Family Medicine

FAMILY MEDICINE Dr. D. Tannenbaum

Angelina Chan, Helen Dempster and Tanya Thornton, chapter editors Tracy Chin, associate editor

FOUR PRINCIPLES OF FAMILY MEDICINE . . 3

PATIENT-CENTERED CLINICAL METHOD . . . 3

PERIODIC HEALTH EXAM (PHE) . . . . . . . . . . . 3Purpose of the PHE Adult Periodic Health Exam Additional Preventative Health Care for the Elderly

HEALTH PROMOTION AND COUNSELLING . . 5Nutrition Exercise Stress Management

End Of Life Care

COMPLEMENTARY THERAPIES . . . . . . . . . . . . 7

COMMON PRESENTING PROBLEMS

ALCOHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Definition Epidemiology History Investigations Management Prognosis

ANXIETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Screening Questions History Treatment

BRONCHITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Acute Bronchitis Acute Exacertabions Of Chronic Bronchitis (A.E.C.B.)

CEREBROVASCULAR DISEASE . . . . . . . . . . . . . 13

CHEST PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Ischemic Heart Disease (IHD)

COMMON COLD (ACUTE RHINITIS) . . . . . . . . 14Epidemiology Prevention Diagnosis Management

CONTRACEPTION . . . . . . . . . . . . . . . . . . . . . . . . . 15History Physical Examination Counselling

MCCQE 2006 Review Notes Family Medicine – FM1

DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Screening QuestionsRisk Factors For Depression Related IssuesTreatmentRisk of Recurrence

DIABETES MELLITUS (DM) . . . . . . . . . . . . . . . . 16DefinitionClassification and Epidemiology DiagnosisScreeningManagement

DIZZINESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EpidemiologyDiagnosisManagement

DOMESTIC VIOLENCE . . . . . . . . . . . . . . . . . . . . . 19EpidemiologyEffects of ViolenceDetection and Management

DYSPNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20DefinitionDifferential DiagnosisHistoryPhysical ExaminationInvestigationsManagement

DYSURIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21EpidemiologyInvestigationsManagement

FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EpidemiologyApproachManagementChronic Fatigue Syndrome

HEADACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EtiologyRed Flags for HeadacheEpisodic Tension-Type Headache Cluster HeadacheMigraine Headaches

FM2 – Family Medicine MCCQE 2006 Review Notes

FAMILY MEDICINE . . . CONT.

HYPERTENSION (HTN) . . . . . . . . . . . . . . . . . . . . 27Epidemiology Definition Etiology Diagnostic Evaluation Therapeutic Considerations

LOW BACK PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . 31Definition Etiology Differential Diagnosis History Physical examination Investigations Management Red Flags

MENOPAUSE/HORMONE REPLACEMENT THERAPY (HRT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Epidemiology Contraindications to HRT Management

OBESITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Definition Epidemiology Diagnosis Investigations Management Natural History

OSTEOARTHRITIS (OA) . . . . . . . . . . . . . . . . . . . . 34Definition Etiology Pathophysiology Signs and Symptoms Investigations Management

OTITIS MEDIA (OM) (ACUTE) . . . . . . . . . . . . . . 35Definition Epidemiology History Physical Examination/Diagnosis Etiology Management

SEXUALLY TRANSMITTEDDISEASES (STD’s) . . . . . . . . . . . . . . . . . . . . . . . . . 36HistoryPatients at RiskOrganismsPreventionDiagnosis/InvestigationsManagement

SKIN LESIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Etiology

SLEEP PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . 37DefinitionEtiologyHistoryPhysical Examination/InvestigationsManagementStress-induced InsomniaPeriodic Limb Movements Of Sleep (PLMS) and

Restless Leg SyndromeCircadian Rhythm DisordersParasomniasExcessive Daytime Sleepiness

SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39EpidemiologyHistoryManagementPrognosis

SORE THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40EtiologyInvestigations and Management

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42


FOUR PRINCIPLES OF FAMILY MEDICINE College of Family Physicians of Canada Guidelines

1. The family physician is a skilled clinician• is skilled in diagnosis/management of diseases common to population served • recognizes importance of early diagnosis of serious life threatening illnesses

2. Family medicine is a community-based discipline• has good knowledge of and access to community services• responds/adapts to changing needs and changing circumstances• collaborates as team member or leader

3. The family physician is a resource to a defined practice population• serves as a health resource• promotes self-directed life-long learning• advocates for public policy to promote health

4. The patient-physician relationship is central to the role of the family physician • is committed to the person, not just disease• promotes continuity of patient care

PATIENT-CENTRED CLINICAL METHOD � explore/define patient problems and decide on management together� consider both agendas

• doctor's agenda: history, physical, investigation• patient's agenda: FIFE = feelings, ideas, function, expectations

� find common ground in management and follow-up planning

ADULT PERIODIC HEALTH EXAM � Canadian Task Force on Preventative Health Care established in 1976; first published in 1979 � reviews the literature for evidence pertaining to prevention of conditions� aids in developing clinical practice guidelines� incorporates primary and secondary preventive measures� most notable recommendation is the abolition of the annual physical exam; to be replaced by the

periodic health examination (PHE)

PURPOSE OF THE PHE � primary prevention � identify risk factors for common chronic disease� detect asymptomatic disease (secondary prevention)� counsel patients to promote healthy behaviour� update clinical data� enhance patient – physician relationship

Table 1. Classification of Recommendations

A good evidence supporting inclusion of the maneuver

B fair evidence supporting inclusion of the maneuver

C poor evidence regarding the inclusion or exclusion of the maneuver/condition

D fair evidence supporting exclusion of the maneuver

E good evidence supporting exclusion of the maneuver

ADULT PERIODIC HEALTH EXAM Counselling Issues � A. Recommendations

• smoker? If yes, counsel on smoking cessation and offer nicotine replacement therapy • dental hygiene (dental visits, brushing, flossing)• folic acid supplementation (ALL females of child bearing age)

0.4 mg 1 month preconception until 3 months postconception• noise control and hearing protection


ADULT PERIODIC HEALTH EXAM . . . CONT .

� B. Recommendations • smokers: referral to valid cessation program after cessation advice• seat belt use • moderate physical activity • diet (counselling on adverse nutritional habits and general dietary advice on fat and cholesterol) • HRT (assess risk factors, discuss risks and benefits of HRT)• sun exposure and protective clothing • alcohol case finding and counselling • counselling to protect against STDs

� for high risk populations only � home visits for child maltreatment (A) � dietary advice on leafy green vegetables and fruit for smokers (B)

Physical Exam � blood pressure measurement (B) � clinical breast exam (50-69 years) (A) � for high risk populations only:

• fundoscopy for diabetics (B) • skin exam for first degree relative with melanoma (B)

Laboratory/Investigations � mammography (50-69 years) (A) � rubella titres for all women of child bearing age (B)� Pap smear (B) � for high risk populations only

• voluntary HIV antibody screening for high risk populations (A)• urine dipstick for adults with insulin-dependent diabetes (A)• gonorrhea, gram stain/culture, cervical or urethral smear for high risk groups (A)• mantoux TB skin test for high risk groups (A)• INH prophylaxis for household contacts and skin test converters (A)• INH prophylaxis for high risk subgroups (B)• colonoscopy for cancer family syndrome (B)• chlamydia, smear culture or analysis for high risk women (B)

Immunizations � rubella for all non-pregnant women of child-bearing age (B)� for high risk populations only

• amantadine chemoprophylaxis for individuals exposed to influenza index case (A)• outreach strategies for influenza vaccination for specific subgroups

(e.g. diabetes, chronic heart disease) (A)• annual immunization for influenza for high risk groups (B)

ADDITIONAL PREVENTATIVE HEALTH CARE FOR THE ELDERLY � A. Recommendations

• outreach strategies for influenza vaccination• for high risk populations only

• multidisciplinary post fall assessment• pneumococcal pneumonia immunization

� B. Recommendations • BP measurement • influenza vaccination • hearing impairment assessment (inquiry, whispered voice test)• visual acuity: Snellen sight card

Reference: Canadian Task Force on Preventative Health Care, 2000.


HEALTH PROMOTION AND COUNSELLING � health promotion is the most effective preventive strategy� 40-70% of productive life lost annually is preventable

NUTRITION Guidelines for the General Population� for people > 4 years old � enjoy a variety of foods from each group every day

• grain products • 5-12 servings/day • choose whole grain and enriched products more often• low in fat, cholesterol; high in B vitamins, iron, fiber• bread, pasta, rice, cereal, crackers, etc.

• vegetables and fruit • 5-10 servings/day • choose dark green and orange vegetables/fruit more often• high in vitamins, minerals, fiber; low in fat, calories, sodium; no cholesterol • broccoli, lettuce, carrots, cantaloupe, potatoes, oranges, bananas, peaches, etc.

• milk products • children 4-9 years, 2-3 servings/day; age 10-16, 3-4/day; adults 2-4/day;

pregnant/breast-feeding, 3-4/day• choose lower-fat milk products more often• high in protein, calcium, phosphorus, niacin, riboflavin, vitamins A and D • milk, cheese, yogurt, ice-cream, etc.

• meat and alternatives • 2-3 servings/day • choose leaner meats, poultry and fish, plus dried peas, bean and lentils more often • high in protein, B vitamins, iron, other minerals• beef, chicken, lunch meats, fresh/canned fish, beans, tofu, eggs, peanut butter, etc.

• other foods • for taste and enjoyment, but may be high in fat or calories, so use in moderation

� aim for fat intake < 30% of total energy• limit saturated fat to < 10% of energy• limit cholesterol to < 300 mg/d

� consume at least 2 fish servings per week� limit salt to < 6 g/day � limit alcohol to low-risk guidelines� balance the number of calories you eat with the number you use

• weight (lbs) X 15 = average number of calories used per day if moderately active • weight (lbs) X 13 = average number of calories used per day if less active

� vegetarian diet is low in fat and cholesterol� soy products can provide high quality protein needed for growth and tissue maintenance � avoid fad diets that purport that one type of food is bad – variety is the key!

Reference: AHA Dietary Guidelines Revision 2000: A statement for healthcare professonals from the nutrition committee of the American Heart Association.

EXERCISE Epidemiology � 25% of population exercise regularly, 50% occasionally, 25% sedentary� 1/3 of Canadians watch > 15 hours of TV/week� daily physical activity decreases with age to middle adulthood, then increases� physical activity reduces morbidity and mortality for CAD, hypertension,

obesity, diabetes, osteoporosis, mental health disorders� moderate activity: activities that can be comfortably sustained for at least

60 minutes (walking, slow biking) � vigorous activity: activities of an intensity sufficient to result in fatigue

within 20 minutes (running, shoveling snow)

History � assess current level of fitness, motivation and accessibility to exercise� medical screen

• age • previous level of activity • current medications

• diuretics affect potassium levels• anticholinergics increase body temperature• insulin can cause hypoglycemia

• cardiovascular risk factors • CBC, blood sugar, cholesterol, urinalysis, stress ECG test

� contraindications: recent MI, conduction abnormalities


HEALTH PROMOTION AND COUNSELLING . . . CONT.

Management � emphasize benefits of exercise

• increases energy level, strength and flexibility• improves cardiovascular and metabolic functions• increases glucose tolerance • increases feeling of well-being and sex drive• improves quality of sleep • decreases depression/anxiety

� types of exercise • emphasize regular, moderate-intensity physical activity• encourage a variety of self-directed activities (walking/cycling to work, climbing the stairs, raking leaves)• over several months, progress to level of activity that includes cardiovascular fitness;

development of muscular strength and joint flexibility is also desirable• aerobic activity involving large muscle groups for 50-60 minutes at

least 3-4 times a week at 60-80% of maximum heart rate• maximum heart rate = 220 – age (men), 226 – age (women)• 5-10 minute stretching routine decreases musculoskeletal injuries

Table 2. Target Heart Rate

Age 60% of Max. (beginner) 70% of Max. (intermediate) 80% of Max. (advanced)

20-29 120 140 160

30-39 114 133 152

40-49 108 126 144

50-59 102 119 136

60-69 96 112 128

70-79 90 105 120

Note: If bicycling, subtract five beats from target; if swimming, subtract ten.

STRESS MANAGEMENT � steps to manage stress • identify sources of stress and make a list • modify environment/events to decrease stress• develop coping strategies

• biofeedback, meditation, mental imagery, hypnosis, diaphragmatic breathing, progressive muscle relaxation, psychotherapy

• focus on goal achievements and personal well-being• give positive feedback and rewards

� for hypertensive patients, individualized cognitive-behavioural interventions are best

END OF LIFE CARE Domains of Quality End-of-Life Care from Patients’ Perspectives

1. Receiving adequate pain and symptom management2. Avoiding inappropriate prolongation of dying3. Achieving a sense of control over end-of-life care decisions4. Relieving burden on loved ones 5. Strengthening relationships

MD’s Role � to provide adequate pain/symptom management� to offer/suggest: DNRs, advanced directives, care-giver respite, family

supports, patient/family community resources

Principles of Pain Management � general

• commit to providing effective pain control• educate the patient, family and other caregivers of the plan• understand the patient's physical, psychological, social and spiritual

beliefs about pain control and dying • remain flexible to the requests of the patient with respect to alternative/complimentary therapy • limit investigations to those that will make a difference in management decisions• do not delay in treating pain


HEALTH PROMOTION AND COUNSELLING . . . CONT.

