FAMILY MEDICINE

Transcription

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) . . . . . . . . . . . 3
Purpose of the PHE
Adult Periodic Health Exam
Additional Preventative Health Care for the Elderly
HEALTH PROMOTION AND COUNSELLING. . 5
Nutrition
Exercise
Stress Management
End Of Life Care
COMPLEMENTARY THERAPIES . . . . . . . . . . . . 7
COMMON PRESENTING PROBLEMS
ALCOHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Definition
Epidemiology
History
Investigations
Management
Prognosis
ANXIETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Screening Questions
History
Treatment
BRONCHITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Acute Bronchitis
Acute Exacertabions Of Chronic Bronchitis (A.E.C.B.)
CEREBROVASCULAR DISEASE . . . . . . . . . . . . .13
CHEST PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Ischemic Heart Disease (IHD)
COMMON COLD (ACUTE RHINITIS) . . . . . . . .14
Epidemiology
Prevention
Diagnosis
Management
CONTRACEPTION . . . . . . . . . . . . . . . . . . . . . . . . .15
History
Physical Examination
Counselling
MCCQE 2002 Review Notes
DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Screening Questions
Risk Factors For Depression
Related Issues
Treatment
Risk of Recurrence
DIABETES MELLITUS (DM) . . . . . . . . . . . . . . . .16
Definition
Classification and Epidemiology
Diagnosis
Screening
Management
DIZZINESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Epidemiology
Diagnosis
Management
DOMESTIC VIOLENCE . . . . . . . . . . . . . . . . . . . . .19
Epidemiology
Effects of Violence
Detection and Management
DYSPNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Definition
Differential Diagnosis
History
Investigations
Management
DYSURIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Epidemiology
Investigations
Management
FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Epidemiology
Approach
Management
Chronic Fatigue Syndrome
HEADACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Etiology
Red Flags for Headache
Episodic Tension-Type Headache
Cluster Headache
Migraine Headaches
Family Medicine – FM1
FAMILY MEDICINE
. . . CONT.
HYPERTENSION (HTN) . . . . . . . . . . . . . . . . . . . .27
Epidemiology
Definition
Etiology
Diagnostic Evaluation
Therapeutic Considerations
SEXUALLY TRANSMITTED
DISEASES (STD’s) . . . . . . . . . . . . . . . . . . . . . . . . .36
History
Patients at Risk
Organisms
Prevention
Diagnosis/Investigations
LOW BACK PAIN . . . . . . . . . . . . . . . . . . . . . . . . . .31 Management
Definition
SKIN LESIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Etiology
Etiology
History
SLEEP PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . .37
Physical examination
Definition
Investigations
Etiology
Management
History
Red Flags
Physical Examination/Investigations
Management
MENOPAUSE/HORMONE REPLACEMENT
THERAPY (HRT) . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Stress-induced Insomnia
Periodic Limb Movements Of Sleep (PLMS) and
Epidemiology
Restless Leg Syndrome
Contraindications to HRT
Circadian Rhythm Disorders
Management
Parasomnias
OBESITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Excessive Daytime Sleepiness
Definition
SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Epidemiology
Epidemiology
Diagnosis
History
Investigations
Management
Management
Prognosis
Natural History
OSTEOARTHRITIS (OA) . . . . . . . . . . . . . . . . . . . .34
Definition
Etiology
Pathophysiology
Signs and Symptoms
Investigations
Management
SORE THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Etiology
Investigations and Management
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
OTITIS MEDIA (OM) (ACUTE) . . . . . . . . . . . . . .35
Definition
Epidemiology
History
Physical Examination/Diagnosis
Etiology
Management
FM2 – Family Medicine
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
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
. . . 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)
• 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)
• 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
• 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
• 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
. . . 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 management
2. Avoiding inappropriate prolongation of dying
3. Achieving a sense of control over end-of-life care decisions
4. 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
. . . 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
Reported Uses (not necessarily
effective)
Possible Adverse Effects
Possible Drug Interactions
Aloe Vera
strong laxative, topical: used for burns
intestinal obstruction, Crohn's,
in children or in pregnancy
K-dependent cardiac drugs
Chamomile
common cold, GI spasm, heartburn,
colitis, IBS
rare sensitization, emesis, anaphylaxis
possible
delayed GI drug absorption
Evening Primrose
CNS stimulant, decongestant,
bronchospasm
headache, restlessness, tachycardias,
hyperglycemia, diuresis
cardiac glycosides MAOIs
Echinacea
boils, erysipelas, septicaemia, cancer,
syphilis, common cold, flu
rare sensitization
potentiates warfarin
Garlic
migraine, arthritis, allergies, and
antipyrexia
heart rate, mouth ulcers,
muscle stiffness
potentiates antithrombotic
medications
Ginger
elevated lipids, high blood pressure,
high serum glucose
can increase bleeding time, gastric
irritation, halitosis
potentiates warfarin, aspirin
Ginkgo
energy enhancer
aggressive behaviors, headache,
menstrual abnormalities
potentiates CNS stimulants
.
