Differential Gastroesophageal Reflux Disease

Cholelithiasis, biliary colic, Acute MI Splenomegaly - Reflux of gastric contents into esophagus causing
acute cholecystitis, acute
cholangitis, acute hepatitis
Liver abscess
Acute pancreatitis
Chronic pancreatitis
Peptic ulcer disease
Splenic infarct
Peptic ulcer
Gastritis
ABDOMINAL PAIN -
mucosal irritation (erosive vs non-erosive)
Sx: heartburn, regurgitation, dysphagia, chest pain,
Budd-Chiari syndrome GERD Nephrolithiasis
Portal vein thrombosis Gastritis Life Threatening Causes globus sensation, odynophagia (uncommon, usually
Pancreatitis Functional dyspepsia - Acute surgical abdomen: indicates esophageal ulcer), chronic cough, hoarseness,
Duodenal ulcer Gastroparesis
Nephrolithiasis o Rigidity, rebound tenderness, wheezing, nausea (uncommon)
involuntary guarding, shake sign + - Alarm features: VBAD (vomiting, bleeding, anemia,
Nephrolithiasis Appendicitis Nephrolithiasis
Pyelonephritis Constipation Pyelonephritis - Ruptured AAA: anorexia/weight loss, abdominal mass, dysphagia or
Constipation SBO, LBO Constipation
o CT imaging of choice- consider contrast- odynophagia)
Infectious colitis IBD, IBS Infectious colitis
Ischemic colitis Celiac disease Ischemic colitis enhanced CT aortography for planning - Diagnosis: clinical unless alarm features present →
Gastroenteritis consider endoscopy
Ischemic colitis
repair, if hemodynically unstable use
AAA FAST → acute stabilization → aneurysm - Management:
repair (open/endovascular) o Lifestyle: weight loss, elevate head of bed,
Appendicitis Cystitis/UTI Diverticulosis/diverticulitis
Nephrolithiasis Acute urinary retention Nephrolithiasis - Ruptured ectopic: reduce caffeine/spicy or acidic foods/alcohol/
Pyelonephritis Appendicitis Pyelonephritis
Infectious colitis Inflammatory bowel Infectious colitis o Diagnosed with +ve hCG & TV US carbonated drinks, avoid NSAIDS, avoid large
IBD disease IBS visualizing pregnancy outside uterine meals & late night eating, smoking cessation
Celiac disease Celiac disease Celiac disease
Inguinal hernia Ovarian cyst Inguinal hernia cavity, if hemodynically unstable use o Pharmacological: antacids PRN → H2RA or PPI
Ovarian cyst/torsion Ovarian cyst/torsion FAST (intraperitoneal bleeding) → o PPI once daily x 8 weeks, if refractory and no
Ectopic pregnancy Ectopic pregnancy
PID PID requires immediate surgical exploration alarm features → split dose BID, consider
+/- salpingectomy switching PPI, consider further workup with
Specific Populations:
endoscopy or H. pylori testing
Children: Irritable Bowel Syndrome
- Common: colic, gastro, mesenteric adenitis, constipation Diagnosis: ROME III Criteria (12+w in past 12 months Peptic Ulcer Disease
- Serious: intussusception (6-9 months), volvulus, NEC, of abdo pain with 2/3 of) Sx:
appendicitis (5-15y), obstruction o Relieved with defecation - 70% ASx, present w/ complications
- Don’t miss: abuse, testicular torsion, mumps, pneumonia, o Associated with a change in frequency - Epigastric pain, may radiate to back
UTI, gyne causes, gastric ulcer, diabetes, sickle cell crisis of stool - Duodenal ulcers: worse 2-5h after meal, & 11pm-2am
o Associate with a change in consistency - Gastric ulcer worse with eating, belching, epiastric
Pregnant women:
of stool fullness, early satiety, fatty food intolerance, N/V
- Ectopic pregnancy +/- rupture, miscarriage, labour,
- Normal physical exam with no red flag features Complications:
placental abruption, uterine rupture, chorioamnionitis,
(weight loss, fever, nocturnal defecation, anemia, - Bleeding (melena, hematemesis, hematochezia)
pregnancy related liver dz, pre-eclampsia/HELLP, fibroid
blood in stool, abnormal findings on endoscopy) - Perforation (sudden severe diffuse abdo pain), triad of
degeneration
- R/o IBD, celiac disease (serum anti-TTG) tachycardia, abdo pain, rigidity
Management: - Gastric outlet obstruction: weight loss, early satiety
Women:
- Reassurance, education, stress reduction - Fistulisation: symptoms related to involved of adjacent
- *r/o pregnancy in all women of reproductive age,
- Diet: fibre at least 25g/day, fluid intake avoid structures (e.g. colon- halitosis & feculent vomiting,
document LMP/sexual Hx/hCG
caffeine/EtOH/legumes, limit lactose/fructose/ abscess, blood vessels e.g. aortoenteric fistula, cystic
- Gyne causes: Mittleschmirtz (midcycle ovulation pain),
citrus, FODMAP diet → refer to dietician artery, exsanguinating hemorrhage)
PID, ectopic pregnancy +/- rupture, ovarian torsion,
- Exercise to decrease bloating & constipation Management: treat etiology
hemorrhagic cysts, fibroid +/- degeneration,
- Pain: antispasmodic (e.g. buscopan) - Stop NSAIDs, alcohol
endometriosis, spontaneous abortion, salpingitis
- Diarrhea: loperamide, cholestyramine - H. pylori:
- Constipation: fluids, fibre, consider laxatives o Amox + clarithro + flagyl + PPI x 2 weeks
Elderly:
- f/u regularly to monitor for new/changing sx o Bismuth + flagyl + tetracycline + PPI x 2 weeks
- ACS, aortic dissection, AAA, mesenteric ischemia
Diverticular Disease Appendicitis Biliary Tract Disease
- Risk Factors: low fibre diet, more common with - Presentation: low grade fever, abdo pain classically Cholelithiasis: formation of gallstones
increasing age, inactivity, obesity, muscle wall periumbilical dull/poorly localized-progresses to - RF: fertile, fair, First Nations, fat/obese, female, 40s, rapid
weakness, constipation localized at McBurney’s point, anorexia, N/V weight loss, estrogen, terminal ileal disease e.g. Crohn’s
- Presentation: diverticulosis asymptomatic o McBurney’s sign: tender 1/3 away from
o Diverticulitis- episodes abdo pain, often LLQ, ASIS to umbilicus on right side Biliary Colic: transiently impacted in cystic duct, no infection
bloating, flatulence, diarrhea/constipation, o Rovsing’s: L sided palpation results in pain - Constant severe pain in RUQ, crescendo/decrescendo
N/V, urinary sx with adjacent inflammation at McBurney’s point pattern, N/V, night time sx or after fatty meal, may radiate
- Complications: abscess, fistula, colonic obstruction, o Psoas sign pain w/ passive hyperextension to R shoulder or scapula
perforation +/- peritonitis, hemorrhage, sepsis of hip or resisted flexion of hip - Ix: all labs normal +/- ↑ bilirubin, US may show
- Staging: Hinchey staging to direct management o Obturator sign: pain with flexion/int or ext cholelithiasis in cystic duct
- Investigations: CT imaging of choice +/- rectal rotation of hip - Rx: analgesia + antiemetics, rehydration → elective lap
contrast, consider upright AXR - Investigations: cholecystectomy, no need to delay
o After resolution of acute episode consider o Labs: mild leukocytosis, CBC + Cr, lytes,
Acute Cholecystitis: inflammation of gallbladder resulting from
colonoscopy, barium enema, or flex sig lactate, B-hCG to r/o perforation, urinalysis
sustained impaction, acalculous cholecystitis in 10% (DM,
- Management: o Imaging: US to visualize US & r/o gyne
immunosuppression, ICU admission, trauma pt, TPN, sepsis)
o Uncomplications: conservative management causes, upright CXR/AXR to r/o perforation,
- Epigastric/RUQ pain, anorexia, N/V, lower grade fever,
o Outpatient: clear fluids only until CT scan imaging of choice
palpable tender gallbladder + Murphy’s sign, Boa’s sign
improvement, Abx (cipro + flagyl) 7-10d - Complications: perforation, abscess, phlegmon
- Ix: ↑WBC, mild ↑ bili, AST, ALT, ALP → US, consider HIDA
o Inpatient: if severe, inability to tolerate oral - Management:
scan if negative
intake, significant comorbidities, failures to o NPO, hydrate, correct electrolyte
- Rx: admit, hydrate, NPO, NG tube if persistent vomiting,
improve on outpatient management abnormalities, pain control/analgesics,
analgesia + antiemetics → Abx: cefazolin
▪ NPO + IV fluids, IV Abx (ceftriaxone antiemetics
o Cholecystectomy: early< 72h vs delayed> 6w
+ flagyl), gradual progression to o Surgical consultation
clear fluids o May consider medical Rx if mild symptoms Choledocholithiasis: stones in CBD
o Surgical indications: unstable with peritonitis o Surgical management: appendectomy - 50% asymptomatic, may present as biliary cholic, acholic
(Hartmann’s), Hinchey 3&4, after 1 episode if (laparoscopic vs open) + perioperative Abx stools + dark urine, jaundice
immunosuppressed, consider ≥2 episodes (cefazolin + metronidazole) - Rx: if no cholangitis- ERCP for CBD stone extraction +/-
Hernia: defect in abdominal wall causing abnormal protrusion of intra-abdominal contents elective cholecystectomy
- Risk Factors: ↑ intra-abdominal pressure (obesity, chronic cough- asthma/COPD, pregnancy, constipation, bladder Acute Cholangitis: obstruction in CBD causing biliary stasis +
outlet obstruction, ascites, heavy lifting), congenital, previous hernia repair, loss of tissue elasticity/strength infection (e.g. from stones, stricture, neoplasm,
(aging, repetitive stress, hiatus hernia) instrumentation, extrinsic compression)
- Presentation: mass variable size, tenderness worse at end of day, relieved with supine position or reduction, - Charcot’s triad: fever/RUQ pain/jaundice (Reynold’s
transmits palpable impulse with cough/strain pentad + shock/confusion)
o Strangulated: vascular supply compromised, pain/colour change/irreducible, requires emergency repair - Labs: CBC, Cr, lytes, blood culture, LFTs (obstructive),
o Incarcerated: irreducible (not necessarily strangulated) amylase/lipase to r/o pancreatitis → ultrasound
- Types: - Rx: BPO, fluids + electrolyte correction +/- NG, antiemetics
o Groin: direct (medial to inferior epigastric artery) & indirect inguinal (lateral to artery), femoral + analgesia → IV Abx, biliary decompression with ERCP or
o Epigastric: defect in linea alba above umbilicus PTC, followed by elective cholecystectomy
o Incisional: ventral hernia at site of wound close, may be 2⁰ to wound infection
o Other: umbilical, Spigelian (central hernia through linea semilunaris) Gallstone Ileus: cholecystoenteric fistula causing bowel
- Management: obstruction near ileocecal valve, Rigler’s triad (pneumobilia,
o Observation for small/asymptomatic inguinal hernias vs delayed surgical treatment- to prevent SBO, gallstones) → NG decompression + enterolithotomy,
complications (strangulation, incarceration, bowel obstruction, infection), cosmesis situla closure, cholecystectomy
Bowel Obstruction: partial or complete blockage of the
bowel resulting in failure of intestinal contents to pass
through lumen
- RF: prior abdo/pelvic surgery, abdo wall or groin
hernia, Hx malignancy, prior radiation
- Etiology (SBO): stricture, hernias, adhesions,
volvulus, intussusception, IBD, neoplasm, gallstones
- Etiology: (LBO): cancer, diverticulitis, volvulus,
constipation, IBD stricture, radiation stricture
- Presentation: N/V, colicky abdo pain, abdo
distension, constipation vs obstipation, increase
‘tinkling’ BS, absent BS (ileus delayed presentation)
- Complications: strangulating obstruction, sepsis →
shock, perforation (risk of small bowel ≥3cm, distal
colon ≥6cm, proximal colon ≥9cm, cecum ≥12cm)
- Ix: upright CXR to identify free air until right
hemidiaphragm, AXR (air fluid levels, bowel
distension, coffee bean sign in sigmoid volvulus)
- Rx: stabilize, fluid & electrolyte management, NPO
+ NG insertion to decompress small bowel, foley →
surgical management if failed trial conservative in
SBO or immediately in LBO
Intestinal Ischemia:
- Etiology:
o Acute: arterio-occlusive e.g. thrombotic,
embolic, extrinsic compression
o Non-occlusive: 2⁰ to hypoperfusion
o Mesenteric venous thrombosis
- Presentation: acute (severe abdo pain out of
proportion to physical findings, metabolic acidosis,
vomiting, bloody diarrhea, hypotension/shock,
sepsis) vs chronic (postprandial pain, fear of eating,
weight loss) → most common sites splenic flexure,
left colon, sigmoid colon
- Ix: labs (leuks ↑, amylase, LDH, CK, consider
hypercoagulability workup) → AXR (intestinal
pneumatosis, free air if perforation), contrast CT
(thickened wall, dilation thrombus, pneumatosis)
CT angio gold standard
- Rx: fluid resus, correct metabolic acidosis, NPO, NG-
decompression, prophylactic broad spectrum Abx,
exploratory laparotomy +/- percutaneous
transluminal angioplasty/stent/embolectomy,
segmental resection of necrotic intestine
Acute Pancreatitis: Colorectal Polyps & Colorectal Cancer:
- Etiology: gallstones >30%, alcohol (mnemonic: I get Polyp: protrubence of colonic mucosa (sessile vs pedunculated)-
smashed- idiopathic, gallstones, ethanol, trauma, nonneoplastic (hyperplastic, inflammatory) vs neoplastic
steroids, mumps/malignancy, autoimmune, (hamartomas, adenomas)
scorpion sting, hypertriglycerides, hypercalcemia, - Usually asymptomatic: do not typically bleed, tenesmus,
ERCP, drugs- HCTZ, azathioprine) intestinal obstruction if large → often detected on routine
- Sx: epigastric pain radiating to back- worse when colonoscopy/screening
supine, N/V, ileus, jaundice, fever, peritoneal signs - Ix: flex sigmoidoscopy → colonoscopy gold standard
+ abdo distension, Cullen’s + Grey Turner’s signs - Rx: endoscopic removal of entire growth if symptomatic or
- Ranson’s criteria: for prognosis risk of malignancy, if large or invading into muscularis may
o Admission: age >55y, WBC >16, glucose required surgical resection, follow up endoscopy in 1y
>11, LDH > 350, AST >250
o Initial 48h: Hct drop >10%, BUN rise >1.8, Colorectal Cancer:
arterial pO2 <60, base deficit >4, calcium - RF: age >50y, genetic syndrome (familial adenomatous
<2, fluid sequestration >6L polyposis, hereditary non-polyposis colorectal cancer), IBD,
- Ix: amylase, lipase, CBC- leukocytosis, ALT + AST, Cr, diet (↑ fat/red meat, ↓ fibre), smoking
lytes, lactate → US → CT if severe for complications - Sx: often asymptomatic, hematochezia/melena, abdo pain,
- Rx: supportive- NPO, hydrate, analgesia, change in BMs, weakness, anemia, weight loss, palpable
antiemetics, early enteric nutrition mass or obstruction- 20% mets at presentation
- Abx if severe of signs of sepsis - Spread: direct, lymphatic, hematogenous (liver, lung, bone,
- Stones pass spontaneously 90%, consider brain, if distal rectum tumour- IVC/lungs)
cholecystectomy same admission- may - Ix: colonoscopy if symptomatic/positive screen, microcytic
need urgent ERCP if conservative failure or anemia, labs- CBC/ferritin, U/A, liver enzymes, CEA
stone impacted in CBD o Staging with CT chest/abdo/pelvis, bone scan, CT
- Rare surgical rx: debridement/drain head if mets suspected, in rectal ca- pelvic US/MRI
necrotizing pancreatitis or abscess - Rx: wide surgical resection + regional LNs + adjuvant
- Complications: pseudocyst, abscess, chemoradiation, for rectal cancer low anterior resection vs
necrosis, vessel thrombosis, DM,sepsis/DIC abdominoperineal resection + adjuvant chemoradiation
Anorectal Disease:
Hemorrhoids: vascular/connective tissue from dilated veins, internal (above dentate line, 3/7/11) vs external (below, painful)
- Internal (grade 1-4): painless rectal bleeding, anemia, prolapse, pruritus, burning, rectal fullness → Rx: high fibre
diet, stool softener, sitz baths, steroid cream +/- pramoxine (anusol) → rubber band ligation, sclerotherapy,
photocoagulation → closed hemorrhoidectomy
- External: painful after BM + blood with wiping, often recur → Rx: medical treatment as above, surgical
decompression within 48h if thrombosed, may leave perianal skin tag
Anal Fissure: tear of anal canal below dentate line, 90% posterior midline usually from forced dilation
- Painful bright red bleeding especially after BMs → conservative Rx stool softeners, fibre, sitz baths → topical
nitroglycerin/nifedipine → lateral anal sphincterotomy (risk fecal incontinence)
Anorectal Abscess: usually bacterial infection- blocked anal gland at dentate line, recurrent abscess in Crohn’s → Rx: I&D/Abx
Fistula-in-Ano: anal fistula from rectum to perianal skin with inflammatory tract
- Intermittent/constant purulent discharge, palpable cord-like tract → Rx: fistulotomy to unroof tract & allow drainage
+ healing by 2⁰ intention +/- seton suture (rare risk fecal incontinence), post-op sitz baths, irrigation, packing
Pilonidal Disease: chronic recurring abscess or draining sinus in sacrococcygeal area, obstruction of hair follicles → cysts/sinus
- Asymptomatic until acutely infected then pain/purulent discharge, Rx: I&D, packing → surgical closure in nonhealing
Inflammatory Bowel Disease Crohn’s Disease vs Ulcerative Colitis
- Chronic inflammatory disease affecting GI & other systems
- Crohn’s: gum to gum, noncontinuous skip lesions Crohn’s Disease Ulcerative Colitis
- UC: colonic mucosal inflammation affecting rectum & Location Any part of GI tract Isolation to large bowel, always involves rectum
extending continuously proximally to cecum PR bleeding Uncommon Very common
Diarrhea Less prevalent Frequent small stools
Extra-Intestinal Manifestations:
Abdo pain Post-prandial, colicky Less common
- Derm: erythema nodosum, pyoderma gangrenosum,
Fever Common Uncommon
perianal skin tags, oral mucosal lesions, associated w/
Tenesmus Uncommon unless rectum involved Common
psoriasis (not true EIM)
Palpable frequent (25%), RLG Rare- cecal
- Rheum: peripheral arthritis, ankylosing spondylitis,
mass
sacroiliitis
Recurrence Common after surgery Non post-colectomy
- Ocular: uveitis (vision threatening), episcleritis (benign)
Endoscopic Ulcers, patchy lesions, pseudopolyps, Continuous inflammation, erythema, friability,
- Hepatobiliary: cholelithiasis, PSC, fatty liver
cobbestoning loss of normal vascular pattern, pseudopolyps
- Urologic: calculi (e.g. following ileal resection), ureteric
Histology Transmural w/ skip lesions, focal Mucosal & continuous, granulomas absent,
obstruction, fistulae
inflammation +/- noncaseating gland destruction & crypt abscesses
- Vascular: thromboembolism, vasculitis
granulomas, fissuring, ulceration,
- Others: osteoporosis, vitamin deficiencies (B12, ADEK
strictures, glands N
vitamins), cardiopulmonary disorders, rare pancreatitis
Radiology Cobblestone mucosa, strictures/fistula, Lack of haustra, stricture rare, need to r/o
Management ‘string sign’ showing bowel wall complicating malignancy
Crohn’s: thickening
- Lifestyle: smoking cessation, enteral diets may aid in Complications Stricture, fistulae, perianal disease Toxic megacolon
remission, consider electrolyte/vitamin supplementation if CRC risk Increased risk if >30% colon involved Increased risk except in proctitis
extensive SB involvement, antidiarrheals for symptom
management * not during acute flare Celiac Disease
o CRC screening in CD if >1/3 colon involved or - Gluten enteropathy, abnormal small intestinal mucosa due to reaction to gliadin
pancolitis in UC, ≥8y disease activity - Sx:
- 5-ASA (sulfasalazine, mesalamine) o Diarrhea, weight loss, anemia, bloating, sx of vitamin/mineral deficiency, failure to thrive
- Abx: perianal disease e.g. flagyl/cipro o Improved with gluten free diet
- Corticosteroids: prednisone 40mg PO daily, IV if severe o Usually more severe in proximal bowel: iron/calcium/folic acid deficiency >> B12 deficiency
- Immunosuppressants to maintain remission, 6- o Association with dermatitis herpetiformis
mercaptopurine, azathioprine, MTX less commonly - Investigations:
- Biologics: Ab to TNF-a e.g. infliximab, adalimumab o SB mucosal biopsy diagnostic: villous atrophy & crypt hyperplasia, ↑ intraepithelial lymphocytes
- Surgical: for complications e.g. fistulae, obstruction,
o Labs to identify anemia & iron deficiency, B12 deficiency, calcium deficiency
abscess, perforation, medically refractory disease
o Serology: serum anti-tTg Ab (IgA), measure serum IgA concomitantly
UC:
- Treatment:
- 5-ASA topical through suppository/enema, PO if extensive
o Dietary counselling
- Corticosteroids to induce remission
- Immunosuppressants: severe US refractory to steroids,
▪ Gluten free diet: avoid barley, rye, wheat
consider IV cyclosporine or infliximab, azathioprine to ▪ Oats, rice & corn flour acceptable
induce/maintain remission as steroids withdrawn (too slow ▪ Iron & folate supplementation (+ other vitamins as required)
for acute flare) o If poor response to dietary change- consider alternate diagnosis, non-adherence, concurrent
- Surgical: failed medical therapy, toxic megacolon, pre- disease (e.g. pancreatic insufficiency, intestinal enteropathy related t-cell lymphoma, intestinal
cancerous changes, inability to taper steroids ulceration)
o
Adult Cardiac Arrest Algorithm VF Asystole