� analgesic therapy • hierarchy

• non-opioid ± adjuvant;• opioid + non-opioid ± adjuvant;• opioid ± non-opioid ± adjuvant• progress through hierarchy until pain is relieved

• give po medication where possible (less cumbersome to manage,more patient freedom) • give regular interval dosing to maintain levels - avoid prn's• ensure coverage for breakthrough pain• anticipate and prevent adverse effects• treat non-pain symptoms (nausea, vomiting, constipation) aggressively• consider adjuvant therapies (i.e. radiation, surgery, chemotherapy) at regular intervals

� monitoring • monitor frequently - timing depends on severity of pain• maintain direct communication with other providers (home nursing, physiotherapy)

Reference: Librach SL, Squires BP, The Pain Manual. Principles and Issues in Cancer Pain Management. Toronto: Pegasus Healthcare International. 1997.

COMPLEMENTARY THERAPIES � knowledge of complementary therapies can improve

• communication with patients who choose these therapies• co-ordination of care • the well-being of patients through appropriate use of these therapies

� many types exist, including (among others): chiropractic, acupuncture, naturopathy, homeopathy,mind-body therapies, bodywork, reflexology, applied kinesiology, herbal remedies, traditional Chinese medicine

Herbal Medications � questions to ask patients who may be taking herbal products

• Are you taking an herbal product, herbal supplement or other “natural remedy”? • If so, are you taking any prescription or nonprescription medications for the same purpose

as the herbal product? • Have you used this herbal product before?• Are you allergic to any plant products?• Are you pregnant or breast-feeding?

Table 3. Common Herbal Medications

Common Name

Aloe Vera

Chamomile

Evening Primrose

Echinacea

Garlic

Ginger

Ginkgo

Goldenseal

Marijuana

Psyllium

St. John’s Wort

Valerian

Reported Uses (not necessarily effective)

strong laxative, topical: used for burns

common cold, GI spasm, heartburn, colitis, IBS

CNS stimulant, decongestant, bronchospasm

boils, erysipelas, septicaemia, cancer, syphilis, common cold, flu

migraine, arthritis, allergies, and antipyrexia

elevated lipids, high blood pressure, high serum glucose

energy enhancer

slows cognitive deterioration in dementia

reduces cognitive function, ocular pressure, bronchodilator, mild appetite stimulant and antiemetic effects, esp. against methotrexate therapy

stabilizes diarrhea, relieves constipation, lowers cholesterol

mild to moderate depression, seasonal affective disorder

hypnotic without residual a.m. sedation, anxiolytic

Possible Adverse Effects

intestinal obstruction, Crohn's, in children or in pregnancy

rare sensitization, emesis, anaphylaxis possible

headache, restlessness, tachycardias, hyperglycemia, diuresis

rare sensitization

heart rate, mouth ulcers, muscle stiffness

can increase bleeding time, gastric irritation, halitosis

aggressive behaviors, headache, menstrual abnormalities

some platelet aggregation inhibition

panic, confusion, anxiety, psychosis, exaggerated apprehension of sensory stimuli, SVT, ovulatory dysfunction

avoid in intestinal stricture, ileus, or obstruction

increased photosensitivity, headache, nausea and dizziness

headache, palpitations, paradoxical insomnia

Possible Drug Interactions

K-dependent cardiac drugs

delayed GI drug absorption

cardiac glycosides MAOIs

potentiates warfarin

potentiates antithrombotic medications

potentiates warfarin, aspirin

potentiates CNS stimulants .

anticoagulants, MAOIs

antagonizes methylcholine

delayed GI drug absorption

MAOIs, BCP

other sedatives


COMMON PRESENTING PROBLEMS

ALCOHOL DEFINITION � one standard drink = 13.6 g of absolute alcohol

• beer (5% alcohol) = 12 oz • wine (12-17%) = 5 oz • fortified wine = 3 oz • hard liquor (80-proof) = 1.5 oz

� diagnostic categories occur along a continuum • abstinence • low-risk drinking

• 2 drinks/day maximum • 9 drinks/week maximum for women, 14 drinks/week maximum for men

• at-risk drinking • consumption above low-risk level but no alcohol-related physical or social problems

• problem drinking • consumption above low-risk level with one or more alcohol related physical or social

problems but no clinical features of established alcohol dependence• alcohol dependence

• DSM-IV criteria of 3 or more of the following in the same 12-month period• tolerance • withdrawal• alcohol consumed in larger amounts or over a longer period of time than intended • persistent desire or unsuccessful efforts to decrease alcohol use• great deal of time spent obtaining, using or recovering from alcohol• neglecting important activities (social, job, recreational) because of drinking • continued consumption despite knowledge of alcohol-related physical or

social problems

EPIDEMIOLOGY � 10-15% of patients in family practice are problem drinkers� over 500,000 Canadians are alcohol-dependent � 10% of all deaths in Canada are alcohol-related� overall cost > 5 billion dollars in Canada � most likely to miss diagnosis in women, elderly, patients with high socioeconomic status

HISTORY � assess drinking profile

• setting, time, place, occasion, with whom• pressures to drink: internal and external• 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?

� rapid screen • Do you think you have a drinking problem?• Have you had a drink in the last 24 hours?

� CAGE questionnaire to screen for alcohol abuse• 2+ for men, 1+ for women: sensitivity 85%, specificity 89%• Have you ever tried to C ut down on your drinking?• Have you every felt A nnoyed by others telling you to cut down?• Have you ever felt G uilty about your drinking?• Have you ever had to have an E ye-opener in the morning?

� medical presentations of alcohol problems • trauma • GI: gastritis, dyspepsia, recurrent diarrhea, bleeds, oral/esophageal cancer, pancreatitis, liver disease • cardiac: hypertension, alcoholic cardiomyopathy• neurologic: Korsakoff’s/Wernicke’s encephalopathy, peripheral neuropathy• hematologic: anemia, coagulopathies • other: insomnia, social/family dysfunction, sexual problems

� if identified positive for alcohol problem • identify other drug use • identify medical/psychiatric complications• ask about substance abuse among family members• ask about drinking and driving • ask about past recovery attempts and current readiness for change


ALCOHOL . . . CONT.

Table 4. Distinguishing Problem Drinking from SevereAlcohol Dependence

Clinical Feature Problem Drinking Alcohol Dependence

withdrawal symptoms no often

amount consumed weekly more than 12 more than 60

drinks moderately (< 4 daily) often rarely

social consequences none or mild often severe

physical consequences none or mild often severe

socially stable usually often not

neglects major responsibilities no yes

Source: Kahan, M. in Canadian Family Physician 1996, Vol. 42, pg. 662

INVESTIGATIONS � GGT and MCV for baseline and follow-up� AST, ALT, platelets (thrombocytopenia)

MANAGEMENT � brief physician-directed intervention for problem drinkers

• review safe drinking guidelines• compare consumption to Canadian norms• offer information on health effects of drinking• have patient commit to drinking goal• review strategies to avoid intoxication (e.g. alternate alcoholic with non-alcoholic drinks,

avoid drinking on empty stomach, start drinking later in evening, sip do not gulp; keep a glass of non-alcoholic drink in your hand)

• keep daily record of alcohol consumption• have regular follow-up • refer for further treatment if problem persists

� Alcoholics Anonymous • outpatient/day programs for those with chronic, resistant problems• 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

• family treatment (Al-Anon, Al-A-Teen, screen for spouse/child abuse)� pharmacologic

• Diazepam for withdrawal (see Psychiatry Chapter for loading protocols)• Disulfiram (Antabuse)

• blocks conversion of acetaldehyde to acetic acid (which leadsto flushing, headache, nausea, hypotension, hyperventilation,anxiety if alcohol is ingested)

• Naltrexone • competitive opioid antagonist that decreases cravings, mean drinking days and relapse rates• note: prescription opioids become ineffective and can trigger withdrawal in

opioid-dependent patients

PROGNOSIS � relapses are 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

Reference: Kahan, M. (in Canadian Family Physician 1996, Vol. 42, pg. 662)


ANXIETY SCREENING QUESTIONS � if positive answers, follow up with symptom-specific questions (See Table 5)

• Have you felt unusually worried about things recently?• Do you tend to be an anxious person? • Have you ever felt like something bad was going to happen?

� to differentiate anxiety disorders, consider symptoms and their duration

HISTORY � associated symptoms (see Table 5) � risk factors: family history of anxiety or depression, past history of anxiety, stressful life event,

isolation, gender (women) � rule out

• cardiac (post MI, arrhythmias) • hyperthyroidism • diabetes • COPD • asthma • somatoform disorders • psychotic disorders and medications (amphetamines, theophylline, thyroid preparations,

diet pill abuse or withdrawal from alcohol, benzodiazepines, street drugs)� assess substance abuse, comorbid depression, suicidal ideations

Table 5. RED FLAGS for Detection of Anxiety Disorders in Primary Care

Symptom Screening Question

Anxiety/worry Have you felt more worried than usual Do you experience episodes of intense worry? (Does the worry have a particular focus?) Do you feel your level of anxiety is excessive?

Phobias Do you avoid or fear social situations? Are there any specific things that you fear or avoid? Do you feel the fear is excessive?

Obsessions Do any repetitive intrusive thoughts bother you?

Compulsions Do you do anything repetitively?

Irritability Have you or your family noticed that you have been more irritable?

Sleep Disturbance Have you had difficulty falling asleep or staying asleep? Do you find that you’re easily fatigued? Do you have difficulty concentrating? Do you find your mind going blank?

Autonomic Hyperactivity Have you experienced: dizzy spells/hot flashes/chills/nausea/diarrhea?

Appetite Disturbance Have you lost your appetite?

Traumatized Do you have recurrent upsetting memories of an event that made you feel frightened or helpless?

Motor Tension Have you felt agitated or on edge?

Chronic Somatization Have you experienced repeated non-response to treatment?

Dermatological Problems Have you had any skin problems for a prolonged period of time?

Large Medical Chart Chronic, frequent users of medical system

Adapted from: From Anxiety Review Panel. Evans M, Bradwejn J, Dunn L (Eds.). Guidelines for the Treatment of Anxiety Disorders in Primary Care. Toronto: Queen’s Printer of Ontario. 2000: 39.

TREATMENT (see Psychiatry Chapter)


ANXIETY . . . CONT.

Figure 1. Differentiating Anxiety Disorders

From Anxiety Review Panel. Evans M, Bradwejn J, Dunn L (Eds.). Guidelines for the Treatment of Anxiety Disorders in Primary Care. Toronto: Queen’s Printer of Ontario. 2000: 41.

BRONCHITIS ACUTE BRONCHITIS Epidemiology � most frequent LRTI in adults (especially in winter months)� 80% viral: rhinovirus, coronavirus, adenovirus, influenza� bacterial: M. pneumoniae, C. pneumoniae, S. pneumonia

Differential Diagnosis� asthma � URTI � occupational exposure � chronic bronchitis � sinusitis � pneumonia � allergic aspergillosis � reflux esophagitis � CHF � bronchogenic CA � other aspiration syndromes

Diagnosis � definition: acute respiratory tract infection where cough (+/– phlegm) is the predominant feature� symptoms

• productive cough (especially at night) and wheezing (most common symptoms) • dyspnea, recent URTI • substernal chest pain with cough, deep respiration and movement• ± mild fever

� signs • purulent sputum (the result of either viral or bacterial etiologies)• rhonchi, wheezing, prolonged expiratory phase• ? pneumonia if crackles, chills, fever or toxic

� investigations (acute bronchitis is typically a clinical diagnosis)• r/o pneumonia and CHF with CXR if abnormal vitals (HR > 100 bpm, RR > 24, T > 38) • r/o asthma if repeated/prolonged, with methacholine challenge test or bronchodilator

improved symptoms • sputum smear/culture = non-informative


BRONCHITIS . . . CONT.

Management for Uncomplicated Acute Bronchitis� applies to immunocompetent adults without comorbidities (e.g. COPD, CHF)� rule out serious illness (pneumonia) 4

• in healthy, nonelderly adults, pneumonia is rare in the absence of abnormal vital signs or asymmetrical lung sounds (no signs of focal consolidation i.e. rales, egophony, fremitus)

• CXR warranted if: cough lasts 3 weeks or longer, abnormal vital signs present,signs of focal consolidation present

� no current evidence for routine antibiotic treatment for acute bronchitis regardless of duration of cough 3,4

• no consistent impact on duration or severity of illness or complications from bronchitis with antibiotic treatment

• if pertussis infection suspected (if persistent cough (> 2-3 weeks) and exposure),perform diagnostic test and start antimicrobial therapy to reduce shedding ofpathogen and spread of infection

� patient satisfaction with care depends most on physician-patient communication rather thanantibiotic therapy 4

• discuss lack of benefit of antibiotic treatment for uncomplicated acute bronchitis• set realistic expectations for the duration of patient’s cough (10-14 days from office visit) • refer to the cough illness as a “chest cold” rather than bronchitis• personalize the risk of unnecessary antibiotic use: increased likelihood of infection

with antibiotic resistant bacteria, side effects (GI), rare anaphylaxis� primary prevention through risk factor reduction is important: smoking cessation, reduction of

irritant exposures � symptomatic relief: rest, fluids, antipyretics, antitussives� frequent bronchial hyperresponsiveness in patients with uncomplicated acute bronchitis:

RCTs show consistent benefit of albuterol therapy for uncomplicated acute bronchitisin reducing duration and severity of symptoms 4

� treatment with antibiotics if elderly, comorbidities exist, pneumonia/toxic is suspected• 1st line: tetracycline 250 mg qid or, erythromycin 1 g divided bid, tid or qid• 2nd line: doxycycline 100 mg bid for 1st day then 100 mg od, or clarithromycin 250-500 mg bid,

or azithromycin 500 mg x1 then 250 mg od x4Reference 1. Hueston WJ, Mainous AG. Acute bronchitis. American Family Physician. March 15, 1998. Vol 57. Pg 1270-9.