Goldenseal
slows cognitive deterioration in
dementia
some platelet aggregation inhibition
anticoagulants, MAOIs
Marijuana
reduces cognitive function, ocular
pressure, bronchodilator, mild
appetite stimulant and antiemetic
effects, esp. against methotrexate
therapy
panic, confusion, anxiety, psychosis,
exaggerated apprehension of sensory
stimuli, SVT, ovulatory dysfunction
antagonizes methylcholine
Psyllium
stabilizes diarrhea, relieves
constipation, lowers cholesterol
avoid in intestinal stricture, ileus, or
obstruction
delayed GI drug absorption
St. John’s Wort
mild to moderate depression,
seasonal affective disorder
increased photosensitivity, headache,
nausea and dizziness
MAOIs, BCP
Valerian
hypnotic without residual a.m.
sedation, anxiolytic
headache, palpitations, paradoxical
insomnia
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 Cut down on your drinking?
• Have you every felt Annoyed by others telling you to cut down?
• Have you ever felt Guilty about your drinking?
• Have you ever had to have an Eye-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 Severe
Alcohol 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 leads
to 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
❏ 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 of
pathogen and spread of infection
❏ patient satisfaction with care depends most on physician-patient communication rather than
antibiotic therapy4
• 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 bronchitis
in reducing duration and severity of symptoms4
❏ 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 x4
Reference
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.
❏ 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
Angina
MI
Pericarditis
Myocarditis
Aortic dissection
Non-cardiac
Pulmonary
GI
MSK/Neuro.
Psychologic
Pneumonia
with pleurisy
Pneumothorax
PE
Pulmonary hypertension
GERD
PUD
Arthritis
Chondritis
Rib fractures
Herpes Zoster
Anxiety
Panic
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 all 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 Disease
Adapted 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 pills
References
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 ≥ 11.1 mmol/L
OR
• a fasting plasma glucose (FPG) ≥ 7.0 mmol/L
OR
• a fasting plasma glucose in the 2-hour sample of the oral glucose challenge test
(OGTT) ≥ 11.1 mmol/L
❏ in all cases, a confirmatory test must be done on another day in the absence of
unequivocal 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 ≤ 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 ≤ 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
Description:
Etiology:
Vertigo
(Vestibular)
• external world seems to revolve around individual
or the individual revolves in space
• an “illusion of motion”
• a “rocking sensation”
Psychogenic
Central
Peripheral
• diagnosis of
• brainstem
• inner ear
exclusion
• cerebellar
• vestibular nerve
• idiopathic
• Menière’s
• BPV
• tumour
• stroke
• drugs
• tumour
• trauma
• drugs
• infection
Nonvertiginous
(Nonvestibular)
• a “whirling sensation”
• feeling “lightheaded”, “giddy”, “dazed”, or
“mentally confused”
Vascular
Ocular
• VBI
• basilar migraine
• TIA
• orthostatic
hypotension
• Stokes Adams
• arrhythmia
• CHF
• aortic stenosis
• decreased visual
acuity
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 atypical
References
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
airflow obstruction is chronic and persistent
airflow obstruction is episodic and usually
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
but not universally seen
marked improvement with bronchodilators or steroids
Chest X-ray
often normal
increased bronchial markings (chronic
bronchitis) and chronic hyperinflation
(emphysema) often co-exist
often normal or episodic hyperinflation;
hyperinflation during asthma attack
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-inflammatory
treatment (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 FEV1 > 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 PaO2 55-59 mm Hg and evidence of cor pulmonale
or polycythemia
• use antibiotics in treatment of acute exacerbations of chronic bronchitis
References
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,
Proteus mirabilis, Enterobacter,
Klebsiella, Pseudomonas
internal dysuria throughout micturition, frequency,
urgency, incontinence, hematuria, nocturia, back pain,
suprapubic discomfort, low grade fever (rare)
Urethritis
C. trachomatis, N. gonorrhea
herpes, Trichomonas, Candida
initial dysuria, history of chlamydia/gonorrhea if
no vaginal discharge
Vaginitis
Candida, Gardnerella,
Trichomonas, C. trachomatis,
atrophic, herpes, condylomata
accuminata, Doderlein’s cytolysis
vaginal discharge, irritation, dyspareunia, external dysuria
(when urine comes in contact with inflammation on outside)
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 Less
than 6 Months Duration
Investigation
Always Perform?