ACLS VT PEA

CPR Quality Reversible Causes

• Push hard (at least 2 inches/5cm) and fast (100-
120/min), allow complete chest recoil 5 Hs
• Minimize interruptions in compressions 1. Hypovolemia
• Avoid excessive ventilation - IV access + fluids, manage
• Rotate every 2 mins, sooner if fatigued hemorrhage, consider
• If no advanced airway, 30:2 ratio transfusion
• Quantitative waveform capnography 2. Hypoxia
o PETCO2 < 10mmHg, improve quality - Airway management, O2
• Intra-arterial pressure - Adequate ventilation
o If diastolic <20mmHg, improve quality
3. Hydrogen (acidosis)
- ABG, adequate ventilation,
Shock Energy for Defibrillation
• Biphasic: manufacturer recommendation (e.g. sodium bicarbonate if
initial dose of 120-200J) if unknown, max available necessary
• Second and subsequent doses should be 4. Hypothermia
equivalent, and higher doses may be considered - Warmer, remove wet
• Monophasic: 360J clothes, warmed fluids
5. Hypo/hyperkalemia
Drug Therapy - Hyper- calcium gluconate,
• Epinephrine IV/IO dose: salbutamol, insulin +
o 1mg every 3-5 minutes dextrose, calcium resonium,
• Amiodarone IV/IO dose: diuretics, dialysis if
o 1st dose: 300mg bolus
refractory
o 2nd dose: 150mg bolus
- Hypo- IV fluids + KCl
Advanced Airway 5 Ts
• Endotracheal intubation or supraglottic advanced 1. Tension pneumothorax
airway - Needle decompression
• Waveform capnography or capnometry to confirm
2. Tamponade
and monitor ET tube placement
- Pericardiocentesis
• Once advanced airway in place, give 1 breath
every 6 seconds (10 breaths/min) with continuous 3. Toxins
chest compressions - Supportive management +/-
reversal agent, contact
Return of Spontaneous Circulation (ROSC) poison control
• Pulse and blood pressure 4. Thrombosis (pulmonary)
• Abrupt sustained increase in PETCO2 (typically - Fibrinolytic / thrombectomy
>40mmHg) 5. Thrombosis (cardiac)
• Spontaneous arterial pressure waves with intra- - MONAC
arterial monitoring - PCI vs fibrinolytic therapy
Reversible Arrhythmias

Hyperkalemia
• Muscle weakness, paralysis, arrhythmias → tall peaked T,
shortened QT, prolonged PR, wide QRS → asystole
• Management as above (C BIG K DROP)

Digoxin toxicity
• GI, confusion weakness, visual changes, electrolyte
abnormalities, → PVCs, conduction blocks, scooped ST + T
wave inversion/flattening
• Digoxin specific antibody, atropine if symptomatic brady

Cocaine intoxication
• Tachycardia, hypotension, euphoria, psychomotor
agitation, seizures, headache, coma
• B-blocker for tachy, benzo for seizures/agitation

Inappropriate Resuscitation

- Inappropriate: valid DNR, signs of irreversible death,

no physiologic benefit expected due to deterioration
of vital functions
- Consider prolonging: young, reversible causes,
overdose, suicide attempt, family concern
- Termination: physician decision based on time to
CPR/defib, comorbidities, pre-arrest state, intra-
arrest physiologic parameters Tachycardias
- Survival rate ↓ as code time ↑ Regular
- Narrow QRS
Code Status Discussion 1. Sinus tachycardia (100-150bpm)
- Current understanding of medial condition 2. Paroxysmal SVT, AVNRT
- Overall goals of care • 180bpm, no P waves
- Goals of care if conditioned worsened 3. Atrial flutter- saw tooth pattern
- Wide QRS
- Specifics:
4. Ventricular tachycardia
o Resuscitation including cardia medications, defibrillation, CPR 5. SVT with RBBB/LBBB
o Intubation + ventilation Irregular
o ICU support - Narrow QRS
- Patient’s wants: pain & symptom control, avoid inappropriate prolongation of dying process, sense of 1. Atrial fibrillation (100-150bpm)
2. Atrial flutter w/ variable block
control, strengthen family relationships
3. Multifocal atrial tachycardia
- Family/caregiver wants: inclusion in decision process, support/assistance at home, loved ones wishes ▪ 3 different P wave morphologies
honored, to be listened to - Wide QRS
o Allow family to be present during codes if possible, explanation during event + post-resuscitation 4. Ventricular fibrillation
debriefing- decreased risk PTSD/prolonged grief 5. AF/MAT with RBBB/LBBB
Bradycardias
• Sinus bradycardia
o SA node slows rate
o Sinus rhythm on ECG
• 1st degree block
o Lengthening of AV node delay
o Widened PR interval
• 2nd degree block (Type 1/Wenkebach)
o Blocked AV node
o Progressive lengthening of PR interval, followed
by dropped QRS
• 2nd degree block (Type 2)
o Blocked bundle of His
o Widened PR with no progression, followed by
dropped QRS
• 3rd degree block
o Complete AV dissociation
o P & QRS conduct with separate rhythms

Airway Management

• Patency (talking) vs obstruction (noisy breathing, hoarse)

• Assess: look, listen, feel
• Managing the airway: jaw thrust, chin lift, suction
o OP/NP airway, LMA, ETT/surgical- definitive
ETT Insertion
- Size: adult male (7.5-8.0mm), adult female (7.0-7.5mm)
- Choose type (straight or curved) and size of laryngoscope blade
- Test cuff integrity, secure stylet inside tube, lubricate
- Position head, open mouth with thumb + index fingers
- Insert blade to visualize glottic opening, insert through vocal cords
- Inflate cuff to seal, remove blade, hold tube & remove stylet
- Attach bag, give breath q6 seconds- watch for chest rise

Confirm placement of ETT: visualise going through cords, exhaled CO2

(gold standard), chest rising symmetrically, condensation on ETT,
bronchoscopy, CXR (position only)

Difficult airway assessment: LEMON

• L: look at facial/neck injuries, may distort internal structures
• E: evaluate 3-3-2, intraoral, mandibular, and hyoid-to thyroid
notch distances
• M: mallampati
• O: obstruction/obesity
• N: neck mobility
Neonatal Resuscitation Algorithm Pediatric Cardiac Arrest Algorithm
Drug Reactions:
- Type A: predictable from known pharmacological ALLERGY Management: (anaphylaxis)
• Remove offending agent, call help (code blue, 911)
properties of a drug e.g. diarrhea with antibiotics, • Rapid assessment of ABCs
gastritis with NSAIDs Dosing: o Intubation/cricothyroidotomy if required
- Type B: hypersensitivity in susceptible individual, Epinephrine: 0.3mL IM(1:1000) q5-15min, paeds 0.01mL/kg • If criteria for anaphylaxis met: administer epinephrine
e.g. allergy, anaphylaxis Diphenhydramine: 25-50mg q6-8h, paeds 5mg/kg/d divided • Place in recumbent position, elevate lower extremities
Prednisone: 50mg PO x5d, paeds 1mg/kg PO x 5d • 2 large-bore IV, 1-2L NS IV bolus
Immunologic Reactions: • Oxygen 8-10L/min via facemask
- I: (A) allergy, atopy, anaphylaxis Anaphylaxis: serious allergic reaction resulting from • Next steps:
o Immediate IgE mediated reaction immune mediated IgE reaction after exposure to an antigen o H1 antihistamines: diphenhydramine
- II: (B) antibody mediated the individual was previously sensitized to o H2 antihistamines: ranitidine
o Salbutamol 2.5-5mg in 3mL saline via nebulizer
o E.g. hemolytic & pernicious anemia, Graves
- Life threatening medical emergency o Glucocorticoid: methylprednisolone/prednisone
- III: (C) immune complex mediated
- Activation of mast cells, basophils, eosinophils • Treatment of refractory symptoms:
o E.g. vasculitis, glomerulonephritis, SLE
resulting in release of inflammatory mediators o Epinephrine infusion
- IV: (D) delayed onset T cell mediated o Vasopressors
- Vasodilation, fluid extravasation, mucosal secretions,
o E.g. contact dermatitis, SJS, DRESS, GBS o Glucagon
smooth muscle contraction
Discharge:
Clinical Features: • Observation at least 4h from last dose IM epi for
• Skin: flushing, erythema, pruritus, urticaria, angioedema, conjunctival erythema, maculopapular rash those at risk of severe anaphylaxis & biphasic
• Respiratory: nasal congestion, shortness of breath, stridor, wheezing, throat/chest tightness, cough, reaction (e.g. asthma, FHx, >1 dose epi)
hoarseness, dyspnea, accessory muscle use, respiratory arrest • Anaphylaxis emergency action plan, educate about
• Cardiac: cyanosis, tachycardia, palpitations, hypotension, arrhythmias, MI, cardiac arrest biphasic reaction
• GI: nausea, vomiting, abdominal pain, diarrhea • Allergen avoidance- referral to allergist & GP follow
• Neuro: headache, dizziness, syncope, confusion, weakness, seizures up within 48h
• Rx for multiple epipens: home, school/work, car- fill
Diagnostic Criteria: (anaphylaxis) prescription immediately
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g. • Educate re: use of epipen and to seek medical
generalize hives, pruritus, swollen lips/tongue/uvula) attention after administration
• AND at least one of:
• Respiratory compromise (e.g. dyspnea, wheeze-bronchospasm, stridor, hypoxia) Allergic Rhinitis
• ↓ BP or associated sx of end-organ dysfunction (e.g. hypotonia, collapse, syncope, incontinence) - IgE mediated inflammation of nasal mucosa after
allergen exposure
2. 2+ of the following that occur rapidly after exposure to likely allergen for that patient (minutes to several hours) - Triggers: animal dander, dust mites, pollen, grass
• Involvement of the skin mucosal tissue (e.g. generalized hives, itch-flush, swollen lips/tongue/uvula) - Sx: rhinorrhea, nasal obstruction, nasal/ocular pruritus,
• Respiratory compromise (e.g. dyspnea, wheeze-bronchospasm, stridor, hypoxemia) sneezing, personal/FHx atopy/allergy
• ↓BP or associated symptoms (e.g. hypotonia, collapse, syncope, incontinence) - O/E: nasal mucosa swollen, clear d/c, ‘shiners’, red eyes
• Persistent gastrointestinal symptoms (e.g. crampy abdominal pain, vomiting)
- Ix: consider skin prick to confirm triggers, nasal
endoscopy to r/o anatomic abnormalities, pulmonary
3. ↓ BP after exposure to known allergen for that patient (minutes to several hours):
function testing to r/o asthma
• Infants and children: low systolic BP (age-specific) or greater than 30% decrease in systolic BP
• Adults: systolic BP or <90mmHg or greater than 30% decrease from that person's baseline - DDx: viral rhinitis, vasomotor rhinitis, nasal polyps