2. Ontario Anti-infective Review Panel, Toronto Canada, Anti-Infective Guidelines for Community-acquired Infections, 2nd Ed., 1997. 3. Orr PH, Scherer K, Macdonald A, Moffatt MEK. Randomized placebo-controlled trials of antibiotics for acute bronchitis: A critical review of the literature.

The Journal of Family Practice 1993;36:507-512. 4. Gonzales R, Bartlett JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Emerg Med.

2001 Jun;37(6):720-7.

ACUTE EXACERTABIONS OF CHRONIC BRONCHITIS (A.E.C.B.) � defined clinically as excessive cough, productive of sputum on most days,

for at least 3 months a year during at least two consecutive years� most common cause = cigarette smoking

Treatment � 50% of A.E.C.B. is non-bacterial; use of antimicrobials controversial� with mild-moderate clinical presentation (limited underlying lung disease)

• 1st line: Tetracycline 250 mg qid or TMP/SMX 1DS tab bid or Amoxicillin 500 mg tid • 2nd line: Doxycycline 100 mg bid first day then 100 mg daily or Azithromycin 500 mg first day

then 250 mg daily x 4 days � with severe clinical presentation (extensive underlying lung disease and/or

other risk factors including age > 65 years, comorbidities such as CHF, DM, CRF)• 1st line: TMP/SMX 1 DS tab bid or Amoxicillin/Clavulanate 500 mg tid or

Cefaclor 250-500 mg tid or Cefuroxime AX 250 mg - 500 mg bid +/– Erythromycin 1 g/day in divided doses; or Azithromycin 500 mg first day then 250 mg daily x 4 days

• 2nd line: Ciprofloxacin 500-750 mg bid Reference: Ontario Anti-infective Review Panel, Toronto Canada, Anti-Infective Guidelines for Community-acquired Infections, 2nd Ed., 1997.


CEREBROVASCULAR DISEASE � see Neurology Chapter for definitions, vascular territories and treatment details

History � symptoms � risk factors (HTN is most important), head trauma� medications and medical conditions that predispose patient:

hypercoagulable states (i.e. OCP), giant cell arteritis , anti-coagulants, etc.

Physical Examination � note level of consciousness, speech and cognition� blood pressure � complete neurological examination� cardiac exam, carotid bruits

Investigations � lab: CBC, FBS, lipid profile, PT/PTT/INR� cardiac: ECG, echocardiography, holter monitor� carotid doppler � imaging: CT (method of choice in acute situations)

Reference: Smucker WD, Disabato JA, Krishen AE. Systematic approach to diagnosis and initial management of stroke. American Family Physician 1995 July; 52(1):225-34.

CHEST PAIN � see Cardiology Chapter

Table 6. Differential Diagnosis of Chest Pain

Cardiac Non-cardiac

Pulmonary GI MSK/Neuro. Psychologic

Angina Pneumonia GERD Arthritis AnxietyMI with pleurisy PUD Chondritis PanicPericarditis Pneumothorax Rib fractures Myocarditis PE Herpes Zoster Aortic dissection Pulmonary hypertension

ISCHEMIC HEART DISEASE � 2-part treatment strategy � risk factor modification: multiple risk factors confer multiplicative risk (not merely additive)

• obesity: promote dietary measures to achieve ideal BMI (20-25)• physical inactivity:encourage moderate exercise 30-60 minutes at least 3x/week • smoking: encourage smoking cessation therapy using bupropion or a nicotine patch and a

counseling program; note: smoking cessation aids are safe for patients with ischemic heart disease• diet: a low saturated fat and high fibre diet (B)• diabetes mellitus: HbA1c < 7%• hypertension • dyslipidemia: initiate therapy with HMG CoA reductase inhibitors if

LDL-C is >3 mmol/L (target <2.5 mmol/L)• age: advancing age should not limit access to use of therapy and

may confer greater benefit � drug therapy

1. disease modifying drugs (reduce mortality): beta-blockers,antiplatelet agents, ACE inhibitors, lipid modifying drugs

2. symptom modifying drugs: beta-blockers, nitrates, calcium channel blockers


CHEST PAIN . . . CONT.

Stable Ischemic Heart Disease

beta-blocker for all post MI patients anti-platelet therapy for al

l patients

ACEi’s for patients > 55 years old anti-lipid therapy for patients with dyslipidemia

symptoms persist

add beta-blocker (if not already using it) + PRN sub-lingual nitrate

symptoms persist

add nitrate or CCB

symptoms persist

add CCB or nitrate

symptoms persist

consider coronary artery revascularization

Figure 2. Treatment Algorithm for Stable Ischemic Heart DiseaseAdapted from: Ontario Drug Therapy Guidelines for Stable Ischemic Heart Disease in Primary Care. Ontario Program for Optimal Therapeutics. Toronto: Queen’s Printer of Ontario: 2000, 10.

COMMON COLD (ACUTE RHINITIS) EPIDEMIOLOGY � leading URTI; peaks in winter months � incidence: adults = 2-4/year, children = 6-10/year� organisms: mainly rhinoviruses; others: adenovirus, RSV, influenza, parainfluenza

• incubation = 1-5 days • transmission: hand contact with agent; can survive on objects/skin

PREVENTION � avoid contacts; frequent hand washing; avoid hand to mucous membranes

DIAGNOSIS � history

• prior episodes, treatments, smoking history, epidemics, sick contacts• respiratory tract symptoms • otalgia, facial/dental pain, hoarseness, sputum, dyspnea, wheezing

� symptoms • local - sneezing, congestion, rhinorrhea, sore throat, non-productive cough• general - malaise, headache, myalgias, mild fever

� signs • boggy nasal mucosa with drip, erythematous nasopharynx, +/– enlarged post lymphoid

tissue and enlarged lymph nodes • 2˚ bacterial infection: fever, localized pain, productive cough

MANAGEMENT � patient education • symptoms peak at day 1-3 and usually subside within one week• cough persists for days to weeks • no antibiotics indicated because of viral etiology• 2˚ bacterial infection can present within 3-10 days after onset of cold symptoms

� symptomatic relief • hydration • relieve congestion: sympathomimetics, decongestants, expectorants• analgesics and antipyretics: acetaminophen, ASA (not children)• cough suppression: dextromethorphan or codeine


CONTRACEPTION � see Gynecology Chapter

HISTORY � relationships, sexual history

• presently or previously sexually active?• consensual? • number of previous partners?• age at first intercourse?

� contraindications and side effects of contraceptive methods� current and previous methods of contraception, expectations� obstetrical and gynecological history

• age of menarche? cycle length, frequency, regularity, flow? LMP? DUB?• last pap, any abnormal paps?• pregnancies and outcomes?

� STD history

PHYSICAL EXAMINATION � blood pressure and breast, abdominal and pelvic exams (including pap +/– STD testing if sexually active)

essential

COUNSELLING � benefits and drawbacks of contraceptive methods

• warn patients that the OCP does not protect against STDs; use condom• benefits of oral contraceptives

• A: anemia decreased • B: benign breast disease and cysts decreased• C: cancer (ovarian and endometrial decreased), cycles regulated• D: dysmenorrhea decreased• E: endometriosis decreased

� how to use contraceptive methods effectively• how and when to take OCP: wait until next cycle, start pill on first day of next period,

take pill at same time each day, let anyone prescribing medications know that she’s on OCP,what to do if she misses a pill

� role of emergency contraception (differentiate it from abortive methods)• emergency contraception = “the morning after pill” = Ovral (high dose OCP) • given only within 72 hours of unprotected intercourse• take 2 tablets now (with gravol) and again in 12 hours• counsel re: nausea side effect (gravol, take pills with food); only effective in 75% of cases;

if pregnancy is established, there is no risk of harm to the fetus from having taken these pillsReferences 1.Heath CC, Sulik SM. Contraception and preconception counselling. PRIM CARE; Clinics in Office Practice, march 1997; 24(1):123-33. 2.Glasier A. Drug Therapy: Emergency Postcoital Contraception. NEJM, Oct. 1997;337(15):1058-1064.

DEPRESSION � see Psychiatry Chapter � lifetime risk of Major Depressive Disorder = 10-25% for women and 5-12% for men � often presents as nonspecific, vague complaints; 85% of cases may go undiagnosed � identification and early treatment improves outcomes

SCREENING QUESTIONS � are you depressed? - high specificity and sensitivity� do you have problems sleeping? - for those not willing to admit� have you lost interest or pleasure in the things you usually like to do?� if yes to screening questions, continue with diagnostic criteria questioning regarding symptomatology

RISK FACTORS FOR DEPRESSION � chronic medical illness � comorbidity with other psychiatric disorders (e.g. 70% co-exist with anxiety)� family history or personal history of depression� stressful life event � increased burden of determinant of health (e.g. poverty)� isolation

RELATED ISSUES � suicidality and homicidality � functional impairment (e.g. work, relationships, etc.)� patient initiated self-treatment � temporal relationships (e.g. seasonal, chronic, etc.)


DEPRESSION . . . CONT.

TREATMENT � phases of treatment • acute phase (6-12 weeks): relieve symptoms in all patients• continuation phase (4-9 months): prevent relapse in all patients

• if maintenance is not required, taper meds over 1-2 months and observe for 6 months • maintenance phase (> 1 year): to prevent recurrence in some patients (those with recurrent course,

severe episode with suicide attempt, chronic duration of episode)

RISK OF RECURRENCE � after 1 depressive episode = 50% � after 2 depressive episodes = 70% � after 3 depressive episodes = 90% Reference: Guidelines for the diagnosis and pharmacological treatment of depression: 1st edition revised. CANMAT, 1999.

DIABETES MELLITUS DEFINITION � diabetes mellitus is a metabolic disorder characterized by the presence of

hyperglycemia due to defective insulin secretion, insulin action or both� associated with significant long term sequelae; damage to various organs,

especially the kidney, eye, nerves, heart and blood vessels

CLASSIFICATION AND EPIDEMIOLOGY � major health concern, personally affecting up to 10% of Canadians� leading cause of new-onset blindness and renal dysfunction� Type 1: autoimmune destruction of pancreatic beta-cells and prone to ketoacidosis

• 10-15% of DM, peak incidence age 10-15� Type 2: ranges from insulin resistance with relative insulin deficiency to predominant

secretory defect with insulin resistance • 85-90% of DM, peak incidence age 50-55• risk factors: family history, obesity, prior GDM, age > 40

� gestational: diabetes first recognized during pregnancy

DIAGNOSIS Diabetes Mellitus � persistent hyperglycemia is the hallmark of all forms of diabetes� diagnosis of diabetes mellitus:

• symptoms of diabetes (fatigue, polyuria, polydipsia, unexplained weight loss)plus a casual PG value ε 11.1 mmol/L OR

• a fasting plasma glucose (FPG) ε 7.0 mmol/LOR

• a fasting plasma glucose in the 2-hour sample of the oral glucose challenge test(OGTT) ε 11.1 mmol/L

� in all cases, a confirmatory test must be done on another day in the absence ofunequivocal hyperglycemia accompanied by acute metabolic decompensation

Impaired Fasting Glucose (IFG) � FPG 6.1-6.9 mmol/L

Impaired Glucose Tolerance (IGT) � PG 2 h after 75 g glucose load 7.8-11.0 mmol/L

SCREENING GDM � all pregnant women between 24 and 28 weeks gestation, with the exception of those in a very

low risk group (lean Caucasian women < 25 years with no personal or family history of diabetes or large babies)

Type 2 Diabetes � mass screening for type 2 DM is not recommended� FPG q3 years in those > 45 years � more frequent or earlier testing (or both) if:

• a first degree relative with DM • member of a high risk population (eg. Aboriginal, Hispanic, Asian and African descent) • HDL δ 0.9 mmol/L • fasting TGs > 2.8 mmol/L


DIABETES MELLITUS . . . CONT.

� annual testing considered if • history of IGT • presence of complications associated with DM• history of GDM or baby with birth wt over 4 kg• presence of HTN, presence of CAD

MANAGEMENT General Goals of Therapy � to avoid the acute complications (e.g. ketoacidosis, hyperglycemia, infection)� to prevent long-term complications

• microvascular: nephropathy, retinopathy, neuropathy• macrovascular: CAD, atherosclerosis, peripheral vascular disease

� to minimize negative sequelae associated with therapies (e.g. hypoglycemia, weight gain)

Specific Goals of Therapy � fasting or pre-meal glucose

• optimal (target goal): 4-7 mmol/L• suboptimal (action may be required): 7.1-10.0 mmol/L• inadequate (action required): >10.0 mmol/L

� HbA1c • optimal: < 0.07 • suboptimal: 0.07 – 0.084 • inadequate: > 0.084

� blood pressure • adults: < 130/80 • children: corresponding age-adjusted 90th percentile values

� lipids • LDL cholesterol δ 2.5 mmol/L• total cholesterol: HDL ratio < 4• triglyceride level < 2.0 mmol/L

Assessment and Monitoring � initial assessment

• medical history: symptoms, past history, functional inquiry, family history, risk factors, social factors, medications, lifestyle

• social and psychological factors: support, finances, insurance• physical exam to monitor eye, thyroid, kidney, foot, nerve, cardiac, and vascular complications• FPG, HbA1c, urinalysis, BUN, creatinine, plasma lipids, ECG, urine dip for proteinuria • ophthalmology consult (type 1 within 5 years, type 2 at diagnosis)• counselling

• monitoring: methods, frequency, quality control • hypoglycemia: awareness, symptoms, frequency, treatment, prevention • antihyperglycemic medications: oral agents, insulin; type, dose, self-adjustments

� q2-4 months • history

• diabetes directed history: lifestyle, activity, glucose monitoring, hypoglycemia (awareness and frequency), use of insulin and oral agents

• assess progress toward decreasing long term complications• physical: blood pressure, foot exam• investigations: HbA1c q2-4 mo and FPG as needed• adjust treatment plan if necessary

� annually • calibrate home glucose monitor• complete neurological exam (and rest of physical examination as per PHE) • ophthalmology consult • dipstick analysis of screen for gross proteinuria

• if negative, microalbuminuria screening with a random daytime urinary albumin:creatinine ratio yearly in Type 2; yearly after 5 years, post-pubertal in Type 1

• if positive, a 24 hour urine test for endogenous creatinine clearance rate and microalbuminuria every 6-12 months

• fasting lipid profile including total, HDL, LDL cholesterol and TG levels• resting or exercise ECG if appropriate (age > 35 years)

Nonpharmacologic Management � diet

• all people with DM should see a registered dietician• strive to attain healthy body weight• avoid simple sugars; encourage complex carbohydrates• decrease saturated fat to <10% of calories

� physical activity and exercise • promotes CV fitness, increased insulin sensitivity, lower BP and improved lipid profile


DIABETES MELLITUS . . . CONT.

