Complete Clinical Card Booklet 2014.2014 Booklet Cropped(1)

8/10/2019 Complete Clinical Card Booklet 2014.2014 Booklet Cropped(1)

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www.cfpc.ca/sharcfm

Seventh Edition - 2014

SHARC-FMThe Shared Canadian Curriculum

in Family Medicine

CUFMEDThe Canadian Undergraduate

Family Medicine Directors

SHARC-FM is a joint initiative of

and

Canadian

Family MedicineClinical Cards

Editor David Keegan MD CCFP(EM) FCFPChief Reviewer Barbara Lent MD CCFP FCFP

Resident Reviewer Yan Yu MD

PEER-REVIEWED


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The editors, authors and reviewers have made every attemptto ensure the information in the Canadian Family Medicine

Clinical Cards is correct it is possible that errors may exist.Accordingly, the source references or other authoritiesshould be consulted to aid in determining the assessment

and management plan of patients.

The Cards are not meant to replace customized patientassessment nor clinical judgment. They are meant to

highlight key considerations in particular clinical scenarios,largely informed by relevant guidelines in effect at the time

of publication. The authors cannot assume any liability forpatient outcomes when these cards are used. They werecreated for clinical education in Canada.

PRODUCTION ASSISTANT

Katherine Thomas-Brothers

Printed in Canada by DoubleQ Printing

Forest Stewardship Council Certifieddoubleq.on.ca


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X = Classic FeaturesSAH Infxn TA CVT Dissxn BIT Mass ACG

Recent Trauma consider CTSudden Onset (exertion) X X XNew (50yrs) X X X X

Worst headache of life X X XProgressive over wks-mnths X pain am/supine/bend over X X XNausea/Vomiting X X X X X XVision changes X X X X XJaw claudication X Level of Consciousness X X XFever XFocal Neuro Findings X X X X XMeningismus X XPetechial Rash XPapilledema X X X

Eye red, cloudy cornea XMid fixed dilated pupil XTender, pulse temp artery X

Canadian Family Medicine Clinical Card

Headache

Dangerous Headaches: Red Flags

Key References: European Journal of Neurology. 2006, 13:1066-77. European Journal ofNeurology. 2006, 13:560-572. Annals of Internal Medicine. 2002, 137(10):840-9. Cephalagia.2004, 24(suppl1):9.

Migraine HeadachesSx: throbbing, unilateral, photo-/phono-phobia, nausea, debilitating, +/- aurasDietary Triggers: EtOH, chocolate, cheese, MSG, aspartame, caffeine, nuts, nitratesTx: 1. NSAIDs (ibuprofen 200-800 mg or ASA 1000mg q4h)

2. Triptans (almotriptan+others)3. Ergotamines

with CAD/CVD/SSRI; DONT USE with MAOI

4. Prochlorperazine 5-10mg IM or IV; Metoclopramide 5-10mg IM or IVPrevention:1. -blockers (propanolol 40-240 mg/day, metoprolol 50-200mg/day)2. Calcium channel blockers (verapamil 240-320mg/day, flunarizine 5-10mg/day)3. Anticonvulsants (valproic acid 500-1800mg/day, topiramate (25-100mg/day)4. TCAs (amitriptyline 50-150mg/day)

ClusterHeadaches

SAH: subarachnoidhemorrhageINFXN: infectionTA: temp arteritisCVT: cerebralvenous thrombosisDissxn: carotid/vertartery BIT: BenignIntracranial HTN(pseudotumor)ACG:Angle Closure

Glaucoma

CT (if-ve)LP

CT (r/o SAH)LP(culture+PCR)Tx (empiric):Ceftriaxone

& Vancomycin +Dexamethasone(+Acyclovir if

suspect HSV)

ESR &/or CRP;TemporalArtery Bx

Tx:steroids

MRAanticoag

CT/MRI

LP open pressure(+ focal neuro+

Imaging N +CSF N)

Tx: Diamox, Lasix

}

Angiography(MR,CT,other)

Preventative Tx:

Diagnosis5 episodes lasting 15-180min Unilateral (orbital/temporal)

Frequency: 8x/d to q2d1 ipsilateral sx (autonomic

eye, nose or face) or agitation

Acute Tx:1. 100% O2 7L/min x 15min2. Sumatriptan 6mg SC

3. Lidocaine 1mL 4% intranasal4. Octreotide 100 mcg SC

1. Prednisone 50mg x 5 day, then taper 10 mg/day [bridging prophylaxis]2. Verapamil 240mg/day, do ECG to watch for PR; takes 2-3 weeks to kick in