Common Triggers Risk of Severe Anaphylactic Reaction: Management

• Food: peanuts, tree nuts, shellfish, fish, milk, eggs • Anaphylaxis & asthma, Hx anaphylaxis - Allergen avoidance + nasal saline irrigation
• Insect bites: bees, wasps, mosquitos • Under-utilized or delay in use of epinephrine - Rx x 2-4w then reassess: PO H1 blocker, intranasal H1
• Latex • Underlying cardiac disease- CVD or HTN blocker, decongestant (<7d), INCS, LTRA
• Inhalants: pollens, mold, animal dander • Age highest incidence 0-19y, especially food - Referral to specialist → specific immunotherapy
Anemia: ↓ in RBC mass which can be detected by Hb, Hct, and
RBC count
-
-
adult male: Hb<130g/L or hct <0.41
adult female: Hb<120g/L or hct <0.36
Classification:
Microcytic (MCV <80)
- TAILS: thalassemia, anemia of chronic disease, iron
deficiency anemia, lead poisoning, sideroblastic anemia
Normocytic (MCV 80-100)
- High retics: >2-3%
o Hemolysis
▪ Inherited: hemoglobinopathy,
membrane defects, metabolic
▪ Acquired (infection, micro-angiopathic
hemolytic anemia e.g. DIC/TTP/HUS/
HELLP, drug)
o Bleeding: e.g. GI/GU
- Low retics: <2%
o Pancytopenia: aplastic anemia, MDS, leukemia,
TB, amyloid/sarcoid
o Non-pancytopenia: anemia of chronic disease,
renal/liver disease
Macrocytic (MCV >100)
- Megaloblastic (B12 deficiency, folate deficiency &
antagonism e.g. methotrexate, sulfa)
- Non-megaloblastic: liver disease, alcoholism,
reticulocytosis, hypothyroidism, myelodysplasia
Investigations
- CBC with differential (MCV, RDW, RBC count), including
retic count (production), blood film, iron profile
- r/o dilutional (↑ circulating volume)
- Ix to r/o nutritional deficit, GI bleeding depending on MCV
Microcytic Anemia Investigations
➔ iron profile + blood film
- Iron ↓: ↓ferritin, ↓serum iron, ↑TIBC, hypochromic
- Chronic Dz: ↑/N ferritin, ↓serum iron, ↓TIBC
- Sideroblastic: ↑/N ferritin, ↑ serum iron, N TIBC,
basophilic stipling
- Thalassemia: ↑/N ferritin, ↑/N serum iron, N TIBC,
hypochromic, basophilic stippling, poikilocytosis → SPEP
ANEMIA
Risk Factors: (who to screen)
- Pts at risk for blood loss: anticoagulation, elderly,
NSAIDs, menorrhagia
- Pts with hemolysis e.g. mechanical valves
- Symptomatic pts: fatigue, dyspnea, angina, CHF
- Babies at high risk: impoverished, pale, low iron
diet, poor weight gain
Clinical Presentation
- Result from ↓ O2 delivery or hypovolemia
Sx:
- Fatigue, malaise, weakness, dyspnea, decreased
exercise tolerance, headache, dizziness, tinnitus
- Severe: syncope, palpitations, confusion, CHF,
angina, arrhythmias, MI
o Persistent hypotension –> shock
- Menstrual history, bleeding history
- Systemic illness, diet, alcohol, FHx
- Rule out pancytopenia
Signs:
- Derm: pallor mucous membranes, palmar crease
- HEENT: conjunctiva if Hb <90g/L, angular cheilosis,
jaundice, glossitis
- Cardiac: tachycardia, orthostatic ↓BP, systolic
flow murmur, wide pulse pressure, signs of CHF
Vitamin B12 Deficiency
Etiology: vegan, gastric mucosal atrophy, pernicious
(autoimmune Ab gastric parietal cells ↓ IF), post-
gastrectomy, malabsorption (e.g. Crohn’s, celiac), tape-
worm, terminal ileum resection, drugs (biguanides, PPI)
Sx: neuro (confusion, delirium, decreasing
proprioception), peripheral neuropathy, lower>upper
Ix: CBC (macrocytic anemia), retics ↓, B12 & folate,
blood film (megaloblastic), bilirubin + LDH, consider
anti-IF Ab, anti-parietal cell Ab
Rx: vitamin B12 1000mg IM monthly or 1000mg PO daily
if intestinal absorption intact
Iron Deficiency Anemia
Etiology: ↑ demand (pregnancy), ↓ supply (dietary, post-
gastrectomy, malabsorption), ↑ loss (hemorrhage e.g.
GI/menorrhagia, occult e.g. PUD, hemolysis)
Ix: ↓ serum ferritin, ↑ TIBC blood film (hypochromic
microcytosis), investigate for blood loss appropriately,
consider Ix for coag disorders/malignancy
Rx:
- Treat underlying cause
- Dietary modification
- Supplementation: oral e.g. ferrous sulphate 325mg
TID, ferrous gluconate 300mg TID, ferrous fumarate
300mg TID → until anemia corrects + 6 months
o IV: if cannot tolerate/absorb PO, e.g. venofer
- Monitoring: retics ↑ after 1w, Hb normalizes by 10g/L
per week (if no blood loss), stores usually replenished
in 3-6 months
Decompensation in Anemia
- Volume status (hypovolemia)
- Clinical features: CHF, angina, shock
Transfusions in Anemia
Red Cells
- Indicated if symptomatic, consider if Hb <80g/L
- 1 unit raises Hb by ~10g/L
- Consider pre-medications with furosemide if at risk for
circulatory overload
Platelets
- For prophylaxis against bleeding or for management of
acute bleeding in thrombocytopenia/plt dysfunction
- Indications: CNS hemorrhage & plt <100, epidural/
significant bleeding & plt <50, ITP & plt <30 (& IVIG)
immune thrombocytopenia & plt <10
- 1 unit raises platelets by ~15-25 x 109/L
Plasma
- For reversing elevated INR/coagulopathy, raises
coagulation factors 20% ~5h
- Consider premedication with furosemide if at risk for
circulatory overload
- For warfarin reversal, use prothrombin complex
concentrate (PCC) + vitamin K 10mg IV before plasma
 ANTIBIOTICS
Common First Line Therapies:
- Bacterial conjunctivitis: erythromycin 0.5% ointment QID x 7d → if severe/contact lenses,
cipro 0.3% 1-2 drops q2h x 2d then q4h x 5d
- Strep pharyngitis: pencillin V 600mg BID x 10d (erythromycin if allergic)
- Otitis externa: ciprodex 4 drops BID x 7d
- Acute otitis media: amoxicillin 500mg TID x 5-10d (azithro if allergic)
- Sinusitis: amoxicillin 500mg TID x 5-10d (azithro if allergic)
- AECOPD (low risk): amoxicillin 500mg TID or septra DS tab BID x 5d
- AECOPD (high risk): clavulin 875mg BID or levoquin 500mg x 7-10d
- CAP: amoxicillin 1g TID x 7-10d (azithro if allergic)
- HAP: amoxicillin 1g TID + azithro or levoquin x 7-10d
- Staph skin infection: mupirocin 2% TID x 7d
Urgent Antibiotic Therapy - Cellulitis: Keflex 500mg QID x 7d
- Do not delay administration if life-threatening infection - Cellulitis (MRSA): septra 1 DS tab BID x 7d
suspected e.g. for diagnostic confirmation - Animal bites/diabetic foot: clavulin 875mg BID x 7-14d
- Bacterial meningitis: - UTI: (uncomplicated) septra 1 DS tab BID x 3d or Macrobid 100mg BID x 5d
o Ceftriaxone 2g IV q12h + vancomycin 1g IV q12h - Trichomonas/BV: flagyl 500mg BID x 7d
o Add ampicillin 2g IV q4-6h for listeria coverage - Candidiasis: clotrimazole 500mg tab x 1
- Sepsis: - Gonorrhea/chlamydia: ceftriaxone 250mg IM x 1 and azithromycin 1g PO x 1
o Vancomycin 1g IV q12h + piptazo 4.5g IV q6h - Bacterial meningitis: ceftriaxone 2g IV q12h + vancomycin 1g IV q12h, add ampicillin 2g IV q4-
- Febrile neutropenia: 6h for listeria coverage
o Piptazo 4.5g IV q6-8h - H.pylori: PAMC (PPI, amox, metronidazole, clarithromycin) or PBMT (PPI, bismuth,
metronidazole, tetracycline) x 14d
Special Considerations - C. difficile: vancomycin 125mg QID x 14d
- ESBL:
Allergic Reactions
o Extended spectrum beta-lactamase → penicillins
- Type I: IgE (anaphylaxis, atopy), within 1h- up to 72h
are ineffective! o E.g. asthma, urticaria, anaphylaxis
o SPICE organisms- serratia, proteus, citrobacteria,
- Type II: IgG/IgM (anti-body mediated), >72h
enterobacter → 1st line carbapenems (or
o E.g. hemolytic anemia, acute graft rejection
nitrofurantoin for UTI)
- Type III: immune complex mediated, 7-14d
- Pseudomonas: o E.g. interstitial nephritis, SLE
o PO: cipro or levofloxacin
- Type IV: cell-mediated (delayed), >72h
o IV: piptazo, ceftazidime, cipro, menopenem
o E.g. contact dermatitis, drug eruptions
- MRSA:
Cross reactivity: ture penicillin allergies and cephalosporins is 5-10%, ↓ w/ each generation
o PO: septra, doxycycline, clindamycin, linezolid Consider rashes due to concurrent viral infection (e.g. EBV)
o IV: vancomycin, daptomycin
Do not re-expose if Hx SJS/TEN
Anxiety: characteristic sensations involving tension + Investigations
apprehension, becomes pathologic when: - Physical exam + investigations relevant to

- Fear out of proportion to risk/severity of threat

ANXIETY r/o medical dx (e.g. CXR, ECG, spirometry)
- Labs: (as needed)
- Response continues beyond existence of threat or Risk Factors: FHx anxiety, personal Hx anxiety or mood o CBC, fasting glucose, lipid profile,
becomes generalized to other situations disorder, childhood stressful events/trauma, female, TSH, electrolytes, liver enzymes,
- Impaired social or occupational function chronic medical illness, behavioural inhibition U/A & toxicology if warranted
Types of Anxiety Disorders Treatment
Panic disorder Recurrent unexpected panic attacks in the absence of triggers Nonpharmacological:
Agoraphobia Marked unreasonable fear or anxiety about a public situations (e.g. leaving the house) - CBT, especially effective for panic disorder
Generalized anxiety Excessive anxiety and worry about multiple events or activities - Minimal intervention formats: self-help
disorder books, telephone/videoconference,
Social anxiety disorder Marked unreasonable fear or anxiety about a social situations in which there is possible internet-based
exposure to scrutiny by others - Specific therapies: exposure therapy
Specific phobia Marked unreasonable fear or anxiety about a specific object or situation (e.g. spiders, (specific phobias), eye movement
heights, flying) desensitization & reprocessing (PTSD)
Obsessive Compulsive Recurrent and persistent thoughts, urges, or images experiences as intrusive and unwanted
Disorder and that cause marked anxiety or distress Benzodiazepines
Post traumatic stress Exposure to traumatic event (actual or threatened death,, serious injury, sexual violation) - Useful adjunct in early treatment for acute
disorder with intrusion symptoms, avoidance of stimuli associated with the event, negative anxiety/agitations or while waiting for
alterations in cognition, mood, arousal & reactivity adequate efficacy of antidepressants
- Useful for occasional use for specific
Anxiety Disorders Specific to Children phobias e.g. needles
Separation Anxiety Developmentally inappropriate and excessive fear or anxiety concerning separation from those to - Complications: dependency, sedation,
Disorder whom the individual is attached, ≥3 of: withdrawal, cognitive impairment (may
- Distress when separation occurs, worry about separation, reluctance to leave home/be persistent after cessation), slurred speech,
alone, nightmares involving separation, complaints of physical symptoms when memory impairment, weakness
separation occurs - Rebound symptoms: short > long acting
Duration at least 4w, onset before 18y, clinically significant distress or impaired functioning
- Falls risk in older pts, fractures
Selective Mutism Consistent failure to speak in specific social situations in which there is an expectation for
speaking, despite speaking in other situations Antidepressants
- SSRIs: escitalopram, fluoxetine,
DDx:
fluvoxamine, paroxetine, sertraline
- Anxiety due to other medical or psychiatric condition or comorbid with other psychiatric condition:
o SE: h/a, irritability, GI, insomnia,
o Psychotic disorder, mood (depression, dysthymia), personality disorders (e.g. OCPD), somatoform
sexual dysfunction, weight gain
o r/o abuse & substance abuse
o Increase risk SI initially, especially
- Medication induced/drug related:
children + adolescents
o Intoxication/drug use- caffeine, amphetamines, cocaine, thyroid meds, ventolin, OTC decongestants withdrawal
o Discontinuation syndrome with
(benzos, alcohol)
abrupt d/c- GI, vasomotor
Medical conditions
symptoms, tremor, anxiety
o Endocrine (hyperthyroidism, pheochromocytoma, hyperparathyroidism, hypoglycemia, hyperadrenalism),
- TCAs: clomipramine
cardiac/resp (arrhythmia, ACS, post-MI, COPD/asthma, CHF, PE), ,metabolic (vitamin B12 deficiency), neuro
- Others venlafaxine, duloxetine, buspirone
(temporal lobe epilepsy, TIA, vestibular dysfunction, encephalitis), meds (see above)
Asthma: reversible airway obstruction and inflammation,
characterized by dyspnea, chest tightness, wheezing,
cough, sputum production ↓
• Associated with variable airflow limitation and a
ASTHMA
degree of airway hyper-responsiveness to stimuli
Pediatric Respiratory Assessment Measure
Diagnosis: - Severity: 0-3 (mild), 4-7 (moderate), 8-12 (severe)
- In children <6y consider diagnosis with FHx and 0 1 2 3
frequent sx with recurrent (2+) exacerbations/month Suprasternal Absent Present
1. Spirometry showing reversible airway obstruction: contraction
o Adults: FEV1/FVC <0.75 or <LLN Scalene Absent Present
o Children: >6y: FEV1/FVC <0.8 or <LLN contraction
AND bronchodilator response with ↑ FEV1 >12% Air entry Normal ↓ ↓↓ Absent/minimal
(and >200cc in adults) bases
2. Decreased PEF with >20% improvement post-SABA or Wheezing Absent Exp Insp & Audible w/o
diurnal variation (adults) exp stethoscope,
3. Positive methacholine or exercise challenge test silent chest
SaO2 ≥95% 92- <92%
Differential Diagnoses: 94%
- FB aspiration: acute onset with playing/feeding,
monophonic wheeze +/- unilateral hyperinflation
Pediatric Acute Management:
- Croup: barking cough (vs pertussis whooping cough)
- Mild: (FEV1 >70%)
- Bronchiectasis: mucopurulent recurrent infections,
o SABA now & q1h PRN, vitals/PRAM q1h
hemoptysis) - Moderate: (FEV1 50-70%)
- URTI, infectious/allergic rhinosinusitis, pneumonia
o O2 to sats >92%, SABA now & q30-60m, oral steroid
- GERD: chronic cough, relation to foods, worse when o Vitals/PRAM q30-60min → consider ipratropium
supine, response to PPI bromide & admission if not improving
- Eosinophilic esophagitis: dysphagia, w/ PO intake - Severe: (FEV1 <50%)
- Bronchiolitis: <2y, RSV-URI sx, wheeze, resp distress o O2 to sats >92%, SABA + ipratropium now & q20min
- Congenital cardiac disease: tachypnea murmur, x 3 doses, then q20-60mins PRN
cyanosis, sx with feeds, FTT, pulmonary edema o Systemic steroid, vitals/PRAM q20mins, consider IV
- CF: chronic wet cough, steatorrhea, FTT, clubbing access & blood gases, likely admission if no
- COPD/overlap: smoking Hx, chronic cough, sputum significant improvement
- Bronchopulmonary dysplasia: premature, prolonged - Impending resp failure: (lethargy, ↑CO2, ↓ resp effort)
supplemental O2 at birth +/- mechanical ventilation o 100% O2, vent support, continuous cardiopulmonary
- Primary ciliary dyskinesia: neonatal resp distress, monitor, continuous neb salbutamol w/ ipratropium
daily cough/congestion, +/- situs inversus o Systemic steroid + IV access, consider magnesium
- Immune dysfunction: recurrent/persistent sever or sulfate, IV fluids, CXR + blood gases, ICU admission or
atypical infections CritiCall assessment
Disease Control:
Uncontrolled: daytime sx 4+ d/w, nighttime sx, abnormal physical activity, frequent exacerbations, school/work absence, SABA
use 4+/week, FEV1/PEF <90% personal best, PEF diurnal variation >10-15%, sputum eosinophils >2-3%, 2+ systemic steroids/y,
serious exacerbations e.g. ICU/hospitalization/mechanical vent in past year, sustained limitation after bronchodilator
Adult Acute Management:
Mild
- End-exp wheeze, O2 >90%, no accessory muscle
use, N vitals, full sentences, FEV1 or PEF >70%
- Inhaled SABA + PO steroid, +/- ICS
- Improved: PO steroid 5d, RTC instructions & f/u
Moderate
- O2 >90%, accessory muscle use, tachypnea,
tachycardia, FEV1 or PEF 40-70%
- High dose SABA + ipratropium q20min x 3 doses,
PO steroids
- Improved- manage as mild, if ongoing admit
Severe
- O2 <90%, significant accessory muscle use,
abnormal vitals, altered mental status, FEV1 or
PEF <40%
- High dose SABA + ipratropium q20mins x 3
doses, consider continuous nebulized albuterol,
PO steroids, consider magnesium IV
- Improved- admit, worsening or evidence of
impending resp arrest- prepare for intubation,
RSI with ketamine 2mg/kg + rocuronium,
consider NIPPV if does not require intubation,
ICU admission
Dosing:
SABA
- Salbutamol 100mcg/puff, MDI: 1-3y 4
puffs/dose, 4-6y 6 puffs/dose, 7y+ 8 puffs/dose
- Salbutamol 5mg/mL, Neb: <10kg 1.25mg/3mL
NS, 10-20kg 2.5mg/3mL NS, >20kg 5mg/3mL NS
Anticholinergic:
- Ipratropium 20mcg/puff, MDI: all pts 3
puffs/dose alternating with salbutamol
- Ipratropium solution, Neb: all pts 250mcg mixed
with salbutamol
Corticosteroids:
- PO prednisone 1-2mg/kg x 1 (max 50mg/dose)
- IV/IM: methylprednisolone 1mg/kg x 1 (max
125mg/dose)
Magnesium sulphate:
- 50mg/kg/dose x 1 (max 2g/dose), over 20-30m
Chronic Asthma Management Pharmacological Management Chronic Asthma (Adults & Children 6y+)
Nonpharmacological:
- Counsel on inhaler technique and spacer use
- Inquire about compliance
- Counsel on general precautions to avoid URI e.g. hand washing
- Avoid irritants/triggers
o Smoking cessation, avoid exposure
o Avoid chemicals/fumes
o Avoid pollen/dust mites, mold
o Avoid pets or hypoallergic only
o Close bedroom windows
o Remove/clean carpeting and soft surfaces
o Allergy covers for pillow & mattress
- Humidifier in bedroom
- Asthma action plan:
o Green: good control
o Yellow: poor control, quadruple ICS 7-14d
o Red: inadequate response/resp distress: ER