Appropriate assessment for presence of anxiety
of depression?
Yes
Appropriate assessment of current life stresses and
past trauma and abuse
Yes
Focused history and physical with special emphasis on
medications, existing chronic illnesses, and presence
of infection, particularly viral
Yes (to determine
whether lab investigations
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
Perform only in these situations
• 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 reduction
in 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, adrenal
function, 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 year
B. headache lasting from 30 minutes to 7 days
C. at least two of the following pain characteristics
1. pressing or tightening (nonpulsating) quality
2. 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 D
B. 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 sweating
6. 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 Aura
A. at least 5 attacks fulfilling criteria B through D
B. each attack, untreated or unsuccessfully treated, lasts 2 to 72 hours
C. at least 2 of the following pain characteristics
1. unilateral location
2. pulsating quality
3. moderate or severe intensity
4. pain aggravated by walking up/down stairs or similar routine physical activity
D. during headache, at least one of the following
1. nausea and/or vomiting
2. photophobia and phonophobia
Diagnostic Criteria for Migraine With Aura
A. at least two attacks fulfilling criterion B
B. at least three of the following characteristics:
1. one or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain
stem dysfunction
2. at least one aura symptom develops gradually over > 4 minutes or two or more symptoms
occur in succession
3. no aura symptom lasts more than 60 minutes
4. 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
incidence
very common
age of onset
15-40
sex bias
more females
Common Migraine
common
variable, can be daily
not common
10-30
family history of headache frequent
headache frequency
Classic Migraine
Cluster Headache
uncommon
20-40
more females
mostly males
very frequent
infrequent
variable, but “never” daily
daily during cluster
triggers
stress or fatigue
stress, fatigue, menstruation
oral contraceptives, certain foods,
alcohol, weather changes,
lights, odors
onset during sleep
extremely rare
not uncommon
warning
none
none
location
bilateral, frontal
or nucho-occipital
often unilateral, sometimes bilateral
severity
mild to moderate
moderate to severe
exacerbators
stress or fatigue
movement, head jarring, head-low position
none
concomitants
none
nausea, sometimes vomiting, photophobia,
sonophobia, etc.
unilateral suffusion of eye with ptosis and tearing
stuffing and rhinorrhea of ipsilateral nostril
duration of headache
hours to days
examination during
headache
little distress; sometimes
tense tender scalp and neck
muscles
alcohol, only during cluster
typical
visual or
sensory aura
hours to “all day” - seldom more than two days
mild to severe distress,
tenderness of scalp arteries
none
unilateral, orbital, temporal, and malar
extremely severe
20-90 minutes
severe distress, eye changes as noted above
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
90 - 104
105 - 114
> 115
normal BP
mild hypertension
moderate hypertension
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
Assess Risk Factors
* age
* male gender
* postmenopausal
* smoking
* high cholesterol
* glucose intolerance
* LVH
YES
Diagnostic Tests
Prior to Visit 3
Ask
* Hx angina or MI?
* Hx TIA/stroke?
* Hx of peripheral
vascular insufficiency?
* Hx renal disease?
* Exogenous causes:
> excess EtOH?
> OCP?
> conj. estrogens?
> NSAIDs?
Examine
* cardiovascular
system
* respiratory system
* neurological exam
* include fundoscopy
for retinopathy
BP < 140/90 mmHg on
Last Diagnostic Visit?