Pharmacologic Management � see Endocrinology Chapter for details � type 1 DM

• aim for optimal glucose levels • multiple daily injections (3 or 4 per day) or the use of continuous subcutaneous insulin infusion

(CSII) usually required • elevated microalbuminuria (30-299 mg albumin in 24 h) or overt nephopathy (> 300 mg albumin

in urine in 24 h) should be treated with an ACE inhibitor even in the absence of HTN� type 2 DM

• stepwise approach • for those with a high degree of hyperglycemia (FPG > 10 mmol/L), metformin or a sulfonylurea

may be chosen as a first agent • metformin is associated with less weight gain and less hypoglycemia that sulfonyureas but GI side

effects may be a limiting factor and it is contraindicated with significant renal or hepatic insufficiency• advance to next level if glycemic goals are not achieved within 2-4 months

• ACE inhibitors are recommended for all hypertensive type 2 patients; normotensive patients with elevated microalbuminuria may also benefit from ACE inhibitor therapy

References 1998 clinical practice guidelines for the management of diabetes in Canada. Supplement to CMAJ 1998: 159 (8 Suppl). Report of the Working Group on Hypercholesterolemia and other Dyslipidemias. Recommendations for the management and treatment of dyslipidemia. CMAJ May 16, 2000; 162 (10). Ontario Program for Optimal Therapeutics. Ontario guidelines for the pharmacotherapeutic management of diabetes mellitus. Fall 2000.

DIZZINESS EPIDEMIOLOGY � 1% of patient visits � frequency proportional to age; commonest complaint of ambulatory patients age > 75

Dizziness

Vertigo Nonvertiginous (Vestibular) (Nonvestibular)

Description: • external world seems to revolve around individual • a “whirling sensation” or the individual revolves in space • feeling “lightheaded”, “giddy”, “dazed”, or

• an “illusion of motion” “mentally confused” • a “rocking sensation”

Psychogenic Central Peripheral • diagnosis of Vascular Ocular • brainstem • inner ear exclusion • cerebellar • vestibular nerve

• idiopathic • Menière’s • BPV

Etiology: • tumour • tumour • VBI • decreased visual • stroke • trauma • basilar migraine acuity • drugs • drugs • TIA

• infection • orthostatic hypotension

• Stokes Adams • arrhythmia • CHF• aortic stenosis

Figure 3. Differential Diagnosis of Dizziness

DIAGNOSIS History � define and elaborate

• vertiginous, non-vertiginous, pre-syncopal, pre-ictal• similar to standing too quickly vs. getting off an amusement ride• step by step explanation of previous diet, feelings, activities and resolutions• dizziness diaries - onset, precipitating factors, timing, duration, alleviators

� duration • instant (psychogenic) • 1 minute (BPV, vascular, vertebral basilar insufficiency)• minutes to hours (Menière’s) • days (acute vestibular) • months to years (psychogenic, CNS, multisensory loss)


DIZZINESS . . . CONT.

� exacerbations • worse with head movement or eye closure (vestibular)• no change with head movement and eye closure (nonvestibular)

� associated symptoms • neurologic

• transient diplopia, dysphagia, ataxia (TIA, VBI, arrhythmias)• persistent sensory and/or motor deficits (CV, CNS)

• audiologic • hypoacusia, tinnitus, otalgia (labyrinthitis, Menière’s, ototoxicity, tumour)

• non-specific • nausea, vomiting (usually peripheral; not central)

Physical Exam/Investigations � syncopal

• O/E: cardiac, peripheral vascular, neurologic• ECG, 24h Holter, treadmill stress test, loop ECG, tilt table testing, carotid doppler, EEG

� vertiginous • O/E: ENT, neurologic • Dix-Hallpike, audiometry, MRI

� non-syncopal, non-vertiginous • Physical ––> cardiac, neurologic• 3 minute hyperventilation trial, ECG, EEG

MANAGEMENT � see Otolaryngology Chapter � dependent on results of history, physical and investigations� refer when significant central disease suspected or when vertigo of peripheral origin is persistent or atypicalReferences 1. Ruckenstein MJ. A practical approach to dizziness: Questions to bring vertigo and other causes into focus. Postgrad Med., March 1995;97(3):70-81. 2. Weinstein BE, Devons CAJ. The dizzy patient: Stepwise workup of a common complaint. Geriatrics, June 1995;50(6):42-49.

DOMESTIC VIOLENCE � emotional, physical, sexual, financial abuse

EPIDEMIOLOGY � 20-30% of women in clinical setting may be abuse victims• women at 3x greater risk than males• 75% of women sexually/physically abused were assaulted by current/former partner,

family member or date • wife assault is leading cause of homicide for Canadian women• MD recognition rates as low as 5%

� occurs in all socioeconomic, educational and cultural groups with increased incidence in pregnancy,disabled women, age group 18-24

� 80% of male batterers were abused and/or witnessed wife abuse in their families as children � 67% of battered women witnessed their mothers being abused� 30-60% chance of child being involved in homes where spousal abuse occurs� 5% of elders abused

EFFECTS OF VIOLENCE � psychological: depression, PTSD, suicide attempts, drug/alcohol abuse� physical: pain, serious bleeding injuries, bruises, welts, burns (electrical, cigarette, acid),

dislocated/broken bones, torn ligaments, perforated eardrums, dental injuries, panic like symptoms(e.g. headaches, chest pain, palpitations)

• often labeled as panic attacks or "functional"• injuries often minimized by patient and/or partner; injuries may not fit history

� multiple visits to the physician with nonspecific complaints

DETECTION AND MANAGEMENT � S - Screen ALL patients (MD often first person to get disclosure)• question and examine woman (or man) alone• ask subtle non-judgmental questions: Sometimes women who present with these symptoms

have difficulty in their relationships: Are you having difficulties?• ask direct non-judgmental questions: Are you afraid of your partner?

Have you been pushed or shoved?� C - Community resources for the abused should be mobilized/provided

• marital counseling not appropriate until woman is safe and violence is under control � A - Avoid being directive; be supportive and patient� R - Reassure patient they are not to blame and spousal abuse is a crime

• report suspected or known child abuse (mandatory)• spousal abuse is a criminal act, but not reportable

� E - Exit plans should be developed to ensure patient safety• women most at risk for homicide when attempting to leave home or following separation

� D - Document all evidence of abuse (pictures, sketches) and related visits• quote patient directly in chart


DYSPNEA � see Respirology and Pediatrics Chapters

DEFINITION � abnormal or uncomfortable breathing in the context of what is normal for a given person

DIFFERENTIAL DIAGNOSIS � respiratory: airway disease (e.g. asthma, COPD), parenchymal lung disease (e.g. pneumonia),

pulmonary vascular disease, pleural disease, neuromuscular and chest wall disorders� cardiovascular: elevated pulmonary venous pressure, decreased cardiac output, severe anemia � anxiety/psychosomatic

HISTORY � dyspnea +/– cough, onset, duration, alleviating and aggravating factors� associated symptoms: wheezing, sputum, fever, chills, chest pain, weight loss� smoking, alcohol, allergen exposure � other respiratory problems/medical conditions � current medications and previous treatments � require oxygen? hospitalizations or ICU stay? � determine functional limitation

PHYSICAL � vitals, level of consciousness � respiratory exam: cyanosis, clubbing, signs of respiratory distress,� wheezing, crackles, decreased air entry, increased resonance� "blue bloaters" (chronic bronchitis) and "pink puffers" (emphysema)� cardiovascular exam: peripheral edema, elevated JVP, S3, S4 (cor pulmonale)

INVESTIGATIONS � CBC, differential, oxygen saturation, spirometry, ABG, CXR, ECG, sputum culture� the best tool for early identification of COPD is spirometric screening of high risk patients;

full PFTs are not required

Table 7. Differentiating COPD from Asthma

COPD Asthma

Age of Onset usually in 6th decade any age

Role of Smoking directly related not directly related but has adverse effects

Reversibility of airflow obstruction is chronic and persistent airflow obstruction is episodic and usually Airflow Obstruction reversible with therapy

Evolution slow, cumulative disabling pattern episodic

History of Allergy infrequent over 50% patients

Symptoms chronic cough, sputum and/or dyspnea dyspnea, chest tightness, wheeze and cough usually intermittent and of variable intensity

Diffusing Capacity decreased (more so in pure emphysema) normal (for pure asthma)

Hypoxemia chronic in advanced stages not usually present episodic with severe attacks

Spirometry may have improvement with bronchodilators marked improvement with bronchodilators or steroids but not universally seen

Chest X-ray often normal often normal or episodic hyperinflation; increased bronchial markings (chronic hyperinflation during asthma attack bronchitis) and chronic hyperinflation (emphysema) often co-exist

Adapted from: Canadian Respiratory Review Panel. Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). 1998.


DYSPNEA . . . CONT.

MANAGEMENT Asthma � environmental control and education (smoking, pets, carpets)� pharmacotherapy

• short term relief: ß2-agonists qid prn • if using ß2-agonists > 3x/week, need to add regular anti-inflammatory medication

• long term prevention: inhaled glucocorticosteroids are best option for initial anti-inflammatorytreatment (initial daily dose equivalent to 200-1000 µg/day beclomethasone dipropionate,generally divided bid)

• if asthma control not yet achieved and on moderate doses of steroids (500-1,000 µg/day), consider addition of other therapy as an alternative to increased doses of inhaled steroids

• e.g. long acting inhaled ß2-agonists, leukotriene receptor antagonists • severe asthma may require additional treatment with prednisone

� always consider aerochamber to optimize drug delivery by puffer� consider turbohaler and disc delivery (powder)� patient should seek medical attention if using bronchodilators > 3-4x/week (unless using for exercise)

or > 3x/day regularly

COPD � prevention of further lung damage

• smoking cessation • immunization: pneumococcal and influenza vaccines• avoidance of occupational and air pollutants

� pharmocotherapy • step-wise approach • if regularly symptomatic: ipratropium bromide 20 ug/puff, 2-4 puffs tid-qid + short acting

ß2-agonist prn; may use combination therapy (Combivent) to simplify treatment • if using a substantial amount of short acting ß2-agonist or symptoms are greater at night or

early morning: consider long acting ß2-agonist• if still regularly symptomatic despite maximum bronchodilator therapy, try 2 week oral

corticosteroid trial • if steroid responder (i.e. improvement in post bronchodilator FEV 1 > 20%),

switch to inhaled corticosteroids to minimize adverse effects• oxygen

• 2-4 L/min 24 hours a day if PaO2 < 55 mm Hg, O2 saturation< 90% or PaO 2 55-59 mm Hg and evidence of cor pulmonaleor polycythemia

• use antibiotics in treatment of acute exacerbations of chronic bronchitisReferences 1. Canadian asthma consensus report, 1999. CMAJ 1999; 161(11 Suppl). 2. Morgan, WC, Hodge, HL. Diagnostic evaluation of dyspnea. American Family Physician. February 15, 1998. 3. Canadian Respiratory Review Panel. Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). 1998.

DYSURIA EPIDEMIOLOGY � 25% of women experience an episode of acute dysuria per year� second most common cause of physician visits by sexually active women (after URTI) � non-infectious causes: poor hygiene, allergic reaction, chemicals, foreign bodies, trauma

Table 8. Etiology, Signs and Symptoms of Dysuria

Infection Etiology Signs and Symptoms

UTI/Cystitis E. coli, S. saprophyticus, internal dysuria throughout micturition, frequency, Proteus mirabilis, Enterobacter, urgency, incontinence, hematuria, nocturia, back pain, Klebsiella, Pseudomonas suprapubic discomfort, low grade fever (rare)

Urethritis C. trachomatis, N. gonorrhea initial dysuria, history of chlamydia/gonorrhea if herpes, Trichomonas, Candida no vaginal discharge

Vaginitis Candida, Gardnerella, vaginal discharge, irritation, dyspareunia, external dysuria Trichomonas, C. trachomatis, (when urine comes in contact with inflammation on outside) atrophic, herpes, condylomata accuminata, Doderlein’s cytolysis

Pyelonephritis same organisms as cystitis internal dysuria, fever, chills, flank pain radiating to groin, CVA tenderness


DYSURIA . . . CONT.