Indications for Referral

- Diagnostic uncertainty
- 2+ exacerbation requiring oral steroids per year
- Refractory despite moderate-dose ICS
- Life-threatening event (ICU admission)
- Need for allergy testing
- Other e.g. parental anxiety, education

Asthma Action Plan:

Atrial fibrillation: a supraventricular tachycardia
with uncoordinated atrial activation
- Valvular AF: significant structural changes in the
valves or congenital heart disease
- Paroxysmal: terminated spontaneously or with
intervention within 7d
- Persistent: lasting >7d
- Permanent: lasting >1y, despite attempts
History:
- Sx: pattern, asymptomatic, palpitations,
reduced exercise capacity, syncope/dizziness,
heart failure, chest pain, dyspnea, stroke sx
- Severity including impact on QoL
Examination:
- BP & HR
- Height & weight
- Comprehensive cardiac exam inc JVP, carotid &
peripheral pulses
Etiology:
- Cardiac: HTN, valvular disease, CAD, CHF,
cardiomyopathy, pericarditis, myocarditis, sick
sinus syndrome
- Non-cardiac: thyrotoxicosis, infection, COPD,
OSA, PE, obesity, diabetes, GERD, stress,
alcohol, cocaine (no associated with caffeine)
Investigations:
- 12 lead ECG: presence of AF, RF for therapy
complications e.g. conduction blocks, baseline
- Labs: CBC + coag, renal function, thyroid, liver
function, lipid profile, fasting glucose & A1c,
baseline INR (+/- serum Mg, Ca, PO4)
- Echo: ventricle size/function, left atrial size,
exclude valvular disease
- Additional investigations: (selected patients)
CXR to exclude concomitant lung dz, Holter ECG,
treadmill exercise test, transesophageal echo,
sleep study, genetic testing (rare familial AF)
ATRIAL FIBRILLATION
Management: (stable)
1. Investigate & treat precipitating causes
2. Assess thromboembolic risk (CHADSVacs) vs
bleeding risk (HASBLED) → antithrombotic
therapy, adjust for CrCl, NOAC preferred over
warfarin in nonvalvular AF & eGFR >30
3. Manage arrhythmia
- Rate control: CHF (B-blockers +/- digoxin), CAD
(B-blockers preferred or nondihydropyridine
CCB or combo), no complications: B-blockers
o Preference rate control 1st (<100bpm)
- Rhythm control: CHF or LV dysfunction:
amiodarone, otherwise flecainide,
propafenone, sotalol → amiodarone/ablation
o Rhythm control first only if highly
symptomatic with QoL impairment
CHADSVasc Score
- 1+ RF → OAC
o CHF
o HTN
o Age ≥ 65y
o DM
o Stroke/TIA
- None of above, CAD or PVD → antiplatelet
HASBLED Score: consider alternative to anticoag if >2:
- HTN (SBP >160mmHg)
- Abnormal LFTs/Cr >200
- Stroke
- Bleeding/anemia
- Labile INR (<60% therapeutic)
- Elderly >65y
- Drugs- 1 (aspirin, Plavix), alcohol- 1
Management: (acute)
- Unstable pt: hypotension, syncope, CP, dyspnea,
heart failure, neuro sx
1. Urgent rate control: IV diltiazem,
metoprolol, verapamil, or digoxin
2. If ineffective: cardioversion + immediate oral
anticoagulant, continue 4w if high risk
- Stable high risk pt: no OAC >3w and either
>48h/unknown duration OR stroke/TIA <6
months, or mechanical/rheumatic valve disease
1. Rate control
2. OAC x 3w then cardioversion, continue >4w
after cardioversion
- Stable low risk pt: onset <48h or OAC >3w
1. Rate/rhythm control + antithrombotic
2. Electrical CV at 150-200J, OAC not required
Antithrombotics in AF Patients with ACS
- AF + stable CAD
o CHADS2 0- ASA
o CHADS2 ≥1- OAC
- AF + recent elective PCI
o CHADS2 0- ASA + clopidogrel x 12
months, then ASA alone
o CHADS2 ≥1- OAC + clopidogrel x 12
months, then OAC alone
- AF + ACS
o CHADS2 0 & no PCI- ASA +
ticagrelor/clopidogrel x 12m → ASA
o CHADS2 0 & PCI- ASA + ticagrelor/
clopidogrel/prasugrel x 12m → ASA
o CHADS2 ≥1 & no PCI- OAC + clopidogrel x
12m → OAC alone
o CHADS2 ≥1 & PCI- OAC + clopidogrel +
ASA x 3-6m → OAC + clopidogrel until
12m → OAC alone
Thrombosis Canada Perioperative Guidelines:
https://thrombosiscanada.ca/tools/?calc=perioperat
iveAnticoagulantAlgorithm
SPIKES Framework for Delivering Bad News BAD NEWS
e.g. poor prognosis, new diagnosis, death of family member

Setting
Arrange for privacy, manage time constraints, silence pager, have tissues available, ensure environment comfortable
Consider bringing family members (patient must consent), organize a translator if necessary- family cannot act as translators!
Involve relevant team members while ensuring confidentiality
Prepare for meeting by knowing background history, treatment and investigations to date

Perception
Use open-ended questions to understand the patient's perception of the medical situation
Obtain understanding of what you will discuss
Obtain patient's understanding for the rationale for investigations done

Invitation
Ask patient how much information they want to know, share intent to be open and honest
Ask the patient if they would/would not want certain family members present

Knowledge
Share information about diagnosis/prognosis
Use appropriate language e.g. lay terms rather than medical terminology, use age-appropriate language
Give information in small chunks and periodically check understanding
Be honest about what the patient and family can expect in the short and long-term future

Empathy
Observe for reactions and emotions, identify the emotion and reasoning
Respond empathetically with patients, use appropriate silences to give patient time to reflect and process information

Summary
Review what you have discussed & give the family and patient the opportunity to ask questions
Provide resources to look at in their own time, ideally written information in appropriate language
Make relevant referral e.g. to specialists, palliative care, counselling
Arrange for a follow up discussion or appointment
Approach to Behaviour Problems in Children:
History:
-
-
From child: how do they see the problem?
Collateral Hx: teachers, parents
- Incorporate behavioural screen (Ages & Stages
questionnaire, pediatric symptom checklist)
- Specific screening: MCHAT (autism) Conners Scale
or SNAP-IV (ADHD)
PMH:
- Maternal RF: TORCH, medications, drug abuse
- Birth Hx: newborn screening, hearing screen
- Hospitalizations, surgeries, chronic illnesses
- Height & weight trajectory
- Developmental milestones
- Head trauma/seizures
- Sleep Hx
Social Hx:
- RF for behaviour problems: low SES, racialized, >3
children at home, mental illness
- Safety at home, r/o abuse
Examination:
- Head circumference: micro/macrocephaly
- Weight & height, FTT, short stature
- General features: dysmorphic characteristics
- Eyes: visual acuity, strabismus, cataracts, tracking
- Ears: shape/placement, recurrent OM, hearing
- Abdomen: hepatosplenomegaly
- Skin: neurocutaneous lesions, vascular markings,
signs of abuse
- Neuro: persistent primitive reflexes, abnormal
tone/strength, DTR or asymmetry
Investigations:
- CBC (anemia), blood lead level if at risk
- TSH, metabolic screening
- Head imaging/EEG if appropriate
Behavioural Issues in Elderly
- Delirium: drugs, electrolytes, lack of drugs
(withdrawal, poor pain control), infection, reduced
sensory input, intracranial, urinary retention/fecal
impaction, myocardial (CHF, ACS)
- Depression, dementia
BEHAVIOURAL PROBLEMS
DDx Behavioural Problems in Children:
- ADHD, ADD, ASD
- Conduct disorder
- Hearing/visual impairment
- Learning disability, developmental delay
- Depression, anxiety (social phobias, separation anxiety, selective
mutism), bipolar disorders, schizophrenia
- Abuse, substance use
- Family issues, adjustment disorder, peer conflicts
- Anemia, thyroid disorder
- Congenital conditions: fetal alcohol syndrome, fragile X syndrome
- Toxins e.g. lead, substance use- marijuana, cocaine
Oppositional Defiant Disorder
- Pattern of negative/hostile behaviour ≥6 months with ≥4 of: loss
of temper, argues with adults, defies adult rules, deliberately
annoys, blames others, easily annoyed, angry & resentful, spiteful
or vindictive
- Causes significant impairment on social/academic/occupational
functioning, not occurring with psychotic/mood disorder
- Not meeting criteria for conduct disorder although may progress
to this, usually onset <8y
Management:
- Establish boundaries, parent management training &
psychoeducation
- Individual/family therapy, school interventions for behaviour
management, pharmacotherapy for comorbid disorders
Conduct Disorder
- Pattern of behaviour that violates rights of others and age
appropriate social norms with ≥3 criteria within past 12m and ≥1
in the past 6 months: (TRAP- theft, rules, aggression, property)
o Aggression to people/animals, destruction of property,
deceitfulness or theft, violation of rules)
- Causes clinically significant impairment on social/academic/
occupational functioning, no APSD if >18y
Management:
- Early intervention*, long-term f/u required, pharmacotherapy for
comorbid disorders, parent management training, CBT/family
therapy, social skills training, education/employment programs
Adolescent Interview: HEADSSS
- H: home & environment
-
-
E: education & employment
A: activities
- D: drugs & alcohol
- S: sexuality, safety, suicide/depression
Adjustment Disorder:
- Emotional or behavioural symptoms in response
to an identifiable stress(s) occurring within 3
months of the onset of the stressor(s)
- Significant impairment in social/occupational
functioning, and does not meet criteria for
another mental health disorder including
normal bereavement
- Once stressor if termination, symptoms do not
persist >6 months
Management:
- Brief psychotherapy (group, individual), crisis
intervention
- Pharmacological:
o Benzodiazepine for anxiety/panic
attacks sx (short term, low dose)
o SSRIs for both depression/anxiety sx
Autism Spectrum Disorder:
- Persistent deficits in social communication and
interaction within 3 areas: social-emotional
reciprocity, nonverbal communicative
behaviours, developing/maintaining/
understanding relationships
- Restricted/repetitive behaviour, interests, activities
- Sx since early developmental period, causing
clinically significant impairment, and not better
explained by intellectual disability/global delay
- Red flags: parental concerns re: social skills/
language/behaviour, delayed language skills (no
babbling by 9m, no gestures by 12m, lack of
orientation to name by 12m, no single words by
16m), lack of pretend play by 18m, no 2-word
phrases by 24m, any loss of language/social skill
Investigations: hearing test, r/o psychotic disorders,
depression, anxiety, abuse, chromosomal analysis
Management: MDT based, family ed/support, Rx for
concomitant problems(aggression, mood, attention)
Attention Deficit Hyperactivity Disorder: Core Sx of ADHD (DSM-5)
- Mental health disorder resulting in above-normal
amounts of impulsive and hyperactive behaviours
- Usually onset in childhood but may present as
adults, strong genetic contribution

Diagnosis:
- Subtypes: combined (6+ hyperactivity sx, 6+
inattention sx), predominantly inattentive,
predominately hyperactive-impulsive
- 5 sx required for older adolescents/adults, see core
symptoms → → →
- Persistence >6 months, onset <12y
- Sx in at least 2 settings, interferes with functioning
- Does not occur exclusively during course of other
psychiatric disorder
- Mnemonic: (ATENTION) annoying, temperamental, Management:
energetic, noisy, task incompletion, inattentive, Non-pharmacological: parent management, anger control strategies, positive reinforcement, social
oppositional, negativism skills training, individual/family therapy, resource rooms + tutors, IEP, classroom intervention,
exercise routines, extracurricular activities
Questionnaires: Pharmacological:
- Conners Scale - Stimulants: (long acting >> short) methylphenidate, amphetamine + amphetamine salts
- WEISS Symptom Record - Non-stimulant options: atomoxetine (Strattera), guanfacine (intuniv)
- SNAP-IV - Treatment of comorbidities: antidepressants, antipsychotics
- Adult ADHD Self-Report Scale
Risk Factors for Breast Cancer Ontario Breast Screening Program (OBSP)
Breast cancer risk calculator • All women age 50-74y, screen routinely q2y
• http://www.cancer.gov/bcrisktool/ BREAST LUMP • FamHx in 1st degree relative: start 10y earlier than
• https://ibis.ikonopedia.com/ age of onset
• Gender (99% female), age (80% of women > 50y) Screening • Counsel on risks: radiation exposure, pain, anxiety,
• Prior Hx breast cancer of prior breast biopsy Higher Risk Screening: errors e.g. false positive/negative
regardless of pathology Women age 30-69y (OBSP), annual mammography + MRI/US
• 1st degree relative with breast cancer (greater risk if • BRCA1/2 carrier, TP53, PTEN, CDH1
premenopausal) • 1st degree relative of genetic mutation carrier (as above) and have declined genetic testing
• BRCA +ve relative • >25% lifetime risk of breast cancer based on risk assessment tool at genetics clinic (IBIS or BOADICEA)
• Increased risk with high breast density • Chest radiation <30 years and at least 8 y previously
• Unopposed estrogen:
o Nulliparity, 1st pregnancy > 30y, menarche Breast Examination:
< 12y, menopause >55y • Not routinely recommended for screening, only performed when relevant Sx/concerns from pt
• Radiation exposure (e.g. chest exposure for o Does not apply to higher risk women (personal Hx, Family Hx in 1 st degree relative, known BRCA1/2
Hodgkin’s disease) mutation, prior chest wall radiation)
• HRT > 5 years
Genetic Screening
• Hx benign breast disease
• Recommended if >1 1st degree relative w/ breast cancer
• Modifiable risk factors:
o 4x risk (postmenopausal) 9x risk (premenopausal)
o OCP use
o Alcohol intake • Patient at risk of BRCA1/2 mutation, family Hx ovarian cancer or male breast cancer, Ashkenazi Jewish heritage
o Sedentary lifestyle Benign Breast Lesions
o Obesity
o Pregnancy Condition Clinical Features Management

Investigations
Imaging
• Diagnostic mammography in all pts w/ mass > 30y
• Normal mammograph does not r/o suspicion of
cancer based on clinical findings
• US: to differentiate cystic vs solid
• MRI: high risk or very dense tissue
• Galactogram/ductogram: ordered if pt presents
with nipple discharge, identified lesions in ducts
Pathology
• Needle aspiration (cystic) + cytology
• FNA
• US/mammography guided core needle biopsy
• Excisional biopsy
Metastatic Workup
• Done after surgery or if any clinic suspicion of
metastatic disease
o CT chest/abdo/pelvis, if indicated- bone
scan, abdo US, CXR
o Head CT only if specific neurological Sx
Fibrocystic disease Mastalgia, focal mobile nodularity UOQ, varies Evaluation of mass + reassurance, analgesia,
with menstrual cycle OCP/danazol if severe
Fibroadenoma Increase risk breast ca if complex, smooth rubbery Core/excisional biopsy, conservative +
nodules, discrete, hormone dependent observation, excision if >2cm/Sx
Intraductal Solitary intraductal benign polyp- unilateral Excision of duct to ensure no atypia/DCIS
hyperplasia bloody nipple discharge + breast mass
Ductal hyperplasia Benign cytology, breast mass +/- nipple discharge No Rx required, slightly increased cancer risk
w/o atypia w/ moderate or extensive hyperplasia
Fat Necrosis Breast trauma, firm ill-defined mass +/- Complete imaging + biopsy to r/o carcinoma,
skin/nipple retraction, tenderness regresses spontaneously
Mammary duct Obstruction of subareolar duct leading to Relevant imaging to r/o malignancy
ectasia inflammation/ fibrosis, mass under nipple + pain Supportive + monitor, R 2⁰ infection
Retroareolar cyst Obstruction of retroareolar gland, inflammation/ Treat secondary infection e.g. mastitis,
(Montgomery) cyst collection, risk of 2⁰ infection resolves spontaneously in weeks- years
Abscess Lactational vs periductal/subareolar, unlilateral r/o inflammatory ca, Rx broad spectrum ABx
localized pain, subareolar mass, nipple discharge + I&D, duct excision if persistent
Malignant Breast Lesions Complications of Breast Cancer Treatment of Breast Cancer
Condition Clinical Features • Surgical treatment
Ductal Neoplasm within breast ducts, 1. Symptoms of surgical treatment o Breast conserving surgery- lumpectomy
Carcinoma in 80% nonpalpable & detected on - Lymphedema – nodal metastasis or w/ wide local excision
Situ (DCIS) screening, breast mass +/- node dissection o Mastectomy (simple vs modified radial)
Non-invasive

nipple discharge, skin - Cellulitis, phantom pain + breast reconstruction

changes/retraction o Sentinel lymph node biopsy +/- axillary
2. Generalized aches and pains lymph node dissection
Lobular Neoplasm contained within
Carcinoma in breast lobule, often not 3. S/E from XRT • Adjuvant/neoadjuvant
Situ (LCIS) palpable & difficult to detect on - Weakness / paresthesia, CAD/valvular o Radiation
mammogram • Almost over after BSC,
Infiltrative (80%) breast mass +/- nipple 4. Side effects of chemotherapy sometimes after mastectomy
ductal discharge, skin - Premature ovarian failure, dilated o Hormonal
Invasive

carcinoma changes/retraction cardiomyopathy, secondary cancer, • Tamoxifen (premenopausal) or

