d 2nd line: amoxicillirv'clavulin 3rd line: macrolideli > 10 y.o.: ernoxicillin 500 mg PO tid x 7-1 Dd penicillin allergy: celuroxime, azithromycin, darithromycin
Otitis Exlllma
PssudcJmonas S. aureus Fungal
Diabetic: ciprofloxacin 500 mg PO bid x 14d Non-diabetic: 1st line: 2-3 drops tid 2nd line: Cortisporin8 IJiic solution 4 drops tid
Bronchitis
Viral: Rhinovirus, Coronavirus, Adenovirus, RSV, lnfluenm, l'lrainfluenm S. pt181Jmoniae H. inffuen1Jie M. pneumoniae
Abx not recommended for acute bronchitis
c. pneumoniae
Toronto Notes 2011

Condition
Antimicrobial Quick Reference
Fam.lly Medicine FMSI
RESPIRATORYlENT
Community Acquired Pnaum111ia
Sua:sptible to beta-lactlllll$: ptlfiiJfiiiXIia H. influenzae S.IUieUS
Adult dosilg (no rs5pimory comorbidili85): erytlrornycin 500 mg PO qid x 71 Od clarithromycin 250.500 mg PO bid x 71 Od azithrornycin 500 mg PO 1st dose then 250 mg PO 0Dx4d Not susceptible to beta-lecblrns: doxycycline200 mg PO 1st dose then 100 mg PO bid Myr:oplasma x7-10d ()llamydia pneumoniae legiooe/Ja pneumoniae
s.
._
Dentlllnl1=cticnl Oral Flora Pariapicallllll Pariadllllllll
Pan Vpotas&ium 500 mg PO qid x 7-1 Od clildernycin 300 mg PO qid x 7-1 Od
GAmGEtmROLOGY
llianhea - Enteritis
Shigella S8/moneiJa
E. coli
Abx asevere, treat according to specific organism isolated
Yemria llianhaa - post abx (convnon with

clildernycin)
c. diffide
H. pylori
Add metronidazole 500 mg PO tid x10.14d or vancomycin 125 mg PO qid
Paptic Ulcer Disease (nol)oNSAID related)
HP-AC (7 blistBr Clld peck):

len&oprliZDie 30 mg PO bid + clarithromycin 500 mg PO bid + amoxicillin 1g PO bid x 7d Penicillin alllllliY: metronidazole 500 mg PO bid + claritlmnycin 250 mg PO bid+ omepraznle 20 mg PO bidx 7-14d
GENnDURINARY
U11/Cyllilil
Klebsiella E. coli Entstobact8r fnlerococci Ptr1teus S. sllfJfOPhyticus

Candida
cipralloxacin 250 mg PO bid or cipro ER 500mg daily x3d Nitrofurantoin mg PO bid x 5d asulfa allergy Pregnancy: amDXicillin 250 -500 mg PO tid x 7d N.B. nitrofurantoin is contraindicated i1 pregnancy after 38 wlcs nuconamle 150 mg PO single dose miconazole 2% vag. C1'81111 = Monistat 718: One applicator (5 g) intravag. qhs X 7d
permethrin cream 1%: apply as liquid on to washed hair for 10 min, then rin&e. Repeat in 1wk
<211% f. coli resistance to TMP-SMX: TMP.SMX 1DS lllblst PO bid x 3d >211% f. coli resistance to TMP.SMX:
Vaginal Candidiasii/Yeast
Lice: Hlld IIIII Pulic

(Crabs)
Pediculosis humamJs capiris
l'htllirus pubis
N. goiiOI1trfe trachomatis
c.
cefixime 400 mg PO dose + 1g PO single dose or dmr,'cyclina 1DO mg PO bid x 7d

acyclovir 400 mg PO tid x 7-1 Od valacyclovir 1g PO bid x 1Od famciclovir 250 mg PO tid x5d
Herpes simplex virus
Bacterial Vqinosis
Unclear, associatlld with: GanlnereJIB vegine/is