INVESTIGATIONS � urine dipstick, R&M, C&S � if vaginal discharge present: microscopy (“wet mount”), KOH test, pH culture for yeast and Trichomonas � endocervical swab for N. gonorrhea and C.trachomatis ; urethral specimen for Chlamydia will increase positive

yield by up to 30%

MANAGEMENT (see Gynecology and Urology Chapter)

UTI/Cystitis � 1st line: TMP-SMX double dose BID X 3 days, trimethoprim or nitrofurantoin� 2nd line: amoxicillin, ciprofloxacin � pregnant women with bacteruria must be treated even if asymptomatic

Urethritis � gonorrhea: cefixime 400 mg po single dose or ceftriaxone 250 mg IM single dose� chlamydia: azithromycin 1 g po in single dose or doxycycline 100 mg BID X 7 days)� always treat for both and reportable to Public Health� all patients should return 4-7 days after completion of therapy for clinical evaluation

Pyelonephritis � inpatient: ampicillin and gentamicin � outpatient: TMP-SMX, ciprofloxacin, norfloxacin or other fluoroquinolone

FATIGUE EPIDEMIOLOGY � 13% of office visits to family physicians; 20-30% of office visits to primary care physicians

• peaks in ages 20-40 • women 3-4x > men

� fatigue of < 6 months duration in adult most commonly has psychosocial causes (up to 80%)� chronic fatigue syndrome (CFS) found in < 5% of cases that present with fatigue

APPROACH Fatigue < 6 Months Duration (refer to Table 9)� most commonly psychosocial causes, especially work, marital or financial stress, grieving a recent loss,

or history of abuse � physical causes of fatigue are less common than psychosocial causes and can usually be diagnosed

by a focused history and physical examination � laboratory investigations for fatigue should be used only when specific diagnoses, suggested by

history and physical examination, are identified� see guidelines in Table 9 for approach to fatigue < 6 months duration

• guidelines in Table 9 are based on level 3 evidence (descriptive studies and expert opinion); no level 1 or 2 evidence exists

• these guidelines are intended for adult patients only; in general, children should be investigated more rigorously

Fatigue > 6 Months Duration � must determine if patient meets criteria for CFS

MANAGEMENT � specific treatment for specific causes � if etiology undetermined (most cases)

• physician support, reassurance and follow-up very important• behavioural or group therapy • aerobic exercise program (keep it simple: 30 minutes per day of walking)• inquire about herbal medications (patients are often embarrassed/intimidated to discuss this subject) • review all medications, watching for drug-drug interactions and side effects• prognosis after 1 year, 40% are no longer fatigued


FATIGUE . . . CONT.

Table 9. Guidelines for Investigating Adult Patients with Fatigue of Lessthan 6 Months Duration

Investigation Always Perform? Perform only in these situations

Appropriate assessment for presence of anxiety Yesof depression?

Appropriate assessment of current life stresses and Yespast trauma and abuse

Focused history and physical with special emphasis on Yes (to determine medications, existing chronic illnesses, and presence whether lab investigations of infection, particularly viral are necessary)

Hemoglobin test No • presence of symptoms, e.g. pallor, tachycardia, dyspnea

• dietary or FHx suggesting risk of anemia • > age 65*

WBC count No • fever or other evidence of infection • weight loss, lymphadenopathy • > age 65*

Erythrocyte sedimentation rate No • evidence of inflammatory arthritis • concern about occult malignancy • > age 65*

Electrolytes No • taking meds known to affect electrolytes, e.g. diuretics, steroids

• indication of medical condition (Cushing’s, Addison’s, parathyroidism)

Renal function tests (urea, creatinine, urinalysis) No • taking meds known to affect renal function • signs or symptoms associated with renal disease

(hypertension, edema, pruritus)

Glucose No • history of GDM (women) • known dx of DM • polydipsia, polyuria • unexplained peripheral neuropathy • > age 65*

TSH No • goiter • hx of thyroiditis • symptoms and signs of hypothyroidism • > age 65*

Chest X-ray No • smoker with cough or hemoptysis (especially if > age 50) • hx of occupational exposure (e.g. asbestos) • exposure to tuberculosis

Other investigations • as indicated by history and physical • weight loss and changes in bowel habits should

prompt GI investigations

* The elderly are not well represented in the literature. The group’s consensus, after consultation with experts in care of the elderly, is to lower the threshold for investigation in this group

Reference: Godwin, M et al. Investigating fatigue of less than 6 months duration. Canadian Family Physician. February, 1999. Vol 45, p 373-379.

CHRONIC FATIGUE SYNDROME (myalgic encephalomyelitis)

Definition (CDC 1994) � presence of unexplained, persistent fatigue, not relieved by rest, which results in occupational,

social and personal difficulties, and with no identifiable medical or psychological cause � concurrent presence of at least four of the following symptoms for a minimum of six months

• impairment of short-term memory or concentration, severe enough to cause a substantial reductionin the patient’s normal activities

• sore throat • tender cervical or axillary lymph nodes• muscle pain, multi-joint pain with no joint swelling or redness• new headache • unrefreshing sleep • post-exertion malaise lasting more than 24 hours


FATIGUE . . . CONT.

� fatigue must be a new, not lifelong, condition with a definite time of onset� often first appears as a viral URTI marked by some combination of fever,

headache, muscle aches, sore throat, earache, congestion, runny nose,cough, diarrhea, and fatigue

Epidemiology � F>>M, Caucasians > other groups, majority in their 30s� proposed causes: likely multifactorial; can include infectious agents and

immunological factors, neurohormonal factors, psychological factors

Approach � full history and physical � mental status examination � no specific laboratory tests that diagnose CFS � initial tests: CBC, ESR, ALT, protein, albumin, ALP, Ca, PO4 , glucose, BUN, electrolytes,

creatinine, TSH, urinalysis, additional tests as clinically indicated

Differential � physical diagnoses

• anemia, sleep apnea, medications, Hep B and C, orthostatic hypotension, adrenalfunction, SLE, narcolepsy, neoplasia, severe obesity, MS, Cushing’s syndrome

� psychiatric diagnoses • EtOH and drug abuse, generalized anxiety, dementia, schizophrenia, compensation syndrome,

bipolar syndrome, eating disorder, personality disorder, major depression, somatoform disorder

Treatment � based on good physician/patient relationship � an understanding physician can limit frequent requests for consultation

and avoid demand for excessive investigations � select medications based on target symptoms, expected side effect

profile, contraindications, patient preference, cost• muscle pain: TCA, muscle relaxants • sleep dysregulation: antidepressants and get patient to wake before 10 AM• depression: antidepressants • fatigue: no known treatment

Course � 3% have complete resolution and 17% have improvement within 18 months� favourable outcomes are seen in the following

• patient attitude • maintaining employment • maintaining the greatest number of physical activities possible• healthy sleep habits; excessive rest should be discouraged• changes in various habits in order to encourage adjustment to fatigue• patient's conviction that fatigue is caused by non-organic factors

HEADACHE ETIOLOGY � see Neurology Chapter � diagnostically and therapeutically useful to divide into primary and secondary� primary headaches

• migraine, tension type and cluster headaches most common• usually recurrent and have no organic disease as their cause

� secondary headaches • caused by underlying disease, ranging from sinusitis to subarachnoid hemorrhage

RED FLAGS FOR HEADACHE � headache beginning after 50 years of age: temporal arteritis, mass lesion� sudden onset of headache: SAH, mass lesion (esp. posterior fossa)� increasing in frequency and severity: mass lesion, subdural hematoma, medication overuse� new-onset headache in patient with risk factors for HIV infection or cancer: meningitis

(chronic or carcinomatous), brain abscess (including toxoplasmosis), metastasis� headache with signs of systemic illness (fever, stiff neck, rash): meningitis, encephalitis

systemic infection, collagen vascular disease � focal neurologic signs or symptoms of disease (other than aura): mass lesion, AVM, stroke,

collagen vascular disease � papilledema: mass lesion, pseudotumour cerebri, meningitis� headache subsequent to head trauma: intracranial hemorrhage, subdural hematoma,

epidural hematoma, post-traumatic headache


HEADACHE . . . CONT.

EPISODIC TENSION-TYPE HEADACHE Diagnostic Criteria A. at least 10 previous headache episodes fulfilling criteria B through D;

number of days with such headaches: less than 180 days per yearB. headache lasting from 30 minutes to 7 daysC. at least two of the following pain characteristics

1. pressing or tightening (nonpulsating) quality2. mild or moderate intensity 3. bilateral location 4. no aggravation by walking stairs or similar routine physical activity

D. both of the following: 1. no nausea or vomiting (anorexia may occur)2. photophobia and phonophobia are absent, or one but not the other is present

Management � acute: acetaminophen 500-1,000 mg q4-6h, NSAIDs, muscle relaxants� preventative: ß-blockers, TCA, education, counselling, stress management, exercise, dietary changes� early follow-up to monitor response

CLUSTER HEADACHE Diagnostic Criteria A. at least five attacks fulfilling criteria B through DB. severe unilateral, supraorbital and/or temporal pain lasting 15 to 180 minutes (untreated) C. headache associated with at least one of the following on the pain side

1. conjunctival injection 2. lacrimation 3. nasal congestion 4. rhinorrhea 5. forehead and facial sweating6. miosis 7. ptosis 8. eyelid edema

D. frequency of attacks: one attack every other day to eight attacks per day

Management � acute: oxygen 6 L/min for 15 minutes is 70% effective, nasal lidocaine 4% solution intransally

on ipsilateral side � prevention: methylsergide is treatment of choice, corticosteroids, lithium carbonate,

calcium channel blockers, valproic acid

MIGRAINE HEADACHES � 85% are common migraine (without aura)� 15% are classical migraine (with aura): transient visual or sensory symptoms lasting 10-30 minutes

between prodrome and headache

Diagnostic Criteria for Migraine Without AuraA. at least 5 attacks fulfilling criteria B through DB. each attack, untreated or unsuccessfully treated, lasts 2 to 72 hoursC. at least 2 of the following pain characteristics

1. unilateral location 2. pulsating quality 3. moderate or severe intensity4. pain aggravated by walking up/down stairs or similar routine physical activity

D. during headache, at least one of the following1. nausea and/or vomiting 2. photophobia and phonophobia

Diagnostic Criteria for Migraine With AuraA. at least two attacks fulfilling criterion BB. at least three of the following characteristics:

1. one or more fully reversible aura symptoms indicating focal cerebral cortical and/or brainstem dysfunction

2. at least one aura symptom develops gradually over > 4 minutes or two or more symptomsoccur in succession

3. no aura symptom lasts more than 60 minutes4. headache follows aura, wih a free interval < 60 minutes (headache may also begin before

or simultansously with aura)� auras = visual symptoms like fortification spectra (zig zags), scintillating scotoma (spots)

and teichopsia (flashing lights))


HEADACHE . . . CONT.

Triggers � heredity plus environmental: stress, stress let down, fatigue, increased/decreased sleep, fasting,

caffeine, menstruation, ovulation, OCP, EtOH, food with tyramine (cheese), phenylethylamine (chocolate), nitrites, MSG, weather changes

Physical Examination/Investigations � primary purpose is to identify causes of secondary headache� vital signs (BP and HR), fundoscopy, cardiovascular assessment, palpation of head and face,

complete neurological exam � investigations only if considered to be ominous in nature

Management � reassurance, lifestyle changes, removal of triggers� pharmacotherapy (indicated if headaches threaten to disrupt the ability to function normally)

• mild attacks (minimal disruption to daily activities)• ASA, ibuprofen, naproxen, no published studies to show acetaminophen works

• moderate attacks (moderate disruption to daily activities)• NSAIDs: ibuprofen, naproxen • selective 5-HT receptor agonist: sumatriptan or other tryptan (PO or SC)

(not concurrently or within 24 h of ergotamine or DHE)• non-selective 5-HT receptor agonist: DHE (SC, IM or IV), ergotamine

(patient specific, some find side effects outweigh benefits)• severe attacks (complete disruption to daily activities, impaired efficiency and severe discomfort)

• 1st line: DHE (SC, IM or IV), sumatriptan (PO or SC), metoclopramide (IV preferred), chlorpromazine (IV or IM), prochlorperazine (IV or IM)

• alternate if above ineffective: ketorolac, dexamethasone• last resort: meperidine

Table 10. Usual Clinical Features Tension Headache Common Migraine Classic Migraine Cluster Headache

incidence very common common not common uncommon

age of onset 15-40 10-30 20-40

sex bias more females more females mostly males

family history of headache frequent very frequent infrequent

headache frequency variable, can be daily variable, but “never” daily daily during cluster

stress, fatigue, menstruation triggers stress or fatigue oral contraceptives, certain foods, alcohol, only during cluster

alcohol, weather changes, lights, odors

onset during sleep extremely rare not uncommon typical

warning none none visual or none sensory aura

location bilateral, frontal often unilateral, sometimes bilateral unilateral, orbital, temporal, and malar or nucho-occipital

severity mild to moderate moderate to severe extremely severe

exacerbators stress or fatigue movement, head jarring, head-low position none

concomitants none nausea, sometimes vomiting, photophobia, unilateral suffusion of eye with ptosis and tearing sonophobia, etc. stuffing and rhinorrhea of ipsilateral nostril

duration of headache hours to days hours to “all day” - seldom more than two days 20-90 minutes

examination during little distress; sometimes mild to severe distress, severe distress, eye changes as noted above headache tense tender scalp and neck tenderness of scalp arteries

muscles

Table Source: Usual Clinical Features of Headaches, (Sandoz, Headache, 1992 Edition), by John Edmeads

References 1. Edmeads, J. Headache. 1997 edition 2. Randall-Clinch. C. Evaluation of acute headaches in adults. American Family Physician. Vol 63, no 4, February 15, 2001.