Invasive (20%) breast mass +/- nipple
lobular discharge, skin
carcinoma changes/retraction
Paget’s Disease Ductal carcinoma that invades
nipple, scaling + eczematoid
lesion on nipple
Inflammatory Breast Dermal lymphatic invasion +/-
Cancer mass, skin hot/red/painful, peau
d’orange if advanced, generally
no fever/WBC to differentiate
from mastitis, most aggressive
form of breast cancer
Male breast cancer <1%, mostly invasive ductal
carcinoma, similar presentation
to females
cognitive dysfunction
5. Mets:
- Bone > lung > liver > brain
6. Meds:
- Estrogen : VTE
- Estrogen antagonists: hot flashes,
vaginal dryness
- Progestin: wt gain, nausea, fluid
retention
- Aromatase inhibitors (e.g.
anastrazole): somnolence, rash
aromatase inhibitor e.g.
anastrozole
• Ovarian ablation (GnRH agonist,
oophrectomy, progestins,
androgens)
o Chemotherapy
• Early disease w/ high recurrence
risk
Post-Treatment Follow-up
• visits q3-6mo x 2 yr and annually thereafter
(frequency is controversial)
• annual mammography; no other imaging
unless clinically indicated
• psychosocial support and counseling

Local/Regional Recurrence
• Recurrence occurs in treated breast or
ipsilateral axilla
• 1% per year up to maximum of 15% risk
of developing contralateral malignancy
• 5x increased risk of developing
metastases

Metastasis
• bone > lungs > pleura > liver > brain
• treatment is palliative: hormone
therapy, chemotherapy, radiation
Approach to Cancer Patients in Family Medicine
- Discuss cancer prevention advice opportunistically
o Smoking cessation
o HOV vaccination, avoid unprotected
intercourse
o High fibre diet, reduce processed foods
o Avoid excess sun exposure/tanning salons
- Advise about available screening in Ontario
- Continue to stay involved after diagnosis, working
with specialists
o Offer regular follow up & support
- Actively inquire about personal and social
consequences of cancer
o Family issues/conflict
o Sources of support
o Coping mechanisms
o Level of functioning in ADLs, IADLs
o Employment, financial concerns
- Actively inquire about side effects of treatment
- Be realistic and honest about discussing prognosis
- Initiate a discussion about goals of care and
advanced care planning early
- If patient has a distant history of cancer, consider
metastatic disease when they present with new sx
Screening: Melanoma
- No recommendation population based screening
- Clinic risk assessment based on age, sex, Hx
melanoma, non-melanoma skin cancer, FHx,
number of nevi, skin & hair pigmentation, response
to sun exposure, evidence of AKs
- High risk: counsel on how to recognize and
document suspicious lesions, skin check q6-12
months will full body examination +/-
photography, dermoscopy, if confirmed- screen for
CDKN2A genetic mutation
- Prevention: avoid sunburns, UV protection
(physical methods + sunscreen SPF 30+),
recommend against sunbeds, avoid excess sun
-
CANCER
Screening: Colon Cancer
- For average risk adults: (50-74y)
o FIT q2y or flexible sigmoidoscopy q10y
o Abnormal FIT should be followed by
colonoscopy within 8 weeks
- High risk adults: prior CRC/polyps, IBD,
signs/symptoms, Hx CRC in 1+ 1st degree
relatives, hereditary syndrome e.g. FAP/Lynch
o 1st degree relative: colonoscopy at age
50y or 10y prior to when relative
diagnosed, repeat q5y if relative <60y or
q10y if >60y
o IBD: colonoscopy q1-2y, start after 8y dz
o FAP: genetic counselling, colonoscopy
q1-2y starting age 10-12y
o HNPCC/Lynch Syndrome: genetic
counselling, colonoscopy starting at 20y
or 10 before familial case onset
Screening: Cervical Cancer
- Average risk women who have been sexually
active, 21-70y:
o Routine screening with pap smear q3y
o Stop at 70y if last 3 tests in last 10y neg
- Not required if: never sexually active, total
hysterectomy for benign disease
- Routine: women sex w/ women, pregnancy,
subtotal hysterectomy/trans men w/ cervix
- High risk women:
o Total hysterectomy for malignancy/
dysplasia- continue to swab vaginal vault
o Previous abnormal pap- LSIL repeat in
6m x 2, ASCUS repeat in 6m x 2 or if >30y
option to test HPV for oncogenic strains
▪ Repeat abnormal or HPV+: colpo
o Immunocompromised: transplant,
steroids, DES exposure, HIV- annual
Screening: Breast Cancer
- Average risk adults: (50-74y)
o Routine screening with
mammography q2y, do not screen
with MRI/US/clinical breast exam/self-
breast examination
- High risk: (30-69y)
o RFs: personal Hx breast ca, FHx breast
ca in 1st degree relative, carrier of
gene mutations (BRCA1/2), first
degree relatives with gene mutations,
chest radiation therapy <30y old and
at least 8y ago
o Annual mammography + MRI/US
- Genetic testing, offer if:
o Multiple cases breast/ovarian ca on
same side of family (especially if:
closely related relatives, >1
generation, breast cancer <50y),
breast ca <35y in family, family
member with both ovarian & breast
ca, family member with bilateral
breast ca- especially <50y, family
members with ovarian ca, family
members with male breast ca, 1st
degree relative of BRA carrier, women
of Ashkenazi Jewish descent with
breast ca <60y
Screening: Lung Cancer
- Adults 55-74y with 30+ pack year Hx, who
currently smoke or quit <15y ago
o Low dose CT scan x 1
Screening: Prostate Cancer
- Men 55-69y, discuss screening options with pt
- Canadian Urological Association recommends
offering PSA screening if life expectancy >10y,
start at 50y (or 45y if high risk)
- Stop screening at 70y or 60y if PSA <1
History:
- Location, onset, provoking factors (exertional,
-
movement), quality, radiation, severity, timing
Aggravating/alleviating factors
- Associated sx (N/V, diaphoresis, SOB, palpitations,
syncope, presyncope)
- Cardiac RF: HTN, DM, smoking, alcohol use,
dyslipidemia, FHx ear CAD (MI <55y M or <65y F)
- ROS to r/o differential (resp, GI, MSK, psych, zoster)
Physical Exam:
- Vital signs: check BP in both arms, pulses
- Volume status: JVP, pedal edema
- CVS: S1/S2, S3 (volume overload), S4
(stiff/hypertrophic ventricle), murmurs, peripheral
vascular exam
- Resp: breath sounds, tracheal deviations, trauma,
wheeze/crackles
- GI: epigastric, RLQ tenderness
Investigations:
- Cardiac/resp:
o Serial ECGs, compare with previous, 15 lead
ECG if new R wave or ST depression in V1/2
o Serial troponin (6h post chest pain onset or if
ongoing in ED then 6h later)
o Labs: CBC, Cr, lytes, extended lytes, LFTs,
fasting glucose, lipid profile
o CXR, consider POCUS for tamponade
o Echocardiogram +/- Holter monitor
- GI
o Endoscopy, esophageal motility
study/barium swallow
o ERCP if biliary disease
o +/- abdo CT if AAA suspected
Life Threatening Causes of Chest Pain
• Myocardial infarction
• Pulmonary embolism
• Cardiac tamponade
• Aortic dissection
• Tension pneumothorax
• Esophageal rupture
• *If epigastric/abdominal pain- r/o AAA rupture
CHEST PAIN
Cardiac vs Non-Cardiac Pain Characteristics
Classic:
- Severe retrosternal chest pressure/ squeezing/ tightness/
heavy sensation
- Diffuse discomfort, difficult to localize
- +/- radiation to shoulder, arm, neck/jaw, epigastrium, back
- Exertional
- Associated sx: SOB, diaphoresis, nausea, +/- palpitations/
dizziness/weakness
Atypical: more common in women, diabetics, elderly
- Sharp, fleeting, stabbing, pins & needles, pleuritic pain
- Discomfort localized with one finger, constant/lasting days
- Primary location mid/lower abdomen
- Clearly reproduced by movement or palpation
Pulmonary Embolism:
- Sx: pleuritic CP, dyspnea, cough/hemoptysis, DVT sx
- O/E: ↓O2, ↑RR, ↑HR, hypotension if massive PE
- Ix: ECG (↑HR, RV strain- T inversion V1-4, S1Q3T3), CXR
(nondiagnostic, Hampton’s hump), d-dimer low risk pts,
CTPA vs VQ scan
Diagnosis:
- Wells: PE #1 Dx (3), HR >100 (1.5), immobilization within
3d or surgery within 4w (1.5), previous PE/DVT (1.5),
hemoptysis (1), malignancy, Rx within 6m/palliative (1)
o <2 D-dimer/PERC, 2-6 D-dimer or CTPA, 6+ CTPA
- PERC: (all negative) age >50y, HR >100, SaO2 <95% on RA,
unilateral leg swelling, hemoptysis, recent surgery/trauma,
prior PE/DVT, hormone use (OCP, HRT)
- Pregnancy: if DVT sx- doppler US + treat as DVT/suspected
PE, if no leg sx & CXR normal → VQ, if CXR abn → CTPA
Management:
- Resuscitation if hemodynamically unstable, O2
- Consult heme/resp, consider IVC filter if anticoag CI
- Anticoagulation: NOAC, LMWH (preferred in active
cancer), fondaparinux, IV UFH (only in severe renal
disease, high bleeding risk, Rx with thrombolytic), warfarin
with LMWH bridge → duration 3m if provoked, longterm if
unprovoked or ongoing RF
- Thrombolysis: massive PE & unstable, rTPA 100mg IV/2h
Angina:
- Typical: all of- substernal chest discomfort with
characteristic quality & duration, provoked by
exertional or emotional stress, relieved by rest or
nitroglycerin
- Atypical: meets 2/3 criteria
- Non-cardiac CP: meets 0-1/3 criteria
Grading:
- Class I: with strenuous/prolonged exertion
- Class II: with 2 blocks or 2 flight of stairs
- Class III: with 1 block or 1 flight of stairs
- Class IV: angina with any physical activity
Investigations to r/o IHD: (see ischemic heart disease)
- Labs: CBC, lipid panel, fasting glucose, A1c, renal
function, consider liver function + TSH
- 12 lead ECG
- Non-invasive cardiac diagnostic testing
o Exercise stress test: able to exercise, no
LBBB initial ECG
o Exercise myocardial perfusion imaging/
exercise echo
o Nuclear imaging (exercise vs persantine)
- Invasive: angiography
Differential:
- Cardiac: ACS, angina, AF + arrhythmias, tamponade,
aortic dissection, myocarditis, pericarditis
- Resp: pneumothorax/tension pneumothorax,
hemothorax, PE, pneumonia, bronchiectasis, TB,
empyema, pulmonary neoplasm
- MSK: rib fracture, muscle strain, costochondritis,
fibromyalgia
- Derm: herpes zoster, abrasions, bruising
- Breast: fibrocystic disease, malignancy,
inflammatory cancer, fat necrosis, mastitis, abscess
- GI: GERD, esophageal spasm, esophagitis,
esophageal rupture, esophageal/gastric ca, PUD,
gastritis, biliary disease, pancreatitis, AAA
- Mediastinal: lymphoma, thyroid
- Psych: anxiety, panic disorders, psychosomatic
Approach to Chronic Disease Diabetic Ketoacidosis (DM one pager)
- Relative insulin deficiency leading to ↓ glucose
CHRONIC DISEASE
- Dedicated appointments at regular intervals to assess
symptom control utilization and fat/TG breakdown + ketoacidosis
- Assess for complications/exacerbations - Diagnosis:
- Assess compliance with treatment regimen regularly - Asthma Exacerbation (asthma one pager) • Blood sugar >14
Salbutamol 4 puffs by MDI with spacer or • Urinary/plasma ketones
o Assess reasons for noncompliance &
• pH <7.3 (anion gap metabolic acidosis)
strategies to improve 2.5mg/3mL by neb, q20mins x 3
- Sx: polyuria, polydipsia, N/V, abdo pain, Kussmal
▪ Re-education - +/- (if moderate) Ipratropium bromide 3
breathing, fruity smelling breath, hypotension,
▪ Action plan for complications puffs by MDI with spacer or 250mcq by
headache, LOC, seizure
▪ Reminders for medication, neb q20mins x 3 - Complications: hypokalemia, hypophosphatemia,
incorporating into routine AKI, cerebral edema, shock
▪ Avoiding triggers - Ix:
▪ Assess barrier to medications, Mild-Moderate • CBC, Cr/lytes, urine + serum ketones,
attending appointments O2 >90%, FEV1/PEF >70% in mild or 40-70% ABG, plasma osmolality, troponin
- Inquire about pain at regular intervals in moderate, accessory muscle use + abn • ECG, consider CXR, urine/blood cultures,
- Inquire about psychological impact at regular intervals vitals in moderate amylase/lipase to look for 2⁰ cause
o Impact on functioning including work, school, - Salbutamol 4-8 puffs by MDI with spacer • Always do urinalysis in children with abdo
and social relationships or 2.5-5mg by neb, q20mins x 3 pain NYD to r/o DKA **
Management
o Impact on mood, consider PHQ-2 - +/- (if moderate) Ipratropium bromide 3
• Find precipitant: 7Is (infection, insulin missed,
o Assess suicide risk puffs by MDI with spacer or 250mcq by
iatrogenic, infarction, intoxication, initial
o Assess for substance abuse as inappropriate neb q20mins x 3 diagnosis, incision)
coping mechanism - Good response • Rehydrate: NS 1-2L/h then 500mL/h x4h, then
o D/c home w/ SABA q4h PRN, RTC 250mL/h x 4h
Acute Arthritis
instruction & f/u • When euvolemic: check serum Na, if
Rheumatoid Arthritis Flare o Adjust home controller med low/normal switch to 1/2 NS, if high
- NSAIDs, steroids o Oral pred 50mg PO daily x 5d continue NS
- Few-joints: consider intra-articular glucocorticoids - Poor/worsening response: • When glucose <11.1, switch to 1/2D5W to
- Multiple-joints: oral steroids with taper or single dose o Admission, SABA + ipratropium maintain glucose of 12-14
IM methylprednisolone q20mins, immediate PO pred • Potassium → insulin:
o Consider ‘severe’ management • K< 3.3, no insulin, add KCl
Osteoarthritis Flare • K 3.3-5.3 and urinating, insulin
Severe 0.1u/kg/h & KCl
- NSAIDs/cox-2 inhibitors, acetaminophen - Salbutamol 8 puffs by MDI with spacer or • K >5.3, insulin as above, no KCl
- Topicals: capsaicin, NSAIDs 2.5-5mg by neb, q20mins x 3 •
- Intra-articular steroids - Ipratropium bromide 3 puffs by MDI with Hyperosmolar Hyperglycemia State
- Nonpharmacological: spacer or 250mcq by neb q20mins x 3 • Dx: glucose >33, pH >7.3, minimal/no ketones
o OT/OT • Sx: dehydration, N/V, abdo pain, Kussmaul
- Supplemental oxygen to maintain SaO2
o Massage breathing, LOC/coma, weakness, vision change,
- Prednisone 50mg PO or complications: vasc occlusion, rhabdomyolysis,
o Ice/rest, activity modification +/- supportive methylprednisolone 1mg/kg IV cerebral edema
brace for comfort - Consider nebulized albuterol • Ix & Rx: as for DKA
continuously, consider magnesium IV
Chronic Pain: Pain Assessment
Management - Hx of pain condition, characterization & evolution
1. Optimize non-pharmacological therapy - Attempted therapies to date & impact (pharm, non-
• Physical activity, aerobic exercise, strengthening exercises, core stabilizing exercise, pharm, substance use)
Tai Chi, yoga, therapeutic aquatic exercise - Patient's experience: FIFE
• Psychological therapies: CBT, mindfulness based interventions, acceptance and - Co-morbid disorders inc mood disorders, addiction history
commitment therapy, respondent behavioural therapies - Relevant physical examination
• Physical therapies: physiotherapy, massage therapy, TENS
Opioid Conversion
2. Optimize non-opioids pharmacotherapy
• Acetaminophen, NSAIDs
• Anticonvulsants: carbamazepine, gabapentin, pregabalin
• Antidepressants: amitriptyline, duloxetine, fluoxetine
• Topical: NSAIDs, rubifacients
3. Treat co-morbid mental illness & substance use disorder
• Active psychiatric disorders should be stabilized before trial of opioids
• Report more severe pain
• Opioids not recommended for patients with current or past substance use disorder
4. Trial of opioids
• Counsel on risks & benefits
• Consider advising naloxone kit
• Start at lowest available dose, oral preparations preferred
• Should be provided by one physician only
• Regular maintenance & monitoring