Alternatives: lithium, methysergide, topiramate, melatonin, ergotamine

1. keep supine2. drops: timolol

& acetazolamide3. analgesia4. antiemetics5. ophtho consult

in less than 1hr

HISTO

RY

PHYSICAL

Creba ASWalker IKeegan DA

A11 2011www.cfpc.ca/sharcfm


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Asthma Devices

Key References: Lougheed et al. Canadian Thoracic Society Asthma Management Continuum2010 ConsensusSummary for children six years of age and over, and adults. Can. Resp. J. Vol. 17(1), 2010 15-24./ Becker A etal. Summary of Recommendations from Canadian Pediatric Asthma Consensus Guidelines, 2003, CMAJ 2005,173 (6 suppl):S1-S56.

How to Use

Device Type Instructions Device Care

MDI +mouth-piecespacer

(1) Remove cap and shake

(2) Insert MDI into spacer

(3) Breathe out and seal lips around mouthpiece

(4) Press down and THEN take slow deep breath;hold for 10 seconds

(5) Brush teeth or gargle/spit water after use

- Clean bysoaking in soapywater

- Let device airdry after

cleaning

- Replace cap onplastic sleeve tostore device

MDI +

maskspacer


(2) Insert MDI into spacer

(3) Put mask against face (do not cover eyes)(4) Press down and take 6 normal breaths (usemouth to inhale)

MDIalone**


(2) Breathe out and seal lips around mouthpiece

(3) Press down as you breathe in slowly

(4) Hold breath for 10s then breathe out slowly

(5) Brush teeth or gargle/spit water after use

**(not recommended except for 3M device)

Turbu

haler

(1) Twist open and turn and click once

(2) Breathe out fully and put turbuhaler in mouth(do not blow into device)

(3) Deep breath in and hold for 10 seconds

- do NOT shake device

- Clean with drycloth

- Store atambienttemperatures

- Keep device

dry

Diskus(1) Push open and slide and click

(2) Breathe out fully and put diskus in mouth (donot blow into device)

(3) Deep breath in and hold for 10 seconds

- do NOT shake device

How to Choose


Chadha NKeegan DA

MDI + mouthpiecespacer

Yes + No No Yes No No No

MDI + Mask +spacer

No + No No Yes No No Yes

Turbuhaler Yes +++ No Yes No No Yes No

Diskus Yes ++ Yes Yes No Yes No No

MeteredDoseInhaler(MDI)

Dry

Powdered

DryPowder

MeteredDose

Inhaler(MDI)

Device Type


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A18


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6 Months add iron-rich foods

- by this point, the infants stores of iron have been largely used up

- CEREAL (iron-fortified): start with rice cereal; mix with breastmilk or water

- every 3-5 days, introduce another single grain cereal (eg. oatmeal)

- use mixed-grain cereals after all single grains introduced

- by 8 months, add plain yoghurt or fruit to keep infant interested in cereal

- tiny bits of/pured meat or chicken, cooked egg yolk, well cooked and tiny bitsof/pured legumes (beans, lentils, chick peas) are other good iron choices


Infant Nutrition

Key References: Nutrition for Healthy Term Infants. Statement of the Joint Working Group: CanadianPaediatric Society, Dieticians of Canada and Health Canada. 2005, www.hc-sc.gc.ca;Feeding Your Baby, Middlesex-London Health Unit, 2006, www.healthunit.com

Keegan DAThornton THBannister SL


Birth

- exclusive breastfeeding until up to 6 months of age

- vitamin D 400 IU / day (orally) while exclusively breastfeeding- if not tolerated, can switch to oral multi/poly vitamin drops

- if breastfeeding is discontinued, switch to iron-fortified formula

- advise extreme caution when warming formula: severe face, neck and mouthburns can occur; microwaving increases risk; shake micro-waved formula andtest temperature prior to giving to infant

6-9 Months add produce, meats and alternates

- start with green or bland foods, every 3-5 days introduce another vegetable- when all veg. started, begin fruits (unsweetened), new fruit every 3-5 days- add in tiny bits of meat & chicken, cooked egg yolk by 9 months if not already

started

9 12 Months add dairy products

- cheese (tiny pieces), high fat yoghurt- at 1 year old, can add homo (full-fat) milk; no more than 24 oz (720mL) / day- at 2 years old, can switch to 2% milk

Key donts

- dont put infant/child to bed with a bottle (++ increases risk of dental caries)- dont give fruit drinks or honey; juice is not recommended- dont give unpasteurized foods