HYPERTENSION EPIDEMIOLOGY � most common outpatient diagnosis (20% of population)� estimated 50% undiagnosed and only 16% have adequate HTN control� risk factors: family history, age, male, obesity, and alcohol/tobacco use

DEFINITION Table 11. Classification of Blood Pressure

dBP (mmHg) < 90 normal BP 90 - 104 mild hypertension 105 - 114 moderate hypertension > 115 severe hypertension

sBP when dBP < 90 mmHg < 140 normal BP 140 - 159 borderline isolated systolic hypertension > 160 isolated systolic hypertension

Accelerated Hypertension � significant recent increase in BP over previous hypertensive levels associated with evidence of

vascular damage on fundoscopy but without papilloedema

Malignant Hypertension � sufficient elevation in BP to cause papilloedema and other manifestations of vascular damage

(retinal hemorrhages, bulging discs, mental status changes, increasing creatinine) � not defined by absolute level of BP, but often requires BP of at least 200/140� develops in about 1% of hypertensive patients

Isolated Systolic HTN� sBP > 160 mmHg, dBP < 90 mm Hg� associated with progressive reduction in vascular compliance� risk factor for CVD and IHD � usually begins 5th decade; up to 11% of 75 year olds

ETIOLOGY (see Nephrology Chapter)� essential (primary) hypertension (90%)

• undetermined cause � renal hypertension (5%)

• renal parenchymal disease (3%)• renovascular hypertension (< 2%)

� endocrine (4-5%) • oral contraceptives (4%) • primary hyperaldosteronism (0.5%)• pheochromocytoma (0.2%) • Cushing’s syndrome (< 0.2%)• hyperparathyroidism (< 0.2%)

� coarctation of the aorta (0.2%) � enzymatic defects � neurological disorders � drug-induced hypertension (e.g. prolonged corticosteroid use)� hypercalcemia from any cause � watch for labile, "white coat" hypertension

DIAGNOSTIC EVALUATION � average of 2 readings where sBP >140 and/or dBP > 90 on three separate visits over 6 months � if BP > 140/90, but < 180/105 at initial visit, four other visits over 6 months necessary to diagnose HTN (B)� patients with target-organ damage can be diagnosed as hypertensive at/after visit 3 (B) � patients presenting as a hypertensive urgency are diagnosed as hypertensive at their initial visit (D)


HYPERTENSION . . . CONT.

Elevated BP at 1st visit

2 more readings at same visit and arrange 3 further visits over 6 months

Search for Target Organ Damage

Review Medical Record AND Diagnostic Tests Prior to Visit 3

Assess Risk Factors Ask Examine * urinalysis * age * Hx angina or MI? * cardiovascular * CBC* male gender * Hx TIA/stroke? system * serum creatinine * postmenopausal * Hx of peripheral * respiratory system * K+ , Na+

* smoking vascular insufficiency? * neurological exam * fasting serum glucose * high cholesterol * Hx renal disease? * include fundoscopy * fasting total cholesterol, * glucose intolerance * Exogenous causes: for retinopathy HDL, LDL, TGs * LVH > excess EtOH? * standard 12 lead ECG

> OCP? * consider CXR > conj. estrogens? > NSAIDs?

BP < 140/90 mmHg on Last Diagnostic Visit?

YES

(< 130/80 for those with DM) NO

Target Organ Damage? Lifestyle modification and/or

NO YES

pharmacological therapy F/U yearly F/U q 4-6 mos

Figure 4. Approach to Hypertension

Adapted from: The Canadian Hypertension Society, 1999.

� suspect secondary causes and consider further investigations if• onset of HTN before age 30 or after age 60• HTN refractory to treatment • accelerated or malignant hypertension • suspicious clinical situation

• presence of paroxysmal headache, palpitations and diaphoresis may suggestpheochromocytoma

• presence of renal bruits may indicate renovascular hypertension• presence of hypokalemia and hypernatremia may suggest hyperaldosteronism

THERAPEUTIC CONSIDERATIONS General Considerations � target BP should be < 140/90

• < 130/80 for those with DM • correction need not be rapid

� referral is indicated for cases of refractory hypertension, suspected secondary cause or worsening renal failure

� hospitalization is indicated for malignant hypertension� follow-up

• nonpharmacological • q 3-6 months

• pharmacological • q 1 month until 2 BP readings < target• more often for symptomatic HTN, severe HTN, antihypertensive drug intolerance, target organ

damage • q 3-6 months once at target BP

Nonpharmacological therapy � smoking cessation � alcohol restriction (C) to low risk drinking guidelines (see Alcohol section)� salt restriction (B) to maximum of 90-130 mmol (3-7 g) per day� saturated fat intake reduction � weight reduction (B) if BMI > 25 (at least 4.5 kg)� regular aerobic exercise (B); moderate intensity, 50-60 min, 3-4x/week� behavioural therapies (B) (see Stress Management section)� potassium/calcium supplements (B) NOT recommended above suggested daily dietary intake

(60 mmol for potassium)



Indications For Pharmacological Therapy� < 60 years of age

• average dBP > 100 mmHg (A) or sBP > 160 mmHg (B)• average dBP > 90 mmHg with hypertensive target organ damage, diabetes mellitus, renal

disease or cardiovascular disease (A – C)• average dBP > 90 mmHg with independent cardiovascular risk factors (i.e. family history) (B – D)

� > 60 years of age • average dBP > 105 mmHg (A) or sBP > 160 mmHg (B)• average dBP > 90 mmHg with hypertensive target organ damage, diabetes mellitus,

renal disease or cardiovascular disease (A – C)• average dBP > 90 mmHg with independent cardiovascular risk factors (i.e. family history) (B – D)

Reference: McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can J Cardiol 2001 May; 17(5):543-59.

Pharmacological Therapy � patients under 60 years old

• initially: monotherapy with thiazide diuretic (low dose: < 50 mg/d HCTZ) (A), a beta-adrenergicantagonist (B), an ACE inhibitor (B) or a long acting dihydropyridine CCB (B)

• if partial response: substitute another drug from the above group• if still not controlled: try other classes of anti-hypertensives in monotherapy or in combination and

search for reasons for poor response to therapy (i.e. noncompliance) (D)• alpha-blockers are not recommended as first-line agents (A)

� patients over 60 years old • initially: low-dose thiazide diuretic (A), a long-acting dihydropyridine CCB (A) or an ACE inhibitor (B)• if partial response: substitute another drug from the above group• avoid hypokalemia in patients taking thiazides• beta-adrenergic blockers (A) and alpha-blockers (A) are not

recommended as first-line agents for uncomplicated hypertension• if partial response to monotherapy: combination therapy (D)• if still not controlled: try other classes of anti-hypertensives (D)

Reference: McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can J Cardiol 2001. May; 17(5):543-59.

� for patients with complicated hypertension (those with co-morbidities): choose antihypertensive agent based on the individual patient (see Figure 5 and Table 12)

Home BP Monitoring � consider if patient is

• suspected to be noncompliant (B)• has diabetes mellitus (D) • suspected of having “white-coat hypertension”

� consider elevated if home BP > 135/85 (B)� only monitoring devices that have met Association for Medical Instrumentation

OR British Hypertension Society standards should be used (D)� patients should be provided with adequate training (D)� accuracy of home BP monitoring device must be checked regularly against a mercury-column

sphygmomanometer (D)

Ambulatory BP Monitoring � consider for treated patients suspected of having the following symptoms (B)

• “white-coat hypertension” (office induced increased BP)• symptoms suggestive of hypotension• fluctuating BP readings • apparent resistance to drug therapy

� only devices that have been validated independently using established protocols should be used (A)� any decision to withhold drug therapy based on ambulatory BP should take into account normal

values for 24 hrs (B), awake ambulating BP and changes in nocturnal BP (A)

Factors Adversely Affecting Prognosis� presence of additional modifiable risk factors� presence of uncontrollable risk factors

• early age of onset, male sex, family history� evidence of target organ damage � malignant hypertension

Reference: Feldman RD, Campbell N, Larochelle P, Bolli P, Burgess ED, Carruthers SG, et. al. 1999 Canadian recommendations for the management of hypertension. CMAJ 1999;161 (12 Suppl).



Adapted from: Feldman RD, Campbell N, Larochelle P. et al. 1999. Canadia recommendations for the management of hypertension. CMAJ. 1999; 161 (12 suppl.).

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LOW BACK PAIN � see Orthopedics and Neurosurgery Chapters

DEFINITION � activity intolerance due to lower back or back-related leg symptoms� acute if < 3 month duration

ETIOLOGY � 50% of working-age adults, of whom 20% seek medical care� 4-5% of primary care visits (lifetime prevalence 90%)� largest WSIB category � most common cause of chronic disability for persons < 45 years old� 90% resolve in 6 weeks, 5% become chronic

DIFFERENTIAL DIAGNOSIS � 98% mechanical cause (e.g. soft tissue injury, disc injury, spondylosis, spondylolisthesis, fracture, stenosis)� systemic disorder (e.g. malignancy, infection, ostoporosis)� neurologic cause (e.g. myopathy, neuropathy)� referred pain (e.g. perforated ulcer, pyelonephritis, ectopic pregnancy, AAA, hip disorder)

HISTORY � symptoms (pain, numbness, weakness, stiffness), duration, onset� impact on daily function (how long can you sit, stand, walk)

PartialResponse

Partial Response

Not Controlled or Adverse Effects

Co-Existing Medical Conditions and/or Target Organ Damage

Inadequate response or adverse effects

Figure 5. Pharmacological Treatment of Hypertension


LOW BACK PAIN . . . CONT.

PHYSICAL EXAMINATION � inspection of spine: curvature, posture � palpation: paraspinal, bony tenderness � ROM of back: flexion, extension, lateral flexion, rotation� straight leg raise, femoral stretch (positive if pain at < 70 degrees, aggravated by dorsiflexion of ankle),

crossover pain (straight raise of well limb elicits pain in leg with sciatica)� neurologic exam (muscle strength, circumferential measurement (significant if difference is > 2 cm),

reflexes, sensory exam)

INVESTIGATIONS � routine testing (labs, plain films) not recommended during first month of activity limitation,

except when red flag is noted or physiologic evidence of tissue insult or neurologic dysfunction � CBC, ESR, urinalysis (infection, tumor) � bone scan (infection, tumor, occult fracture) � CT, MRI (neural, soft tissue damage)

MANAGEMENT � provide reassurance and education if no underlying serious condition

• 90% of low back pain will recover spontaneously in 6 weeks� recommend comfort measures

• > 4 days bed rest has potentially debilitating effects and no proven efficacy• activity alterations to avoid back irritation (lift objects close to body, use soft support placed

at small of back, armrests when sitting) • encourage return to normal activities as soon as possible• encourage low-stress aerobic exercise (condition trunk muscles after 2 weeks)

� pharmacological • NSAIDs • acetaminophen • NOT muscle relaxants or opiods (poor tolerance, drowsiness)

� physical methods • manipulation of low back during first month of symptoms without radiculopathy• NO proven efficacy of traction, massage, heat or cold, U/S, cutaneous laser treatment, TENS,

needle acupuncture, injection procedures (with corticosteroids, lidocaine, opiods)� if no improvement after one month of conservative therapy consider further investigations� order x-rays and appropriate labs in presence of any Red Flags� consider surgery when there is clinical evidence of nerve root irritation or neurological deficit after

one month of conservative therapy

RED FLAGS � BACK PAIN

• B: bowel or bladder dysfunction • A: anesthesia (saddle) • C: constitutional symptoms/malignancy • K: chronic disease • P: paresthesias • A: age > 50 • I: IV drug use • N: neuromotor deficits

� surgical emergencies • cauda equina syndrome: fecal incontinence, urinary retention, saddle anesthesia, decreased anal tone • abdominal aortic aneurysm: pulsatile abdominal mass

� medical conditions • neoplastic (primary, metastatic) • infectious (osteomyelitis, tuberculosis) • inflammatory(seronegative spondyloarthropathies)• metabolic (osteoporosis with fractures, osteomalacia, Paget's disease)• visceral (prostatitis, endometriosis, pyelonephritis, pancreatitis)

Reference: Acute Low Back Problems Guideline Panel. Acute Low Back Problems in Adults: Assessment and Treatment. American Family Physician Feb 1, 1995; 52(2): 469-484


MENOPAUSE/HRT � see Gynecology Chapter

EPIDEMIOLOGY � Canadian female life span = 81.2 years� mean age of menopause = 51.4 years� a woman will spend over 1/3 of her life in menopause� risk of CAD and osteoporosis increases dramatically after menopause

CONTRAINDICATIONS TO HRT � A: acute liver disease/chronically impaired liver� B: bleeding (undiagnosed vaginal) � C: cancer (breast or uterus) � D: DVT (acute vascular thrombosis or thromboembolic disease)

MANAGEMENT � encourage physical exercise and vitamin D/calcium supplements� routine use of HRT still controversial� examples of HRT routines

• cyclic estrogen + progesterone• continuous estrogen + progesterone• estrogen ring • estrogen gel • raloxifene (SERM)

OBESITY DEFINITION � obesity is an excess of body fat � body mass index (BMI) = kg/m 2 (WHO Classification)

• normal range: 20-25 • overweight: 25-30 • obese: 30-40 • morbidly obese: > 40

� BMI has a correlation of 0.7-0.8 with body fat content in adults� waist-hip ratio (WHR) = circumference of the waist divided by the circumference of the hips

• may be a better predictor of the sequelae associated obesity than BMI (central adiposity) • men > 1.0, women > 0.8, shown to predict complications from

obesity, independent of BMI

EPIDEMIOLOGY � close to 50% of adult Canadians are overweight and ~20% obese� increasing prevalence of childhood obesity in many countries, including Canada and U.S.