• Switching: if uncontrolled pain, intolerable side effects, switching route of

administration
• Method 1: decrease total daily dose of current opioid by 25-50% and convert to
new opioid equivalent
• Method 2: cross taper, decrease total daily dose of current opioids by 10-25% per
week by titrating up total daily dose of new opioids by 10-20% with a goal of Pain Ladder
switching over 3-4 weeks

• Tapering:
• When to taper: trial to determine if original pain condition resolved , safety risk
(overdose, evidence of diversion, opioids use disorder), impaired functioning,
adverse effects not tolerated, non-adherence, not effective, using >90mg
morphine equivalents/day chronic non-cancer pain)
• Method: gradual (2w-4m), caution in pregnancy (premature labour/spont
abortion)/CAD/severe or unstable psychiatric disorder
• Gradually decrease dose by 5-10% of morphine equivalent every 2-4
weeks with frequent follow-up
• Consider controlled release options on fixed dosing schedule

Mechanism (Hormonal)
- Estrogen: suppression of ovulation
- Progesterone: endometrial thinning, thickening
of cervical mucous, impairs tubal motility
Contraindications (Combined Hormonal)
- Absolute: <4w postpartum (breastfeeding), <21d
postpartum (not breastfeeding), smoker >15/d +
>35y, vascular disease, HTN >160/100, acute VTE
or Hx VTE not on antiocoag, thrombophilia, CAD,
CVA, SLE + unknown APA, migraine + aura,
current breast ca, cirrhosis/hepatocellular ca
- Relative: 2-6w postpartum + other VTE risk, Hx
VTE, immobility, smoker <15/day + >35y,
multiple risk factors of CVD, controlled HTN o
<160/100, Hx breast ca, symptomatic gallbladder
disease, acute viral hep, DM >20y or w/
complications, ART, anticonvulsants
Contraindications (Progesterone)
- Absolute: pregnant, unexplained vaginal
bleeding, current breast cancer
- Relative: cirrhosis, active viral
hepatitis/adenoma, breast cancer within 5y
Benefits + Side Effects
Combined
Benefits: cycle regulation, ↓ flow/ dysmenorrhea/pelvic
pain, ↑ BMD, ↓ perimenopausal Sx,
↓PMS/acne/hirsutism, ↓endometrial/ovarian/
colorectal cancer, ↓ fibroids + ovarian cysts, ↓ benign
breast disease
Side Effects: 2-3x VTE risk, irregular bleeding, nausea,
?weight ↑, ?mood, breast tenderness, h/a
Progesterone
Benefits: amenorrhea, ↓ endometrial ca, ↓PMS/pelvic
pain, ↓PID, ↓seizure
Side Effects: menstrual disturbance, weight ↑, mood
*Missed Pills: COCP w1: B/U 7d, w2 or 3: < 3d missed
omit placebo and if 3+d requires B/U 7d + consider EPC
POP if >3h late, B/u x 48h then remainder of pack N
CONTRACEPTION
Hormonal Contraception
- OCP
- Start within 5d LMP or immediately with
7d back-up contraception
- Reversible + effective, *missed pills
- 21 vs 28 days packs, continuous 84d (4
packs) to reduce PMS
- POP
- Start within 5d LMP or immediately with
7d back-up contraception
- No pill free days (continuous)
- Irregular bleeding: treat with NSAIDs,
supplement estrogen/ switch to COCP
- Combined Patch (Evra)
- 1 patch/week x 3 week then 1 week off
- Keep in fridge, do not apply to breasts
- Less effective if weight ≥90kg
- Combined Ring (Nuvaring)
- Ring x 3 weeks, 1 week off, keep in fridge
- SE: FB sensation, expulsion, interrupts
intercourse
- Levonogestrel IUD
- Effective x 5y, ↓dysmenorrhea/flow,
endometrial ca
- Contraindications: (absolute) pregnancy,
PID/recent STI post-septic abortion,
distorted uterine cavity, unexplained
vaginal bleeding, progesterone receptor
positive breast cancer
- Risks: perforation, PID, expulsion, ectopic
- Insert at any time, if >7d from LMP use
back-up x 7d
- F/u 4-12w, routine U/s not required
- Progesterone injection (depo-provera)
- Start within 5d of LMP or immediately
with 7d back-up contraception
- IM injection q12 weeks
- supplement vit D + calcium as ↓BMD
Non-Hormonal Contraception
- Male condom
- Female condom (up to 8h prior)
- Sponge:
- ↑ risk abrasions, lasts 24h, leave in
at least 6h post-intercourse
- Cervical cap
- Can place up to 2h prior, use w/
spermicide, leave in 6h post-
intercourse, up to 48h, reusable
- Diaphragm
- Can place up to 2h prior, use with
spermicide, leave in 6h post-
intercourse, up to 24h
- Spermicides
- Insert 15mins prior w/ another
method
- Natural methods
- Fertility awareness, lactational
amenorrhea, withdrawal,
abstinence
Copper IUD
- Contraindications: pregnancy, PID,
STI , post-septic abortion, distorted
cavity, unexplained vaginal
bleeding, cervical/endometrial
cancer
- Lasts 5y, insert at any time, back-up
contraception not required
- Surgical
- Vasectomy, tubal ligation/occlusion
Emergency (Post-Coital) Contraception
F/u pregnancy test in 21d if no menstruation
1. Copper IUD: 7d, effective long-term
2. Ulipristal acetate: 5d, ↓ efficacy if ↑BMI,
start long-term in 5d, 30mg single dose
3. Levonorgestrel (plan B): no Rx, 3-5d, 750mg
q12h x 2 doses or single dose, start long-
term option in 1d, ↓ efficacy if ↑BMI
4. Yuzpe: 3d, 2 x 100mcg E/500mcg P, repeat
in 12h, least effective, easy access