- dont give nuts, egg white or shellfish in first year of life- dont re-use formula/breastmilk that the infant didnt finish

Notes

- offer solid foods after nursing or formula feeding until at least 9 months of age- if a type of food is refused, offer it again 1-2 weeks later- switch to cup or sippy cup by 12 months of age- additional infant nutrition education resources:

healthunit.comcaringforkids.ca


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C di F il M di i Cli i l C d A18


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18 Month Enhanced Visit

Key References: Getting it Right at 18 MonthsMaking it Right for a Lifetime. Report of the Expert Panelon the 18 Month Well Baby Visit, September 2005, Ontario Childrens Health Network and the Ontario College

of Family Physicians; Frankenbury WE, Dodds JB, Denver II Developmental Screening Tests, Denver Universityof Colorado Medical Center, 1990; Rourke L, Leduc D, Rourke J, The Rourke Baby Record, The CanadianFamily Physician, 2006; NDDS, The Nipissing District Developmental Screen, www.ndds.ca, 2011.

A. Developmental Screen- caregiver(s) completes Nipissing District Developmental Screen (NDDS)- medical team reviews responses & explores any no

B. History- family situation- nutrition (no sleeping with bottle; limit juices; milk up to 20 oz/day)- development questions

Social: manageable behaviour, seeks comfort if distressed, easy to soothe Communication: points to 3 body parts, 20-50 words, responds to own

name, points to pictures Gross Motor: runs, throws a ball, kicks a ball, walks up steps, walks

backwards 2steps Fine Motor: scribbles, turns pages in a book Adaptive: may brush with help, removes hat on own, uses spoon and fork,

drinks from cup- dental care, consider soother only for sleep, ensure being seen by dentist- ensure being seen by optometrist- assess risk of lead in toys and pipes/welding in home plumbing

C. Physical Exam- growth (head circ., weight,

height, plot on graphs)- gait assessment- eyes & vision- hearing- dental examination- general phys. examination

D. Safety Issues (see Injury Prevention Card for more details)- car seat discussion - safety gate- b ath safety (burns and drowning) - medicine safety- choking risk of small toys and certain foods

E. Immunization- review immunizations to date- administer 18 month immunizations

- Pentacel (DTaP/IPV/Hib) and MMR

F. Reinforce- good/great things the parents are doing- age appropriate activities and toys (see NDDS)- provide community resource information

Ontario Poison Centre 1-800-268-9017ON Govt. Services www.children.gov.on.caChild Health Info www.caringforkids.cps.ca, www.cfpc.caGreat Kids Resources www.cfc-efc.ca

G. Refer as needed

Mini-Developmental Examination-say childs name (observe response)-see what child does with pen and paper-observe play with toy/doll-observe interaction with parents-observe spontaneous gross & fine motor

-ask Whos that?, Whats this?

Keegan DAThornton THBannister SL



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il di i l k hi


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SNAPPS Model of Case Presentation

S Summarizebrieflythehistoryandfindings.N NarrowtheDx ormanagementto23relevant

possibilities.

A

Analyze

the

reasoning

by

reviewing

the

findings

or

examiningtheevidence;compareandcontrast.P

Probe

thepreceptorbyaskingquestionsaboutuncertainties,difficultiesoralternateapproaches.

P Planmanagementforthepatientsmedicalissues.S Selectacaserelatedissueforselfdirectedlearning.

Wolpaw TM,Wolpaw DR,PappKK. SNAPPS: ALearnerCentred ModelforOutpatientEducation. Acad Med. 78:893898. 2003.

[email protected]

ucalgary.ca/familymedicine/undergraduate/clerkship

26 Clinical Presentations for FM Clerkship

1. AbdominalPain2. Anxiety3. Asthma4. ChestPain5. Contraception6. Cough/Dyspnea7. Depression8. DiabetesTypeII

9. Diarrhea10. Dizziness11. Earache12. ElderlyPatient

(potentiallycompromised)

13. Fatigue14. Fever

15. Headache16. Hypertension17. IschemicHeartDisease18. JointPain19. LowBackPain20. Obesity21. PeriodHealthExam /

PeriodicScreening

22. PrenatalCare

23. SkinDisorders24. UpperRespiratoryTract

Infection25. UrinarySymptoms

(dysuria)&GenitalDischarge

26. WellbabyCare

Coredocument&detailed objectivesavailableathttp://www.ucalgary.ca/mdprogram/mdprogram/clerkshipfamilymed

Documents

Complete Clinical Card Booklet 2014.2014 Booklet Cropped(1)