(prevalence doubled in the U.S. in the last 20 years)� 1/3 of obese individuals binge eat � only 10-15% of population consume < 30% fat

DIAGNOSIS � complete diet history: include past attempts to lose weight, successes, obstacles, goals � calculate BMI and waist-hip ratio (see above)� assess patient's self-image

• does patient feel underweight, overweight, or normal?• does patient feel that weight interferes with health? with activities?• screen for eating disorders (see Psychiatry Chapter)

� personal/family history of obesity/nutrition problems• strong genetic component (70-80% risk with 2 obese parents)

� review of systems: include sleep habits, apneic spells, OTC medication (e.g. laxatives) � physical exam

• directed at pertinent positives from review of systems• respiratory capacity • weight bearing joints

INVESTIGATIONS � discretionary

• fasting fractionated lipid profile• sleep study • exercise tolerance testing


OBESITY . . . CONT.

MANAGEMENT � success in weight control occurs when > 50% of weight loss is maintained at one year• discuss nutrition-related problems • heart disease, obesity, hypertension, osteoporosis, anemia, dental decay, cancer, gastrointestinal

disorders, respiratory compromise, high lipids, diabetes, sleep apnea, osteoarthritis� use Canada's Food Guide as a teaching guide � counselling on diet (when applicable); stress weight maintenance if currently in healthy weight range

• discourage fad diets: no long-term benefits• there is no ideal weight, but rather a range of healthy weights

Treatment Approaches � behaviour modification

• very effective, low side effects • daily records of foods eaten (eating slower and less)• change environment, preparation styles, etc.• lose about 0.5 kg/week • rewards when goal achieved (not food!) • positive self-affirmation

� exercise • associated with long-term weight maintenance• 50-60 minutes, 3 times per week

� group support • Weight Watchers, Overeaters Anonymous• uses behaviour modification • high attrition rates (up to 80%)

� pharmacological • sibutramine (Meridia), appetite suppressant; inhibits NE and 5-HT reuptake; not associated with

primary pulmonary HTN or heart valve abnormalities• orlistat (Xenical), reduces fat absorption; pancreatic lipase inhibitor

� surgery � vertical band gastroplasty and gastric bypass

NATURAL HISTORY � obesity is a chronic problem, refractory to most treatments� after 5 years, < 30% of patients maintain > 25% of lost weight� complications of obesity include

• higher incidence of adult-onset diabetes, hypertension, hypercholesterolemia• increased risk of certain cancers (colon, rectum, prostate, gallbladder, biliary tract, breast, cervix,

endometrium, ovary), cholelithiasis, obstructive sleep apnea, venous thromboembolism, and osteoarthritis

• lower quality of life by limiting mobility and physical endurance, through social, academic, and job discrimination

OSTEOARTHRITIS � see Rheumatology Chapter

DEFINITION � condition of synovial joints characterized by focal cartilage loss and an accompanying reparative

bone response

ETIOLOGY � most common joint disease, affects 10-12% of population� age > 65, almost everyone shows signs based on x-ray, but only 33% of these will be symptomatic � age < 45, more frequent in males; age > 55, more frequent in females� primary OA is mostly related to aging (wear-and-tear phenomenon)� causes of secondary OA include obesity, repeated trauma or surgery to joint structures, congenital

abnormalities, gout, diabetes, and other hormone disorders

PATHOPHYSIOLOGY � disease primarily affects cartilage • progressive breakdown of articular cartilage that lines joint surfaces• dense, smooth surface bone formation at base of cartilage lesion and formation of osteophytes

at joint margins � multi-factorial disease process (biochemical, biomechanical, inflammatory, immunologic)

SIGNS AND SYMPTOMS � pain with weight bearing, improved with rest � early morning stiffness or gelling � tender to palpation, bony enlargement, crepitus, limitation of movement� pseudolaxity of collateral ligaments develops with degeneration of cartilage� usually affects distal joints of hands and feet, spine, and large weight-bearing joints (hips, knees)


OSTEOARHTRITIS . . . CONT.

INVESTIGATIONS � there are no laboratory tests for the diagnosis of OA� radiographic features:

• joint space narrowing • subchondral sclerosis • subchondral cyst formation • heterotopic ossification (marginal osteophytes)

MANAGEMENT � goals: relieve pain, preserve joint motion and function, prevent further injury and wear of cartilage� biomechanical factors: weight loss, use of canes/crutches, correct postural abnormalities, proper shoe

support, exercise (OT/PT) � pain control

• first choice: acetaminophen 500 mg tid titrated to a maximum dose of 1 g qid (OA is not an inflammatory disorder)

• then NSAIDs, Naprosyn 500 mg bid or ibuprofen 600 mg qid (does not alter natural course of OA)• topical analgesics (capsaicin, methylsalicylate creams)• opiod analgesics in acute flare (codeine)• then corticosteroid (intra-articular injection may be helpful in acute flares, oral/parenteral therapy

not indicated) � surgery, joint arthroplasty may relieve pain, stabilize joints, improve function; total joint arthroplasty

successful for the knee and hip � chondrocyte harvesting, expansion in vitro, and reimplantation is being investigated

Reference: Ontario Treatment Guidelines for Osteoarthritis, Rheumatoid Arthritis, and Acute Musculoskeletal Injury, June 2000. Ontario Musculoskeletal Therapeutics Review Panel

OTITIS MEDIA (ACUTE) � see Otolaryngology Chapter

DEFINITION � sudden onset of inflammation of the middle ear associated with an effusion and one or more of the

following: pain, fever, irritability

EPIDEMIOLOGY � most common diagnosis in pediatric age group� most common reason for treatment with antibiotics� peak incidence 6 months to 2 years old

HISTORY � fever, otalgia, ear pulling, otorrhea � vomiting, anorexia, diarrhea, irritability, lethargy� recent URI

PHYSICAL EXAMINATION/DIAGNOSIS � E.M.I.L.Y. Method of TM Examination

E = Where is the E rythema? (be aware of normal areas of erythemaand tympanic flush when child crying)

M = Are the long and short processes of the Malleus visualized?Is the pars flaccida bulging?

I = Use I nsufflation to detect mobility of tympanic membrane.L = Is the L ight reflex fully visible?Y = Check the colour on/behind the TM ( Yellow)

ETIOLOGY � bacterial: S. pneumoniae (34%), H. influenza(24%), M. catarrhalis (13%)� viral: RSV, CMV, rhinovirus

MANAGEMENT � antibiotics (treat for 10 days)

• 1st line: amoxicillin, TMP-SMX• 2nd line: amoxicillin/clavulinate, cephalosporins• symptoms should resolve within 72 hours

� controversy over antibiotic use • trend exists toward a decrease in antibiotic use• studies show that 60% of children are pain free within 24 hours of presentation without antibiotic use• children receiving antibiotics have almost twice the amount of vomiting, diarrhea, and rashes

� bacterial and viral vaccines currently being developed


SEXUALLY TRANSMITTED DISEASES HISTORY Sexual History � sexually active? types of activities? (oral, anal and/or vaginal intercourse)� at what age did you become sexually active? � sex with men, women or both? � while traveling, were you sexually active with strangers? which countries?� number of partners in the past life/year/month/week? duration of involvement with each?� problems related to sexual activity (dyspareunia, premature ejaculation, obtaining/maintaining an

erection, reaching orgasm, lubrication, premature ejaculation, not interested, being forced)

STD History � are you aware of STDs? ever had one? ever been tested?� contraception history � symptoms such as genital burning, itching, discharge, sores, vesicles� associated symptoms such as fever, arthralgia, lymphadenopathy� last PAP test and results � have you discussed this with your partner?

PATIENTS AT RISK � sexually active males and females < 25 y.o. � most at risk

• contact to known case of STD • street involved and/or substance use • unprotected sex • new or > 2 partners in past 6 mos • previous STD

ORGANISMS � bacteria: Chlamydia trachomatis, Neisseria gonorrhoeae � viruses: HSV, HIV, hepatitis A virus, hepatitis B virus, hepatitis C virus (especially IV drug users), syphilis

PREVENTION � counsel regarding the risks of HIV (homosexuality is not a risk factor, unprotected sex and especially anal sex are risk factors), hepatitis and other STDs

� counsel about sexual practices; abstinence, condoms (male/female), immunization against hepatitis A and B � urinate after sexual contact

DIAGNOSIS/INVESTIGATIONS � PHE recommends screening in high risk groups for:

• HIV (A recommendation) • Gonorrhea (A recommendation) • Chlamydia (B recommendation)

� examine for ulcer/papules � test for HSV if lesions � serology for VDRL, hepatitis B

Females � see Gynecology Chapter

Males � if mucopurulent discharge and/or presence of dysuria AND/OR Gram stain shows > 4 leukocytes

per oil immersion, test for Gonorrhea and Chlamydia , screen for other STDs• if > 4 leukocytes per oil immersion field and presence of Gram negative intracellular diplococci,

then treat for Gonorrhea and Chlamydia • if > 4 leukocytes per oil immersion and NO intracellular diplococci treat only for Chlamydia • evaluate and treat partners immediately if tests are positive for patient• follow-up visit: repeat the diagnostic test if symptoms and signs persist• if abnormalities persist consider other diagnosis (i.e. non-infectious causes, non-bacterial prostatitis)

� if clear discharge AND < 4 leukocytes per oil immersion field• test for Gonorrhea and Chlamydia • screen for other STDs • treat depending on result • evaluate and treat partners of positive cases• follow-up visit as above

MANAGEMENT � an STD patient is not considered treated until the management of their partner(s) is(are) ensured � Gonorrhea : cefixime 8 mg/kg po x 1 dose (max. 400 mg)� Chlamydia : azithromycin 10-15 mg/kg po x 1 dose (max.1 g)� cefixime and azithromycin preferred for contact management, even in absence of positive tests

and symptoms � genital herpes: 1st episode: acyclovir 400 mg tid 5-7 days; recurrent episode with prodrome:

acyclovir 400 mg tid x 5 days; chronic suppresive therapy: acyclovir 400 mg bid po� syphilis: benzathine penicillin G 2.4 to 7.2 million U im� bacterial vaginosis: metronidazole 500 mg po bid x 7 days� yeast: OTC topical treatment, imidazole or fluconazole 150 mg po single dose� T. vaginalis : metronidazole 2 g po single dose


SKIN LESIONS � see Dermatology Chapter

ETIOLOGY � 60% of all cutaneous diagnoses are seen by non-dermatologists� comprises 7% of office visits to family physicians

Top 10 Diagnoses by Family Physicians� dermatitis

• contact/irritant dermatitis • pruritic, inflammatory reaction that progresses from erythema to vesiculobullous exanthem• caused by a delayed cellular (type IV) hypersensitivity mechanism• Tx: symptomatic care (cool water, moisturizing lotion), antihistamines/acetaminophen/ibuprofen

for pruritus • xerotic eczema (winter itch)

• occurs in the winter and in the elderly on the legs, arms, and hands• characterized by dry, cracked, fissured skin and pruritus• Tx: avoid overbathing with soap, room humidifiers, tepid water baths with oils with

application of moisturizing cream after drying, medium-potency corticosteroids appliedBID until eczema clears, topical alpha-hydroxy acids (such as glycolic acid or lactic acid)

• stasis dermatitis • chronic dermatitis of the lower legs in people with chronic venous insufficiency • mild pruritus, pain (if an ulcer is present), aching discomfort in the limb, swelling of the ankle,

nocturnal cramps • atopic dermatitis (infantile eczema)

• see Pediatrics Chapter� pyoderma � viral wart � Tinea (unguis – nails, pedis – foot, cruris – perineum, corporis – body, capitis – scalp) � epidermoid cyst � Candida � acne vulgaris � benign tumors � dermatosis, NOS � actinic keratosis

SLEEP PROBLEMS DEFINITION � most often characterized by one of three complaints:

• insomnia – inability to initiate sleep or inability to maintain sleep, such as frequent nighttimeor early-morning wakenings

• excessive daytime sleepiness• parasomnias – unusual occurrences during sleep

� insomnia affects 1/3 of population at some time, persistent in 10%

ETIOLOGY � primary sleep disorders

• obstructive sleep apnea, insomnia, restless legs syndrome, narcolepsy� secondary causes

• medical/surgical (COPD, asthma, CHF, hyperthyroidism, chronic pain)• drugs (EtOH, caffeine, nicotine, beta-agonists, thyroxin, steroids, theophylline) • psychiatric disorders • lifestyle factors (shift work)

HISTORY � take thorough sleep history from patient and bed partner

• onset and persistence of symptoms, including any changes over weekends/vacations • chief sleep symptom (initial insomnia, waking at night)• medical, job, or stress-inducing events at time of onset and whether these factors have persisted• presence of medical or psychiatric conditions that could affect sleep• collateral from bed partner (snoring, movements, apneic episodes, sleep paralysis) • impact of sleep complaint on patient’s quality of life• sleep hygiene (regularity of sleep time, sleep environment, use of stimulants such as caffeine, etc.)• family history of sleep disorders• treatments attempted and their effectiveness• drug and alcohol use


SLEEP PROBLEMS . . . CONT.