Chronic Obstructive Pulmonary Disease: progressive &
irreversible condition characterized by chronic
obstruction to airflow with periodic exacerbations
- Subtypes: chronic bronchitis & emphysema
Risk Factors:
- Smoking**
- Environmental: air pollution, occupational exposures e.g.
wood smoke/cooking fuels
- A1 antitrypsin deficiency
- Demographics: age, family Hx, Hx childhood resp
infections, low SES
Clinical Features:
- Bronchitis: chronic productive cough, purulent sputum,
hemoptysis, mild dyspnea initially, peripheral edema
from RV failure
- Emphysema: dyspnea +/- worse on exertion, minimal
cough, tachypnea, ↓ exercise tolerance, cachectic +
hyperinflation/barrel chest, ↓ breath sounds
Dyspnea Scale:
- 0: only on strenuous exercise
- 1: SOB with exertion on the level or slight hill
- 2: walks slow than others on level due to SOB
- 3: stops for breath after ~100m or a few minutes on level
- 4: too breathless to leave house, dressing/undressing
Diagnosis:
- Progressive + persistent resp sx, worse with
exercise, chronic cough, & ↑ sputum
o AND one of:
▪ Exposure to cigarette smoking
▪ Hx environmental/occupational
exposure gas/dust/fumes
▪ Frequent respiratory infections
- Confirm with spirometry, FEV1/FVC <LLN/0.7
- GOLD Severity: based on FEV1
o Mild: ≥80% predicted
o Moderate: 50-80% predicted
o Severe: 30-50% predicted
o Very severe: ≤30% predicted
- due to rupture of bullae
COPD
Investigations:
- PFTs: ↓ FEV1, ↓FEV1/FVC, ↑TLC in emphysema
- CXR: enlarged heart w/ cor pulmonale, ↑ bronchovascular
markings, ↑ AP diameter in emphysema, flat
hemidiaphragm, bullae
Nonpharmacological Management:
- Smoking cessation: counselling, nicotine replacement,
bupropion, varenicline
- Exercise + dietary changes to maintain normal BMI
- Pulmonary rehabilitation
- Education: inhaler technique, breathing techniques, early
recognition of exacerbations with written action plan
- Vaccination: influenza annually, pneumococcal (conjugate-
Prevnar 13 & polysaccharide- pneumovax 23)
- Home oxygen: indicated if resting SpO2 <88%, PaO2
<55mmHg or <60mmHg w/ cor pulmonale or polycythemia
- Advanced care planning
Pharmacological Management: (Chronic)
1. Short acting bronchodilator PRN (Ventolin)
2. LAMA or LABA (Spiriva/Incruse or Serevent)
3. LAMA & LABA combination (Anoro Ellipta/Inspiolto)
4. LAMA + LABA/ICS (Spiriva + Advair, or Trelegy Ellipta)
5. Oral therapies (e.g. romflumilast- daxas) +/- daily
macrolide, NAC
Acute Exacerbations: sustained (>24h) worsening
dyspnea, cough, or sputum production
Etiology
- Viral URTI, bacterial resp infection
- Air pollution
- Consider CHF, PE, MI
Management:
1. ABCs, consider assisted ventilation if ↓ LOC
or poor ABGs
2. O2, target 88-92% for CO2 retainers
3. Bronchodilators
- Salbutamol 2.5-5mg in 3mL NS via neb
q15 mins x 3 PRN or 4-8 puffs via MDI w/
spacer q 15 mins x 3 PRN
- Atrovent 0.25-0.5mg in 3mL NS via neb q
15 mins x 3 PRN or 4-8 puffs via MDI w/
spacer q15mins x 3 PRN
4. Corticosteroids
- Prednisone 50mg PO x 5d or IV
methylprednisone 125mg BID-QID
5. Antibiotics
- Required if 2+ of: increased dyspnea,
increased sputum volume, increased
sputum purulence
- Duration 5-7d out-pt, 7-10d in-pt,
alternative class if Abx within 3 months
- Simple: FEV1 >50%, ≤4/y, no significant
cardiac disease → amoxicillin 500mg TID
(others: doxy, septra, 2nd gen macrolide)
- Complicated: FEV1 <50%, significant
cardiac disease, 4+/y, supplemental O2,
Abx within 3 months → clavulin 875mg
BID (others- levo, moxi)
- Pseudomonas risk: FEV1 <30%, multiple
RFs e.g. frequent exacerbations, chronic
PO steroids, FEV1 <50% at baseline,
constant purulent sputum,
bronchiectasis → cipro 500mg BID
Complications: polycythemia 2⁰ to hypoxemia,
chronic hypoxemia, pulmonary HTN from
vasoconstriction, cor pulmonale, pneumothorax
Assessment:
Differential
- Acute life-threatening
o Pneumonia: fever, productive cough,
dyspnea, pleuritic CP
o Severe exacerbation asthma/COPD
o PE: hemoptysis, dyspnea, pleuritic CP, sx DVT
o Pneumothorax: acute onset dyspnea, CP, +/-
Hx of trauma
o CHF: orthopnea, PND, elevated JVD, edema
- Acute non-life-threatening:
o Infection (URTI, bronchitis, sinusitis, croup,
pneumonia)
o Exacerbation of pre-existing condition
(asthma, COPD, post-nasal drip/UACS)
- Subacute/chronic cough:
o Most common(90%): UACS, GERD, asthma
o Others:
▪ COPD
▪ Pertussis, TB, bronchiectasis
▪ Lung cancer
▪ Interstitial lung disease
▪ Paeds: CF, FB
▪ CHF
▪ Medication induced
▪ Chronic allergic rhinitis, post-viral
History
- Duration (acute <3w, subacute 3-8w, chronic >8w),
timing, frequency, time of day
- Characteristics of cough- productive vs non-
productive
- Sputum characteristics
- Hemoptysis
- Associated dyspnea, wheeze, URTI sx, fever
- Constitutional sx: weight loss, fatigue, night sweats,
chills
- Smoking
- Sick contacts
- Recent travel
- Meds: ACEI, B-blocker
- Occupation, environmental exposures, pets
COUGH
Approach to Subacute/Chronic Cough:
- Initial assessment: history + examination
- CXR: treat underlying cause
- If normal:
1. Smoking cessation, stop ACE inhibitor if present
2. Empirically treat UACS/post-nasal drip w/ nasal corticosteroids x 2-3 w
3. If no improvement → spirometry/PFTs or trial empiric treatment of asthma x 2-3w
4. If no improvement → empirically treat GERD with lifestyle management, PPI- consider endoscopy
- Consider further investigations as required: CT, echocardiogram, endoscopy +/- referral
Condition Presentation Investigations & Management
Asthma Cough, dyspnea, wheeze, atopic Spirometry/PFTs demonstrating
Hx (allergic rhinitis, eczema) reversible airway obstruction
Triggers: cold, allergens, perfume, Response to inhalers (Ventolin
emotion, pet dander PRN initially, Flovent for
Nighttime or early am sx exacerbations or if poor control-
see asthma handout)
Upper airway cough syndrome Sensation of secretion at back of Treat empiricially with nasal saline
(previously post-nasal drip) throat, irritation + cough & rinse +/- nasal corticosteroids +/-
through clearing oral antihistamines
GERD Heartburn, acid regurgitation Lifestyle changes (decrease
Alarm features (VBAD- requires caffeine, alcohol, smoking,
endoscopy- vomiting, bleeding, NSAIDs, spicy foods, acidic foods,
anemia/abdo mass/anorexia or large meals) avoid eating 2h
weight loss, dysphagia or before bed, consider elevating
odynophagia) head of bed
H2 blocker PRN→ scheduled
PPI trial x 8w
COPD Smoking Hx or 2nd hand smoke Spirometry/PFTs- demonstrates
exposure, increase irreversible airway obstruction
cough/dyspnea/ sputum Smoking cessation- see COPD
production handout
Post-viral Non-productive/dry cough Clinical diagnosis, consider CXR if
following Hx of UTI abnormal findings on auscultation
Medication induced e.g. ACE Non-productive/dry cough after Diagnosis of exclusion, resolved in
inhibitor, beta-blocker initiation or dose increase of med, 4w after stopping medications
can occur after longterm use of
medication
Approach to Counselling:
- Allow adequate time for assessment
- Evaluate your own skills & abilities
o Recognize you own limits
o Recognize when you are approaching
boundaries or limits & re-evaluate your role
o Recognize when own beliefs may interfere
Transference: unconscious redirection/projection of the
feelings an individual has about a primary relationship
towards a counsellor (e.g. transferring feelings about one’s
own patents towards counsellor)
Counter-transference: unconscious redirection of the feeling
an individual has about a primary relationship towards a
patient, induced by patient’s behaviour (e.g. transferring
feelings about own’s own children towards a patient)
Indications
- Treatment of psychiatric disorder, with goal of reducing
symptoms and improving functioning
- Changing maladaptive thoughts/behaviours/relationships
- Providing support in crisis, difficult period, or in chronic
situation that impairs functioning
- Enhancing a patient’s capacity to making behavioural
changes or adherence to medical treatment
- Helping ↓ relational problems
- ↑ family cooperation with treatment
Types of Counselling:
- Psychotherapies
o Cognitive behavioural therapy
o Psychodynamic therapy
o Interpersonal therapy
o Motivational interviewing & behavioural
counselling
o Dialectical behavioural therapy
- Format:
o Individual
o Couple
o Family
o Group
COUNSELLING
Counselling Strategies:
Five A's Ask: ask about behavioural health risks, open to discussion
(ask, assess, Assess: patient readiness to make behavioural change
advise, assist, Advise: give clear, specific, and personalized change advice, including information about
arrange) personal harms and benefits
Assist: aid the patient in achieving agreed upon goals by acquiring the skills/ support +/-
pharmacotherapy
Arrange: schedule regular follow up, adjust plan as needed
FRAMES Feedback: give feedback on behavioural health risks
Responsibility: emphasize that the patient is responsible for making the decision to
change health behaviours
Advice to change: straightforward advice on making change
Menu of strategies: give many options to choose from, allowing the patient to be involved
in decision making
Empathetic: be empathetic, respectful, non-judgemental
Self-efficacy: encourage patient to make a change for themselves
Stages of Change Pre-contemplation
Model/Motivation Contemplation
al Interviewing Preparation
Action
Maintenance
+/- Relapse
Problem Solving Problem definition: obtain factual information to clarify the nature of the problem e.g.
Therapy What part of the situation is most distressing?
Generating alternative solutions: encourage the patient to brainstorm solution e.g. What
options have you considered?
Decision making: evaluate possible solution, predict possible consequences e.g. Which of
the options that we've talked about seem better to you?
Solution verification and implementation: restate the plan, review any obstacles e.g. 'At
this point your plan is…' Is there anything that could get in your way?
BATHE Background: What's going on in your life?
Affect: How do you feel about (a situation that has happened to the patient)? Many
people in this situation feel…
Troubles: What bothers you the most about the situation?
Handling: How are you coping with the situation?
Empathy: That sounds frightening/sad/stressful/frustrating etc.
Office Medical & Nonmedical Crises
Preparation
- Prepare your practice environment for
possible crisis
- Include colleagues in the planning for both
medical and nonmedical crises
o Assign roles & delegate
- Establish office policies for managing
agitated/dangerous patients
- Prepare for common emergencies in the
office (e.g. asthma, anaphylaxis, syncope,
seizures, cardiac arrest)
- Purchase equipment/meds for anticipated
emergencies (e.g. universal antidotes)
o Assess & anticipate environment and
equipment needs
- Familiarize all staff with equipment/protocols
General Management for Office Emergencies
- Ask for help! (call 911, help button, call code)
- ABCs, vitals
- Communicate assessment and thought
process to team
- Closed-loop communication when giving
orders
Meds
• ASA in 81mg doses
• Normal saline 1-2L or Ringer's lactate
• 1:1000 epinephrine and syringes, epipen
• Nitroglycerin spray
• 25% dextrose
• Salbutamol metered dose inhaler
• Aerochamber and pediatric mask
• Oxygen tank
• Acetaminophen
• IV diazepam or lorazepam
• Diphenhydramine or cetirizine
• Naloxone
• Morphine
• Ibuprofen
• Prednisone
CRISIS
Office Equipment & Environment
• Universal precautions
• Bag valve mask with various sizes
• Nonrebreather O2 mask
• Pulse oximeter
• Nasal or oral airway +/- intubation kit
• Automatic external defibrillator
• Blood pressure cuff, pediatrics + bariatric sizes
• Glucometer & test strips
• IV access & tubing
• Nasogastric tube
• Suction bulb
• Cord clamp and scissors
• Soap
• Isopropyl alcohol
• Dressing materials- gauze, tape, etc.
• Room set-up with doctor nearest to door
• Panic button under desk
Psychoactive Medications for Mental Health Crises
• Provide rx for pain, sleep, psychiatric illness
• Goals of medication is to:
o Decreased symptoms of re-experiencing,
avoidance/numbness or hyper-arousal
o Help with comorbid illness
o ↓Suicidal behaviour/impulses/ aggression
• Antipsychotic: for psychosis/mood stabilizing
effect/agitation
o 1st generation: haloperidol 2-10mg IV/IM for
acute sx q15m, PO q6h, max 30mg/day
o 2nd generation: olanzapine 5-10mg IM/PO q2-
4h PRN, max 20mg/day
o SSRI- risk suicidal ideation within first 2 weeks
o Benzodiazepines acute for agitation
o TCA- risk overdose potential
o Beta-blockers: may reduce symptoms of PTSD
• Follow-up: reassess status/safety, positive efforts
o Higher level of care may be indicated if failure
to improve with current treatment
Mental Health Crises
Approach
• Take adequate time to assess
• Assess sources of support (family, friends)
• Assess for coping strategies
o Including unhealthy coping mechanisms:
alcohol, recreational drugs, gambling,
eating, violence
• Offer appropriate community supports
• Ask about others that may need help e.g. family
members, children
• Negotiate a follow up plan including safety plan
Things to Avoid
• Ensure not to cross boundaries when patients
are in crisis
• Do not exchange gifts, services, money
• Do not schedule appointments outside of
regular office hours, especially unchaperoned
• Do not provide excessive self-disclosure as can
strain rapport
• Physical contact can be misinterpreted and blur
relationship boundaries
Assess Suicidality
• SADPERSONS
• Inpatient management if safety concerns, Form
1+ 42 vs Form 7 to be brought in by police
• Thoughts of death, intention, plan & actions,
lethality of methods
• Availability of means e.g. firearms, access to
prescription medications
• Previous attempts, nature & outcome
• Family history of suicide
• Homicidality
• Legally mandated duty to warn if there is a clear
risk to identifiable person(s) that could cause
serious and imminent harm
• r/o abuse, substance use
Etiology:
- Viral laryngotracheitis, usually parainfluenza type
1 other resp viruses including RSV/rhinoviruses,
secondary bacterial infection
- Local spread of viruses from nasal/pharyngeal
mucosa, narrowing of subglottic airway
Risk Factors:
- Congenital anatomic narrowing of airway
- Hyperactive airways
- Acquired airway narrowing e.g. post-intubation
Clinical Presentation:
- Typically 6 months- 3 years
- URTI Sx (nasal d/c, congestion) → fever,
hoarseness, barking cough, stridor (biphasic
stridor at rest is sign of significant upper airway
obstruction)
- Increased WOB (intercostal retraction,
diminished breath sounds, tracheal tug)
- O/E: assess upper airway, lungs, TMs, rash
- Severity assessment (Westley croup score)
o LOC
o Cyanosis
o Stridor
o Air entry
o Retractions
- Signs of airway obstruction: tripod/sniffing
position, grunting, flaring, suprasternal/
supraclavicular retraction, cyanosis, unable to
speak/cough
Investigations:
- Clinical diagnosis
- *Do not do labs/CXR if Hx/exam compatible
o CXR: consider to r/o FB or epiglottitis
(thumb sign), croup XR shows subglottic
narrowing ‘steeple sign’
CROUP
Treatment
- Antipyretics/analgesia PRN
- Steroids: dexamethasone 0.6mg/kg PO, max 16mg PO
Based on Severity:
Mild (Westley <2)
- Single dose PO dex 0.6mg/kg (max 16mg) or PO pred
1mg/kg
- D/c if tolerating fluids, caregiver education (signs of resp
distress, when to see medical assistance, f/u in 24h)
Moderate (Westley 3-7)
- Minimize discomfort, humidified air or O2
- Single dose dex 0.6mg/kg PO or IV/IM if needed
- Antipyretics, PO fluids or IV if unable to tolerate
- Racemic epinephrine via nebulizer, observe 3-4h
o If worsening, repeat nebulized epinephrine &
admit to pediatric ICU
Severe (Westley 8-11)
- Refer to ER department, minimize discomfort,
humidified air or O2
- Single dose dex 0.6mg/kg PO, or IV/IM if needed
- Racemic epinephrine via nebulizer, assess response
o If improving, observe 3-4h, antipyretics, fluids,
repeat nebulized epi & admit to peds ward
o If worse, repeat nebulized epi & admit to
pediatric ICU
Signs of Impending Respiratory Failure (Westley ≥12)
- Racemic epinephrine via nebulizer
- Single dose dexamethasone 0.6mg/kg IV/IM
- Intubation if warranted in controlled setting with ENT or
anesthetics if possible
o ET tube 0.5-1mm smaller than typically used
- Rapid transfer to appropriate setting for airway
management, admit to pediatric ICU
Differential Diagnoses (Stridor)
Bacterial tracheitis
- Mild/mod illness x 2-7 days then abruptly
worse, croup complication
- High fever, toxic, stridor/cough, poor
response to epi nebs
- Ix: ragged edge/membrane spanning trachea
on xray
- Rx: support resp + O2, IV Abx + intubation,
ICU admission
Epiglottitis
- Absence of barky cough, high fever, toxic,
anxious, hoarse/muffled voice, ‘3Ds’
(dysphonia, dysphagia, drooling)
- Rx: airway management, IV Abx + peds ICU
admission
Retropharyngeal/peritonsillar abscess
- High fever, neck pain, sore throat, dysphagia,
‘hot potato voice’
- Torticollis, drooling, trismus, respiratory
distress, stridor
- Rx: intubation + surgical drainage if airway
obstruction, ENT + IV Abx, if stable- contrast
CT neck then IV Abx vs abscess drainage
Foreign Body Inhalation
- Croupy cough, choking episode, wheezing,
biphasic stridor, dyspnea, ↓ air entry
- Rx: airway management if obstructed, x-
ray/CT, bronchoscopy for removal
Anaphylaxis
- Rapid onset dyspnea, wheeze, stridor,
possible cutaneous signs
- Rx: airway management + O2, remove
exposure, epinephrine 0.01mg/kg max 0.5mg
in large child- repeat q5-15min x 3 as required
o Nebulized albuterol, antihistamine,
glucocorticoids + monitors
o Consider IV fluids + pressors to
maintain BP
Clinical Presentation: DVT
- Unilateral leg edema, erythema, warmth,
tenderness
- Difference in calf diameter >3cm (measured 10cm
below tibial tuberosity)
- Dilated superficial veins
- Pain & tenderness along the course of deep veins
- Homan’s sign: calf pain with passive dorsiflexion
Clinical Presentation: PE
- Sudden onset dyspnea, pleuritic chest pain
- Presyncope/syncope, ↑HR, ↑RR, ↓O2, ↓BP
- Signs of DVT (above)
- ECG: sinus tachycardia, RV strain S1Q3T3, RBBB)
Risk Factors:
- Previous Hx DVT/PE
- Prolonged immobility (bedridden, post-op, >6h
airplane travel)
- Pregnancy or post-partum
- Malignancy
- Advanced age (>65)
- Smoking
- Obesity
- Exogenous estrogen (OCP, HRT)
- Thrombophilias: factor V leiden, prothrombin
mutation, protein C/S deficiency, antithrombin
deficiency, APLA syndrome
Diagnosis:
- Pre-test probability, validated tool e.g. Wells
- D-dimer >90% sensitive, but not specific
o Elevated in inflammatory diseases,
malignancy, pregnancy, surgery,
hospitalization, trauma, advanced age
- Duplex scanning: combination of venous
compression US & doppler flow US, if
noncompressible → highly suggestive of DVT
o If negative and high probability/elevated
D-dimer, repeat US in 1 week to exclude
distal DVT that has extended proximally
DVT Prophylaxis: all hospitalized patients require
risk assessment
DEEP VENOUS - Low risk: minor surgery, medical mobile pt
- Mod risk: gen/gyne/uro surgery, bedrest
THROMBOSIS - High risk: hip/knee/spinal surgery, cancer
resection/other major surgery
Post-Phlebitic Syndrome: symptomatic chronic venous insufficiency after DVT (pain, edema, dilation +
pigmentation, ulcers) → Rx: compression stockings 30-40mmHg after DVT treatment x 2m, exercise, skin care
Clinical Decision Tools
Wells Score: DVT → 2+: DVT likely
- Paralysis, paresis or recent orthopedic casting of lower extremity (1)
- Bedridden >3d recently or major surgery within past 12 weeks (1)
- Localized tenderness of the deep veins (1)
- Swelling of entire leg (1)
- Calf swelling 3cm greater than other leg (1)
- Pitting edema greater in symptomatic leg (1)
- Non-varicose collateral superficial veins (1)
- Active cancer or cancer treated within 6 months (1)
- Previously documented DVT (1)
- Alternative diagnosis at least as likely as DVT (Baker’s cyst, cellulitis, muscle damage, superficial vein
thrombosis, post-thrombotic syndrome, inguinal lymphadenopathy, extrinsic venous compression) (-2)
Wells Score: PE → 4.5+: PE likely, CTPA or V/Q scan(renal insufficiency, contrast allergy, pregnancy), cardiac
echo if unavailable (R heart overload, RV/pulmonary artery thrombus)
- Clinical signs & symptoms of DVT (3)
- Previous DVT or PE (1.5)
- Immobilization for >3days or surgery within 4 weeks (1.5)
- Heart rate >100bpm (1.5)
- Hemoptysis (1)
- Malignancy (1)
- No alternative diagnosis more likely than PE (3)
PERC Score: rules out PE if low pre-test probability & all criteria met
- Age <50y
- Initial HR <100bpm
- Initial SpO2 >94% on room air
- No unilateral leg swelling
- No hemoptysis
- No surgery or trauma ≤4 weeks
- No Hx of VTE
- No estrogen use
DVT Management:
- Start anticoagulation before diagnosis confirmed if
high pre-test probability unless compression US
rapidly available (<4h)
- Outpatient management preferred
- Initial treatment should have immediate outpatient
effect (LMWH, DOAC)
- If immediate anticoagulation not possible (high risk
of bleeding/active bleeding)- consult heme or IR to
consider IVC filter
- Most will not extend proximally, anticoagulation
indicated if severe sx or RF for extension (thrombus
>5cm, involvement of multiple deep veins, close to
popliteal vein, previous VTE, inpatient, active cancer,
positive D-dimer)
Anticoagulation
- Options for initial anticoagulation
o DOAC monotherapy (apixaban and rivaroxaban)
o Unfractionated heparin or LMWH followed by a
DOAC (dabigatran and edoxaban)
o Unfractionated heparin or LMWH bridging to warfarin
o LMWH monotherapy
- DOAC more convenient & lower bleeding risk
o Should not be used in pregnant or breastfeeding women or with severe renal dysfunction
o Apixaban 10mg PO BID x7d then 5mg PO BID for duration of treatment
o Rivaroxaban 15mg PO BID x 21d then 20mg PO daily for duration of treatment
o Dabigatran 150mg PO BID for duration of treatment (bridge with LMWH 5-10d), reduce to
110mg PO BID if >80y or RFs for bleeding
o Edoxaban 60mg PO daily for duration of treatment (bridge with LMWH 5-10d)

PE Management:
- Start anticoagulation before diagnosis confirmed if
high pre-test probability, unless high bleeding risk
- Stratify risk using (PESI) Pulmonary Embolism
Severity Index to determine inpatient vs outpatient
management
- Initial treatment should have immediate outpatient
effect (LMWH, DOAC)
- If immediate anticoagulation not possible (high risk
bleeding/active bleeding)- consult heme
Massive PE: thrombolysis
- Anatomically moderate to large PE + persistent
hypotension (SBP <90mmHg)
- tPA 100mg over 2 hours
- IV UFH should be used initially after thrombolytic
therapy, followed by transition to longer term agent
- LMWH: 1st line in patients with active cancer & in pregnancy, avoid in severe renal insufficiency
o Dalteparin 200U/kg SC daily or 100U/kg SC BID
o Enoxaparin 1.5mg/kg SC daily or 1mg/kg SC BID
- Unfractionated heparin
o Initial bolus 800U/kg IV then infusion of 20U/kg/h IV
o Dosing guided by standardized normograms to achieve target aPTT
o Only indicated if: CrCl <30, very high risk of bleeding that may need rapid reversal of
anticoagulation, patients who receive thrombolytic therapy
- Warfarin
o Initial 5mg PO daily, bridge with LMWH for at least 5d until INR reaches 2
o Frequent monitoring required until stable INR reached, start with lower dose in elderly
o Advantages: rapid reversal, less expensive, safe in renal insufficiency
o Disadvantages: regular monitoring, teratogenic
IVC Filter: indicated in patients within 4w acute proximal DVT or PE with contraindications to anticoag