(< 130/80 for those with DM)
* urinalysis
* CBC
* serum creatinine
* K+, Na+
* fasting serum glucose
* fasting total cholesterol,
HDL, LDL, TGs
* standard 12 lead ECG
* consider CXR
NO
Target Organ Damage?
NO
F/U yearly
YES
F/U q 4-6 mos
Lifestyle modification and/or
pharmacological therapy
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 suggest
pheochromocytoma
• 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)
HYPERTENSION
. . . CONT.
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-adrenergic
antagonist (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).
ACE inhibitors, (thiazide
diuretics as additive therapy)
Renal Disease
ISA=intrinsic sympathomimetic activity
low dose thiazides,
ACE inhibitors
hydralazine,
Emergency (BP > 169/90) =
labetalol, nifedipine
methyldopa
potassium sparing + thiazide
diuretics for patients on
salbutamol
With Systolic HTN
low dose thiazides
dihydropyridine
Ca2+ antagonist
Smoking
Pregnancy
Gout
Asthma
Nephropathy
ACE inhibitors
Diabetes Mellitus
Without Nephropathy
ACE inhibitors, ß-blockers
low dose thiazides,
ACE inhibitors,
ß-blockers with ISA
as for uncomplicated HTN
Dyslipidemias
Peripheral Vascular Disease
ACE inhibitors
(thiazide diuretics as
additive therapy)
ß-blockers, ACE inhibitors
Ischemic Heart Disease
• Angina/Recent Myocardial Infarction
Congestive Heart Failure
Recommended Drugs
Condition or Risk Factor
dihydropyridine Ca++ antagonists
labetolol, pindolol, oxprenolol,
nifedipine Ca++ antagonists
ß-blockers
ACE inhibitors
thiazides, but asymptomatic
hyperuricemia is not a
contraindication
ß-blockers
α-blockers, centrally acting drugs
(with autonomic neuropathy)
high dose thiazides
ß-blockers without ISA
α-blockers
AII antagonists
Ca++ antagonists
centrally acting drugs
AII-receptor antagonists
ß-blockers (with severe disease)
Not Recommended
as for uncomplicated HTN
hydralazine + isosorbide dinitrate
AII antagonists
Ca++ antagonists, eg. diltiazem
and verapamil
Alternative Drugs
Table 12. Pharmacologic Treatment of Hypertension with Co-existing Conditions
HYPERTENSION
. . . CONT.
Adapted from: Feldman RD, Campbell N, Larochelle P. et al. 1999. Canadia recommendations for the management of hypertension.
CMAJ. 1999; 161 (12 suppl.).
HYPERTENSION
. . . CONT.
Co-Existing Medical Conditions
and/or Target Organ Damage
Inadequate response or
adverse effects
Partial
Response
Partial
Response
Not Controlled or
Adverse Effects
Figure 5. Pharmacological Treatment of Hypertension
Adapted from: The Canadian Hypertension Society, 1999.
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)
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
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/m2 (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
=
M =
I
L
Y
=
=
=
Where is the Erythema? (be aware of normal areas of erythema
and tympanic flush when child crying)
Are the long and short processes of the Malleus visualized?
Is the pars flaccida bulging?
Use Insufflation to detect mobility of tympanic membrane.
Is the Light reflex fully visible?
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
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 applied
BID 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 nighttime
or 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 whose
family 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)*
POINTS
1
1
1
1
1
0
–1
Is COUGH ABSENT?
Is there a HISTORY OF FEVER OVER 38ºC (101ºF)?
Is there TONSILLAR EXUDATE?
Are there SWOLLEN, TENDER ANTERIOR NODES?
Age 3-14 years
Age 15-44 years
Age > 45 years
In communities with moderate levels of strep infection
(10% to 20% of sore throats):
SCORE
Chance that patient
has strep throat
Suggested action
0
1
2
2-3%
3-7%
8-16%
No culture
or antibiotic
3
19-34%
Culture all, treat only
if culture is positive
4
41-61%
Culture all, treat with
penicillin on clinical grounds1
1Clinical
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 J
Cardiol 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 generation of the Rourke Baby Record. Canadian Family Physician, March 1998;44:558-567.

FAMILY MEDICINE

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