Myr:oplasma hominis Pnwote/la sp.
mstronidamle 500 mg PO bid x 7d mstronidamle gel1 applicator intravag. daily x 5d
Atopobium vaginae

Canditi111
Antimicrobial Quick Reference/References

Anlimicralial
Toronto Notes 2011
DERMATOLDGIC
Mlllitis Tinea Crurii/Pedis (Jock lt!:hfAihlete's Foot)
S.pyogenes
Trichophyton
s.
iiUfiWS
cloxacillin 500 mg PO qid x 7d cephlllexin 500 mg PO qid x 7d clotrillliiZUie 1% cream -apply bid
ketoconiiZOie 2% cre1111 - apply bid
Celulitis
1atlina:cephlllexin 5DD rng PO q6hx 10-14d 2nd lile: cloxacillin SDD rng PO q6hx or clindamyci'l 300 rng PO q6-8h x 14d, total < 1.8 gld
Ad8110Yirus None Note: vrsy contagious
OPHTHALMOLOGY
Conjunctivitis (viral) Conjunctivitis (bactarial)
S. 8llfiiUS pnaumoniae E. Coli H. influefllae
s.
dacallmide: 1-Z glt8
7-10d
gentamicin: 1-2 gtts q4h x 7-1 Dd el'(llmnycin ointment: apply to lid margils bid-qid, M: 3.5 gtuba el'(llmnycin ophthalmic ointment of no proven benefit If associilllld with rosacea: doxycyclina 1DO mg PO bid x 14d
Blephlrilil
Etiology unclear
S.auteUS
AJI doses are 'This c111rt is nat
s. epidalmidis
attumisespet:ified 111d is nan-inclJIMI ohpecill mu:eptia1ls Ii.e.
poar 111111 clallll1ce, lie.)
....
References
Fagllly CT, lUge S. McCord E. CoiTIIIIIil:ltiig with patieolli about intimm parlnel violence: smening 111d intmviewilg approac!Es. Ftm Med 2002; 34{5): 369-75. Nllilnll Cllitar an lilar Alula Ill tlla Amarican Public HLmllln Sarvic:aa Associllian. National Elder Abu11lncidanca Study: htqr/{Www.aaa.guv/tldflm/lilar_Righ!W Elder Fulpdf Wlt!MnCN, MacMilan larviolencaagainstwomen. JAMA 2003;28915):589-99.
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... IIRrtiiiCar.dilll Hypertension Education l'rupn. 2009 Cllllll111 Hypertenion EG!catian l'rogrlm an 11111111 flm Physician 2009; 55l7):697 100. Cr.dilll Hypnnsion Education l'rupn. 2010 Canadan Hypartanion EG!catian l'rogrlm raCCIIIIIlllldllions fur tha m1nagamant of Cn J Cardia! 2010; 26151: 241258. Elm PJ etal. Efllcls lillstyla modification on diat weight physiclllitniiS. and blood PfMIUr& COIIII81: 18-montllnssub af emdamizlad lrill. Alii Intern Med 2006:144{7):48S-95. Ftmw JA &Tcnra-Amiona G. Comparlliva1DIIIIIiityaftha HMG.eoA rdlctlsa Drug Sai2000;2Jl3):197-213. Ganart J. Fnlltdl J. Fadar G. RaCCIII'IIWidations fur tlla m1MQ111111n! af tha af cardiMiculer di-: suntmal'f aflhl 2003 updi!B. CMAJ 2003;169191:821-824. Gilham DJ et aL D:idence af hi)IJitllized rhabdomyolysis in pa1ienb nod with lipid-1Mring drugs. JAMA 2004;292121):258&-911. M1111Dn JE Ill al. fstrDgan pkis progallin and tlls rilkof ca!Dilary hlert di-. NEJM 2003;349(6):523-34. Mcl'herscm Ret 11. Clllldiln CanliiiVISCUIIT Society pasitian slltement- RecammenlittiJns for the diagnosis 111d treatment af dyslipiderria and JllfVenlion rl cardiavascljar disa111. Can J Canlial2006; 22111 ):913927. Dnlaia Drug Thanpy liuidslin81 for Slllbla '-thalric Haart lilease in Primary Care 12!XXl). Dnlaia Prog111m fur Optimal Tha11paulics. Taranbx Oueaa"s Printl! af On\wiD, pp, 10. OnuakD E.lllagnosilg SICCindlly hypartansion. Am Fam PhysiciM 2003; 61(1):67-74. Ucttt8nrlllil AH, 1111.12006). Dill and ilal8 111t0111mandations ravision 2006: Ascientific r1111mar1t 110m tha American Heart Association Nutrition Conri1ae. Cin:ulation, 114: 82-96. af dyslipidamill and 1hl piiMintionof Summ1ry af1hll003 updi!B.IIaprintad fnlm CMAJ 28 Octobar 2003; 16811): 121-824.
Toronto Notes 2011
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FM