PHYSICAL EXAMINATION/INVESTIGATIONS � keep sleep log, which tracks time in bed, time asleep, wakenings, etc.� address specific medical problems (CBC with differential, TSH)� sleep study referral if primary cause is suspected (for nighttime polysomnogram or daytime

multiple sleep latency test)

MANAGEMENT � treat and manage any suspected medical cause � promote good sleep hygiene (avoid caffeine, nicotine, EtOH; exercise regularly; use bed only for sex,

sleep, sickness; comfortable sleep environment; go to bed when drowsy)� patients can develop tolerances or dependencies to many of the medicines; pharmacological

interventions should be used for the short term � drug therapies may be periodically changed; patients may take "drug holidays" for one or two weeks

once or twice each year

STRESS-INDUCED INSOMNIA � majority of cases � may persist well beyond the event that brought the onset of the condition� person reacts to the insomnia with fear or anxiety around bedtime or with a change in sleep hygiene � can progress to a chronic disorder (psychophysiological insomnia)

Treatment � improve sleep hygiene (do not use bed for viewing television, eating, or other wakeful activities),

avoid daytime naps, do not lie awake in bed for long periods, avoid caffeine or alcohol� biofeedback and other self-control techniques, including restriction of wakeful time in bed, may be effective � hypnotic agents and TCAs may be appropriate as short-term treatment

PERIODIC LIMB MOVEMENTS OF SLEEP (PLMS) AND RESTLESS LEG SYNDROME � RLS characterized by an uncomfortable feeling usually in the calves that is relieved by activities such

as walking � RLS is a waking disorder that is almost always accompanied by nighttime PLMS� PLMS (also known as nocturnal myoclonus) is characterized by frequent leg or arm jerks during sleep,

and may occur in the absence of RLS � PLMS sufferers may complain of insomnia or EDS but be unaware of their limb jerks� diagnosis: confirmed by polysomnography � treatment: clonazepam, temazepam

CIRCADIAN RHYTHM DISORDERS � result either from an internal "clock" that is not in sync with society's sleep-wake cycle, or from difficulty

in readjusting the internal clock to changes such as a rapid change in time zones (jet lag)• e.g. non-24-hour sleep-wake cycle, shift work disorder

� treatment: sleep hygiene, "chronotherapy" (sleep is progressively phase delayed until bedtime is at an acceptable time), bright-light exposure, antidepressants, benzodiazepines, opioids, melatonin(?)

PARASOMNIAS � abnormal occurrences during sleep � may or may not result in complaints of insomnia or EDS� sleepwalking and night terrors (periods of apparently intense anxiety often accompanied by loud cries;

occur while the individual is still asleep and are not associated with specific dreams)• often seen in children • usually outgrow the disorder, but may require psychotherapeutic treatment

� sleep paralysis • normally associated with narcolepsy, can occur in non-narcoleptic patients• can usually be left untreated, but does respond to low dosages of TCAs

EXCESSIVE DAYTIME SLEEPINESS (EDS) � chronic sleep deprivation – may not be getting enough sleep� narcolepsy

• clinical presentation: EDS and unusually early episodes of REM phase during sleep, cataplexy, sleep paralysis, and hypnagogic hallucinations

• family history is likely • confirmed by sleep study • treatment: optimal sleep hygiene and scheduled daytime naps, CNS stimulants for EDS,

anticholinergics and antidepressants (trazadone) for cataplexy� obstructive sleep apnea

• objective indices of severity elicited by polysomnography should include a high index of respiratory disturbances per hour, repetitive episodes of hypoxemia, and an abnormally shortened sleep latency

• treatment: oral/dental appliances, CPAP, surgical intervention


SMOKING EPIDEMIOLOGY � 70% of smokers see a physician each year� 70% of smokers report that they want to quit and have made one serious attempt to quit � single most preventable cause of death� responsible for 80% of lung cancers, COPD, cardiovascular disease� highest prevalence among ages 25-34� 15% of smokers smoke > 25 cigarettes/day� see Community Health Chapter for Stages of Change

HISTORY � smoking habits: amount, duration, frequency, time of day� gain from smoking (e.g. weight loss, decreased anxiety, social relationships)� personal concerns about smoking and quitting� foreseen benefits from quitting � interest in quitting (a person will only quit if they are willing)� previous attempts and results � medical situation: cough, SOB, asthma, COPD, HTN� social situation: other smokers in family/social network� nicotine dependence � preoccupation or compulsion to use� impairment or loss of control over use� continued use despite negative consequences� minimization or denial of problems associated with use

MANAGEMENT � enhance motivation to quit

• relevance: medical conditions, family/social situation• smoking risks

• short-term – SOB, asthma exacerbation, impotence, infertility• long-term – heart attacks, strokes, lung cancer, COPD, other cancers • environmental – increased risk in spouse/children of lung CA, SIDS, asthma,

respiratory infections• rewards: improved health, better-tasting food, saving money, good

example to children, freedom from addiction� relapse prevention

• highest relapse rate within 3 months of quitting• minimal practice – congratulate, encourage abstinence on each visit; review benefits, problems• prescriptive interventions – address problems with weight gain, negative mood,

withdrawal symptoms, and lack of support; offer recommendations• anticipate problems

� self-help materials • remove ashtrays/lighters • increase high fibre snacks/gum• increase aerobic exercise • self-reward

Nicotine Gum � indications: patient preference, failure with nicotine patch, contraindication to patch � relative contraindications: pregnancy, cardiovascular diseases, mouth soreness, dyspepsia � dosage: 2 mg (< 30 pieces/day), 4 mg (< 20 pieces/day if failed 2 mg treatment or highly dependent

on nicotine); 1 piece q1-2 hours for 1-3 months� abstain from smoking � acidic beverages (soft drinks, coffee, juice) interfere with absorption and should be avoided 15 minutes

before and during chewing � chew until “peppery” taste emerges, then “park” between gum and cheek to facilitate nicotine absorption

(chew-park intermittently for 30 minutes)

Nicotine Patch � preferable for routine clinical use compared to gum� continuous self-regulated amount of nicotine� decreases craving and/or withdrawal� will not replace immediate effects of smoking habit or pleasure� indications: nicotine dependent, high motivation to quit smoking� contraindications: smoking while on patch� relative contraindications: pregnancy, skin reaction, cardiovascular diseases� duration of treatment: 4-12 weeks usually adequate� dose: 21 mg/d X 6 weeks, then 14 mg/d X 2 weeks, then 7 mg/d X 2 weeks


SMOKING . . . CONT.

Bupropion (Zyban/Wellbutrin) � acts on dopaminergic (reward) and noradrenergic (withdrawal) pathways� contraindications: seizure disorder, alcoholism, eating disorder, recent MAOI use, current pregnancy;

caution if using SSRI (reduction of seizure threshold)� dose: 150 mg bid x 1-10 wks; may vary with amount the patients smokes� patient continues to smoke for first week of treatment and then completely stops

(therapeutic levels reached in one week) � recommend abstinence from alcohol due to risk of toxic levels with liver dysfunction� side effects: headache, insomnia, dry mouth, weight gain� follow-up: set firm dates � continue to monitor/support, do not give up if failed

PROGNOSIS � most relapses occur in first year � most try > 5 times before quitting

Reference: AHCPR Smoking Cessation Guidline (in JAMA 1996, vol. 275(16):1270-1280)

SORE THROAT ETIOLOGY Viral � most common cause, often mimics bacterial infection� occurs year round � more common in preschool children and those with nasal symptoms� Adenovirus

• primarily summer months, lasts 5 days • pharyngitis, rhinitis, conjunctivitis, fever

� Coxsackie virus • primarly late summer, early fall • sudden onset fever, pharyngitis, dysphagia, vomiting• appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharyx• ulcers are pale gray, several mm in diameter, have surrounding erythema, may appear on hands

and feet (hand, foot and mouth disease) � Herpes simplex virus

• like coxsackie virus but ulcers are fewer and larger� EBV (infectious mononucleosis)

• pharyngitis, tonsilar exudate, fever, lymphadenopathy, fatigue, rash� Mycoplasma pneumoniae

• nonexudative pharyngitis, fever, headache, malaise progressing to cough, pneumonia

Bacterial � Group A ß-hemolytic Streptococci (GABHS)

• most common bacterial cause • most prevalent between 5-17 years old and in winter months• four classic symptoms

• fever • tonsillar or pharyngeal exudate • swollen, tender anterior cervical nodes• absence of cough

• complications • rheumatic fever • glomerulonephritis • suppurative complications (abscess, sinusitis, otitis media, pneumonia, cervical adenitis) • meningitis • impetigo • spread of disease to others • Note: incidence of glomerulonephritis is not decreased with antibiotic treatment

• see Table 13 for approach to diagnosis and management of GABHS• some feel laboratory confirmation should be done in: children from 5-15 years, those with

previous rheumatic heart disease, family members of individuals with previous rheumatic heart disease and young adults in closed communities (i.e. military recruits, college students, etc.)

� others: Neisseria gonorrhoeae, Chlamydia, Candida, Corynebacterium diphtheriae


SORE THROAT . . . CONT.

INVESTIGATIONS AND MANAGEMENT Suspected GABHS � gold standard for diagnosis is throat culture (refer to Table 13 for indications for throat culture) � rapid test for streptococcal antigen only 50-90% sensitive but 95% specific

• if rapid test positive, treat patient• if rapid test negative, take culture and call the patient, if culture

positive start antibiotics � no increased incidence of rheumatic fever with 48 hour delay in treatment� Penicillin V is drug of choice; erythromycin if penicillin allergic� follow-up throat culture for GABHS after antibiotic therapy only

recommended for patients with history of rheumatic fever, patients whosefamily member has history of acute rheumatic fever, suspected strep carrier

Suspected Viral Pharyngitis � symptomatic therapy for viral pharyngitis: acetaminophen/NSAIDs for fever and muscle aches, decongestants

Table 13. SORE THROAT SCORE (Approach to diagnosis and management of GABHS)*

POINTSIs COUGH ABSENT? 1Is there a HISTORY OF FEVER OVER 38ºC (101ºF)? 1Is there TONSILLAR EXUDATE? 1Are there SWOLLEN, TENDER ANTERIOR NODES? 1Age 3-14 years 1Age 15-44 years 0Age > 45 years –1In communities with moderate levels of strep infection (10% to 20% of sore throats):

SCORE

0 1 2 3 4Chance that patient 2-3% 3-7% 8-16% 19-34% 41-61%has strep throat Suggested action No culture Culture all, treat only Culture all, treat with

or antibiotic if culture is positive penicillin on clinical grounds 1

1 Clinical grounds include a high fever or other indicators that the patient is clinically unwell and is presenting early in the the course of the illness. If the patient is allergic to penicillin, use erythromycin.

* Limitations: * This score is not applicable to patients less than 15 years of age. * If an outbreak or epidemic of illness caused by GAS is occuring in any community, the score

is invalid and should not be used.

Adapted from: Centor RM et al., Med Decis Making 1981; 1: 239-246; McIsaac WI, White D, Tannenbaum D, Low DE, CMAJ 1998; 158(1):75-83.


REFERENCES Anti-infective Guidelines for Community-acquired Infections:2nd edition. Ontario Anti-infective Review Panel. Toronto, Canada. 1997.

Canadian Asthma Guidelines Quick Reference Tool. CMAJ, 1999;161 (11 Suppl).

Canadian recommendations for the management of hypertension. CMAJ 1999;161(12).

Gonzales R, Bartlett JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Emerg Med . 2001 Jun;37(6):720-7.

Gray J. Therapeutic Choices: 3rd Edition. Canadian Pharmacists Association, 2000.

Guidelines for the Diagnosis and Pharmacological Treatment of Depression: 1st edition revised. Toronto, ON; CANMAT, 1999.

Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). Canadian Respiratory Review Panel. 1998.

Herbert FL. Et. Al. Diagnostic pearls for 10 common problems. Patient Care Canada , 1995;6(1):28-50.

Marshall KG. Mosby’s Family Practice Sourcebook: Evidence-Based Emphasis. Harcourt Brace & Co., Canada, 2001.

McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can JCardiol 2001 May; 17(5):543-59.

Ontario Drug Therapy Guidelines for Stable Ischemic Heart Disease in Primary Care. Ontario Program for Optimal Therapeutics. June 2000.

Ontario Drug Therapy Guidelines for Chronic heart Failure in Primary Care. Ontario Program for Optimal Therapeutics. Queen’s Printer of Ontario, June 2000.

Ontario Guidelines for Peptic Ulcer Disease and Gastroesophageal Reflux. Ontario GI Therapy Review panel. Queen’s Printer of Ontario, June 2000.

Ontario Guidelines for the Pharmacotherapeutic Management of Diabetes Mellitus. Ontario Program for Optimal Therapeutics. Queen’s Printer of Ontario, June 2000.

Ontario Guidelines for the Prevention and Treatment of Osteoporosis. Ontario Program for Optimal Therapeutics. Queen’s Printer of Ontario, June 2000.

Ontario Guidelines for the Management of Anxiety Disorders in Primary Care. Anxiety Review Panel. Queen’s Printer of Ontario, Sept. 2000.

Ontario Treatment Guidelines for Osteoarthritis, Rheumatoid Arthritis, and Acute Musculoskeletal Injury. Ontario Musculoskeletal Therapeutics Review Panel. Queen’s Printer of Ontario, June 2000.

Panagiotou L, Rourke LL, Rourke JTB, Wakefield JG, Winfield D. Evidence-based well-baby care. Part 1: Overview of the next genera- tion of the Rourke Baby Record. Canadian Family Physician , March 1998;44:558-567.

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