Health Promotion and Counselling

Common Presenting Problems

Toronto Notes 2011

Famlly Medicine FMI

FM2 Family Medicine

Four Principles ofFamlly Medidne/Perlodic: Health Eum.ination

Toronto Notes 2011

Four Principles of Family Medicine

Patillnt'o Agenda FIFE fillings ldExpectmions

Periodic Health Examination (PHE)

Purpose of the PHE

Toronto Notes 2011

Periodic Health Examination/Health Promotion and CounseJlins

Family Medidne FM3

Tabla 1. Pariodic Health Exam (continued) .....

unless Dlherwin specified.

teaclling of br8llll salf-IIXIIminatian

Health Promotion and Counselling

Motivational Strategies for Behavioural Change

Offer rlllllistic options for chqe and

Adllptlld from lbt P.

FM4 Family Medicine

Health Promotion and Counselling

Toronto Notes 2011

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

Cardiovascular Disease Prevention

Etfac:ts Lower LDL

Omaga-3 fitly acid ric:hfaoda Salt Alcohol

Decreased: sudden death, death from CAD

Lower BP Excess alcohol increases risk Dl hyperbiglyceridemia, HTN

Energy Content If Food Carbohydmn 4 kcaVg Protein 4 kcaVg

Tabla 5. Introduction to Yrtamins and Minerals V"damii/Mineral

Calcullllq Total Daily Energy Expendibi'ITDEE)

women. 2700-2900 kcaVd for man

considertalcing V"rtllmin D supplementation of 1,000 IU/day

Toronto Notes 2011

Health Promotion and CoUDBe11ing

Family Medicine FMS

Tabla 5. Introduction to V"damins and Minerals (continued)

Soy, chrns, wheat genn,

Weakness, convulsions, neuromuscular irritability and dysfunction, failure to llrive

Meat. mil, bananas, prunes, raisins, orange, grapafruit.

Table 6. Macronutrient Distribution Ranges

Mlcranutriant 11 'l'o uf Daily Cllarial Fat Carbehydrm

5-20 10-30 1035

it'' Weiabt Lotina

Men .s.1OZ em (40 in) WunJen .S,88 cm (35 il)

Men >102 em (40 ill Wum1111 >88 Cll (35 in)

<18.5 18.524.9 25.fl.29.9 30.fl.34.9 35.fl.39.9 40.0+

Results in 12 lb (D.>1 kg) weight

Low BMI i Auoc:il.ted with: Ost.oporosis Eating di&Oider&

Alive,. Mlllicll CoMequenca of

Sleep lplllll Certain cancers

Gallbladder dis Non-alcoholic

FM6 Family Medicine

Health Promotion and Counselling

Toronto Notes 2011

If BMI > 25 kGfm' or waist circumference is lbcve cutoff point

Heelth 111m to advise lifestyle modification program

gLicaiL Amount. wiQit -

Phlrmaclllherapy BMI ;?.27 kQfm' + risk factors or BMI <!:30 lqr'm'

AddT811S other risk fllclors: periodic