Duration of Therapy
- VTE provoked by transient RF & resolved: 3 months
o Major: surgery with general anesthestic ≥30 mins, admission & bedridden for at least 3d
o Minor: surgery w/ general anesthetic <30mins, admission for acute illness <3d, confined to bed 3d outside hospital, hormonal therapy,
pregnancy/puerperium, leg injury associated with ↓ mobility at least 3d
- Unprovoked VTE, strong persistent RF (e.g. active cancer, thrombophilia), recurrent: indefinite if bleeding risk acceptable
Clinical Presentation Fluid Replacement
Volume depletion
DEHYDRATION
Emergent rehydration
- Fatigue, thirst, muscle cramps, postural dizziness, - Isotonic saline IV: 0.5-1 L bolus
↓ urine output, ischemia (mesenteric, coronary,
o Paeds: 20mL/kg IV bolus
cerebral) Severity of Dehydration o Neonate: 10mL/kg IV bolus
Electrolyte abnormalities Mild Moderate Severe
- Muscle weakness (↓/↑K), polyuria/polydipsia Secondary rehydration
HR N ↑ ↑↑, weak
(↓K, ↑glucose), tachypnea (↑H+), confusion, - Oral if possible: 100mL/kg over 4h if
sBP N N/↓ ↓, shock
lethargy, seizures (↓/↑Na, ↓glucose) U/O N/↓ ↓↓ Anuric moderate, 50mL/kg over 4h if mild
Symptoms related to etiology: vomiting, diarrhea, Weight loss 3-5% 6-10% 10-15% - IV if: cannot tolerate PO, caretaker can’t
polyuria, burns, dementia, delirium Thirst ↑ ↑↑ ↑↑↑ provide, persistent vomiting, severe
Pediatrics: ↓wet diapers, ↓tears, lethargy, weight ↓ Behaviour N Irritable Lethargic electrolytes disturbance
Mucosa N Dry Very dry Maintenance
Physical Exam
Tears Present ↓ Absent - Replace losses, input matches output
Vitals more reliable than exam- especially in elderly, Eyes N N/sunken Sunken
pediatrics, pregnant - Paeds: 4:2:1 rule (per hour)- 4mL/kg/h for 1st
Skin turgor N ↓ Tenting
- HR changes 1st, resting tachycardia Skin N Cool Cool, 10kg + 2mL/kg/h for next 10kg + 1mL/kg/1
- Postural vitals: 30/20/10 rule mottling for wt >20kg OR 100:50:20 rule (per 24h)
- Flat JVP Fontanelle Flat Reduced Sunken - Neonate: day 1 term 60mL/kg/day, day 1
Skin turgor, mucosa, eyes, CRT, fontanelle in infants CRT 2-3s >5s >8s preterm 80mL/kg/day, increase by
Etiology Choice of Fluid 20mL/kg/day to goal of 150mL/kg/day
1. ↓ Intake Osm Na Cl K Other Replace Losses
- Poor oral intake- acute illness, dysphagia, D5W 252 - - - Dextrose 5g/100mL - One large vom/diarrhea = 8mL/kg body wt
cognitive impairment, mobility issues 0.9% NaCl 308 154 154 - - - Deficit = pre illness wt – post illness body wt
- Breastfeeding difficulties in infants 0.45% 154 77 77 - -
- Eating disorders NaCl Monitoring
2. ↑ Losses Ringers 273 130 109 4 Lactate 28, Ca 2.7 - Urine output (0.5-1mL/kg/h), daily ins & outs
- GI: diarrhea, vomiting, bleeding, pancreatitis, lactate - HR (<100bpm)
cirrhosis w/ ascites Plasmalyte 294 140 98 5 Acetate 27, Mg 3, - BP
- Skin: fever, sweating, burns, stomatitis Gluconate 23
- Serum lactate
- Vascular: trauma, hemorrhage Burns - Labs: lytes (if >50% maintenance IV), VBG,
- Heart failure, tachypnea - Parkland Formula (initial 24h fluid) = 4mL/kg RL x %TBSA Cr/BUN, urine specific gravity & osmolality
- Urinary: hyperglycemia/DKA, diuretics, post- o Give ½ in 1st 8h & ½ in next 16h o Na: PO 2-5mEq/kg/day divided doses,
obstructive/ATN diuresis - Rule of 9s to estimate TBSA, palm approximates 1% TBSA not faster than 8-12mEq/L/24h
- SIADH/salt wasting nephropathy- DI, psychogenic
o K: PO 2-5mEq/day divided doses, dose
polydipsia, adrenal insufficiency
IV >0.5mEq/kg/dose (max 40mEq/h)
Risks of Dehydration in Pregnancy **cardiac monitoring
- ↓SVR, ↑ venous pooling o Mg: PO 10-20mg elemental/kg/dose
- ↑ physiological reserve therefore markers of BID-QID, IV 2.5-5mg element/kg/dose
dehydration are delayed o Ca: 50-150mg elemental/kg/day div QID
- Risks: T1/2- SA/oligohydramnios/low BW, T3- o Phos: PO 0.08-0.32mmol/kg/day, IV
premature labour, abruption, miscarriage 0.5-2mmol/kg/day divided doses
Definition: major neurocognitive disorder, decline in Delirium: reversible clinical syndrome 5 key features: disturbance
in attn & awareness, develops in short period and is change from
DEMENTIA
cognition involving one or more cognitive domains,
interferes with daily function & independence baseline, additional disturbance in cognition, not better explained
- Language, learning & memory, executive function, by pre-existing condition, evidence from Hx/exam/Ix caused by
Dementia vs Normal Aging medial condition/ substance use or withdrawal/ med side effect
complex attention, perceptual-motor function, social
cognition
Mild: ADLs & IADLs, MMSE 20-25, MoCA 18-15
Moderate: some IADLs, no ADLs, MMSE 10-20, MoCA 10-17
Severe: no IADLs and no ADLs, MMSE <10, MoCA <10

Clinical Features:
- Spouse or caregiver concern, gradually progressive Sx Mild Cognitive Impairment: intermediate between normal aging & dementia, normal ADLs/IADLS
- Behaviour changes, change from baseline
- Forgetfulness, difficulty retaining information Types of Dementia/Major Neurocognitive Disorder
- Difficult with complex tasks e.g. finances Condition Clinical Features
Alzheimer’s Disease Memory impairment + impaired executive function, gradually progressive, late
- Impaired reasoning
stage behavioural problems/psychologic/apraxia/sleep disturbance
- Impaired spatial ability/orientation, e.g. getting lost Vascular Impaired executive function/processing speed, stepwise deterioration
- Language e.g. word finding Lewy body dementia Gradual progressive decline + concomitant Parkinsonism, REM sleep disorder,
Parkinson’s Disease visual hallucinations, fluctuating LOC – vs PD dementia Sx start ~5y after onset
AD 5As- anomia, apraxia, amnesia, aphasia, apathy
Dementia of Parkinsonism
History: Frontotemporal Prominent changes in social behaviour, personality, or aphasia + degeneration
- PMH including meds (analgesia, anticholinergics, dementia of frontal/ temporal lobes, executive function preserved early
psychotropic, sedatives), vision, hearing, pain, Parkinsonian syndromes (PSP, MSA, CBD)- see Parkinsonism one pager
NPH: (wet, wild, wacky) urinary incontinence, cognitive decline, ataxic gait
infections Sx, CV risk, depression screen)
CJD: rapidly progressive dementia from prior disease, behavioural + sleep abnormalities, myoclonus, cerebellar Sx
- Functional assessment
Wernicke-Korsakoff Syndrome: ↓ thiamine (CAN) confusion/confabulation, ataxia, nystagmus/ophthalmoplegia
o ADLs: bathing, dressing, ambulating, toileting,
transferring, eating Dementia Mimics
o IADLs: transportation, shopping, housework, Condition Symptoms Examples
finances, cooking, taking meds, Cerebrovascular Stepwise sudden deterioration, episodic Vascular, multi-infarct dementia,
communication, finances disease confusion, aphasia, slurred speech, focal neuro subcortical dementia
Delirium Acute cognitive impairment +/-LOC & clouded Hypo/hyperglycemia/ natremia,
Examination: focal neuro Sx (prior stroke), Parkinsonism sensorium, difficulty with attention, fluctuating hypoxia, anemia, alcohol
(TRAP), gait abnormalities, CV risk withdrawal, sepsis/infections
Depression Complains of memory loss, ↓ concentration, MDD, dysthymic disorder,
Investigations: no evidence for/against routine labs unless impaired judgement, worse in am, SIGECAPS complex grief reaction
ruling out delirium
- B12 deficiency, hypothyroidism, hypo/hypercalcemia, Treatment: ABCDs
folate deficiency e.g. alcoholism - Affective disorders, ADLs - Directives, driving
- Imaging: CT/MRI indicated if new (<2y) unclear - Behavioural problems - Sensory enhancement (hearing aids, glasses)
diagnosis, onset < 60y, acute onset, r/o ICH/stroke - Caretaker support, cognitive medications (see reverse) + cognitive stimulation
o
Pharmacological Treatment:
- Cholinesterase inhibitors: donepezil,
galantamine, rivastigmine-modest Sx benefit,
NOT neuroprotective/altering disease
trajectory, SE: falls, bradycardia, GI Sx
o Offer to all new Dx, F/u 2w → 3/6m
- Memantine: NDMA receptor antagonist,
modest benefit in mod-severe AD/VD, SE:
dizziness/confusion/halluicnations
MoT Driving Regulations Genetic Counselling
- Mod-severe dementia is contraindication,
Early onset familial AD: amyloid precursor protein,
(loss of 1 ADL, 2 IADLs)
presenilin 1/ 2- buildup of amyloid plaques
- Mild: reassess q6-12 months
FTD: progranulin, Tau
- Trails B (3 minutes or 3 errors), clock test
Huntington’s disease
- Hx accidents, family concerns
Counsel with family to ensure adequate consent &
- Document & report to MoT (legal
understanding of possible results & implications for
obligation)- risk management before
other family members
assessment, contact CMPA if necessary
Clinical Features: ≥5 of the following nearly every day for > 2
weeks (must include either low mood or anhedonia)
• SIGECAPS
• S: sleep- insomnia or hypersomnia
• I: interest- diminished interest in almost all activities
most of the day
• G: guilt- feelings of worthlessness, inappropriate guilt
• E: energy- fatigue or loss of energy
• C: concentration- diminished ability to
think/concentrate, indecisiveness
• A: appetite- ↓/↑appetite, significant weight
loss/gain (>5% of body weight in a month)
• P: psychomotor agitation or retardation
• S: suicidal ideation- recurrent thoughts of death,
ideation or attempts
High Risk Groups: substance use, postpartum + pregnancy,
chronic pain, low socioeconomic status, elderly in nursing home,
mental health Hx/ family Hx
Comorbid Conditions: anxiety, bipolar disorder, personality
disorders, abuse (inquire about past/current/witnessed/inflicted)
sexual/physical/emotional, substance use disorder, medical illness
(e.g. cancer, CVA, DM neurodegenerative disease, HIV/AIDS, pain)
Assessment: PHQ-9, 2 question screen, Edinburgh Postnatal
Depression Scale, Geriatric Depression Scale
- R/o organic causes: CBC + ferritin, lytes, Cr, TSH, folate,
B12, LFTs, EGC for QT prolongation, consider drug screen
Suicide Risk: Columbia Suicide Severity Scale, SADPERSONS
- Sex: male
- Age: 25-44, 65+
- D: depression
- P: previous attempt
- E: ethanol abuse
- R: rational thinking lost
- S: social support lacking
- O: organized plan
- N: no spouse (divorced, widowed, single male)
- S: sickness (chronic/debilitating illness)
Disposition: outpatient Rx with close f/u vs hospitalizations
Criteria for hospitalization/form 1: MD must reasonably believe
the individual is at risk of self-harm, harm to others, or unable to
care for self
- Allows admission for psychiatric assessment, 72h
- Submit with form 42: notice to patient
- Form 2: same criteria, based on information presented by
members of the public, 7d, allows police to bring to hospital
Presentation in Specific Populations:
Children: irritability, ↓ sleep, boredom, ↓performance, social withdrawal
D DEPRESSION Elderly: somatic complaints, anxiety, ?prodrome to dementia
Post-partum: MDE during pregnancy or 4w postpartum, screen all pts
Perimenopausal: presents with vasomotor Sx, insomnia, ↓ estrogen state
Differential Diagnosis:
Condition Presentation
Adjustment disorder Development of emotional/behavioural Sx in response to identifiable stressor
(w/ depressed mood) occurring ≤3 months from stressor, marked distress out of proportion and/or
functional impairment, Sx resolve ≤6 months after stressor terminated
Persistent depressive Sx ≥2 years with no 2 months without Sx, depressed mood for most of the day more
disorder (dysthymia) days than not, ≥2 SIGECAPS
Complex bereavement Severe persistent grief reaction ≥6 months, see grief handout for details
Bipolar disorder Type 1: manic episode ≥1w or hospitalization, and ≥3 DIGFAST (≥4 if irritable mood),
marked impairment or psychotic features, +/- MDE or hypomanic episode
--Distractible, impulsive, grandiose, flight of ideas, ↑activity, ↓sleep, talkative
Type 2: hypomanic episode lasting 4 days, no marked
impairment/hospitalization/psychosis/manic episodes, +/- MDE
Schizoaffective MDE or major manic episode + criterion A of schizophrenia (≥2 of delusions,
disorder hallucinations, disorganized speech, catatonic/negative Sx)
Anxiety disorder
Treatment (overview):
•Choose 1st line pharmacotherapy based on comorbid onditions, response/side effects, potential
Organic disease:
Step 1 interactions, cost
•Use objective scales to monitor for improvement and signs of remission, reasses in 2-4 weeks
•If > 20% improvement, continue and reassess in 6-8 weeks
Step 2 •If < 20% improvement, proeceed to step 3
•Tolerating: increase dose and reassess in 2-4 weeks
•Not tolerating: switch to another first line med or add adjunct and reassess in 2-4 weeks
Step 3 •Failure of > 1 antidepressants, consider switch to 2nd line
•Maintenance: treat x 6 months if 1st episode
Step 4 •Treat x 2 years (min) if high risk, severe, or resistant
•Slow taper over several weeks, monitor for discontinuation syndrome
Step 5
Nonpharmacological Management:
- Therapy: CBT, IPT, mindfulness based, behavioural activation
- Complementary: St. John’s Wort, exercise, omega-3, light therapy, folate, acetyl-L carnitine
- Neurostimulation: rTMS, ECT
- Patient education: goals of therapy, side effects, timelines
Screening & Diagnosis:

DIABETES
Management

Targets for Glycemic Control:

- ≤6.5: adults with T2DM to reduce risk of CKD & retinopathy if at low
risk of hypoglycemia
- ≤7.0: most adults with type 1 or type 2 DM
- 7.1-8.0: functionally dependent
- 7.1-8.5: recurrent severe hypoglycemia and/or hypoglycemia
unawareness, limited life expectancy, frail elderly &/or dementia
Type 2 DM Pharmacological Management: see table on reverse CV Protection:
*Make timely adjustments to attain target A1c within 3-6 months
1. Healthy behaviour interventions
2. Reassess A1c in 3 months
- <1.5% above target: start metformin / ↑ dose
- ≥1.5% above target: start metformin immediately, consider 2nd concurrent antihyperglycemic agent
- Symptomatic hyperglycemia &/or metabolic decompensation: initiate insulin +/- metformin
3. Reassess A1c in 3 months
- Clinical CVD
o Yes: start antihyperglycemic agent w/ CV benefit (empagliflozin, liraglutide, canagliflozin)
o No: add antihyperglycemic agent best suited to individual
▪ Avoidances of hypos, avoidance of weight gain: DPP-4I, GLP1-RA, or SGLT2I
▪ Consider eGFR, CVD risk, comorbidities e.g. CHF/hepatic disease, pregnancy, $$, preference
4. Reassess A1c in 3 months
- If not at target, add another antihyperglycemic from a different class &/or intensity therapy → consider insulin
if still above target on 3 antihyperglycemic therapies
Antihyperglycemic Medications
Class CVD Effect Hypo Weight A1c Therapeutic Considerations Cost
Biguanide/Metformin Neutral Rare Neutral ↓↓ GI effects: N/V/D, infection, rare lactic acidosis $
Insulin Neutral Yes ↑↑ ↓↓↓ No dose ceiling, flexible regimens, requires SC injection $-$$$
GLP1-RA e.g. liraglutide, exenatide Superior Rare ↓↓ ↓↓↓ GI side effects, gallstone disease, CI w/ person/FHx medullary thyroid ca or MEN $$$$
(lira) 2 Syndrome, requires SC injection
SGLT2I e.g. empa/cana/dapagliflozin Superior Rare ↓↓ ↓↓↓ Genital candida/UTI, caution with renal dysfunction/loop diuretics/↓BP/elderly $$$
(empa/cana) Rare euglycemic DKA, risk fractures/amputations with cana
DPP-4I e.g. sita/linagliptin Neutral Rare Neutral ↓↓ Caution with saxagliptin in CHF, rare joint pain $$$
Thiazolidinediones e.g. pioglitazone Neutral Rare ↑↑ ↓↓ Risk fluid retention/CHF, fractures, rare bladder ca $$
Sulfonylureas e.g. glyburide, glipizide Neutral Yes ↑↑ ↓↓ Rapid BG-lowering response, risk hypoglycemia, usually requires multiple dosing $
Alpha glucosidase inhibitors e.g. acarbose Unknown Rare ↑↑ ↓ Significant GI effects common, requires TID dosing, increased transaminases $$

Hypoglycemia: autonomic neuroglycopenic sx, glucose Sick Day Rules:
<4.0mmol/L & sx respond to administration of carbohydrate - Rehydrate appropriately, hold
- Autonomic sx: trembling, palpitations, sweating, anxiety, SADMANS- restart when able to
hunger, nausea, tingling eat/drink normally
- Neuroglycopenic sx: difficulty concentrating, confusion, o Sulfonylureas, ACEI, diuretics,
weakness, drowsiness, vision/speech changes, metformin, ARB, NSAIDs, SGLT2I
headache, dizziness
Considerations for Women:
Severity:
- Pregnancy when A1c <7%, ideally <6.5%
- Mild: autonomic sx, able to self-treat
- Stop non-insulin antihyperglycemics
- Moderate: autonomic + neuroglycopenic sx, self-treat
other than metformin/glyburide, statins,
- Severe: requires assistance, +/- LOC, glucose typically <2
ACEI/ARB
Treatment:
- Start folate 1mg/day 3 months prior
- 15g of glucose (↑BG 2.1mol/L in 20 mins) e.g. glucose
- Aim for healthy BMI
tabs, 3 tsp sugar dissolved in water, 5 cubes sugar,
150mL juice, 6 life savers, 15mL honey) Screening for Complications:
- Glucagon 1mg SC/IM 1. Diabetic nephropathy: yearly ACR & Cr
- Recognize signs, counsel pts using insulin/secretagogues → if present, start statin + ACEI &
- Screen for hypoglycemia unawareness optimize A1b + BP
Prevention:
- Indications for nephron referral:
- Consider meds with lower risk hypos
- Discuss causes & strategies to prevent o eGFR<30
o Rapid deterioration in kidney
Driving Safety: function (decline <5 in 6m)
- Check BG before driving & every 4h while driving, if o ACR >60
<4/any sx, stop + treat & wait 40 mins before driving o 5y KFRE ≥5%
again (BG >5mmol/L)
- If hypoglycemia unawareness, check BG before driving & 2. Diabetic retinopathy: yearly retinopathy
every 2h while driving, or wear a real-time continuous screen by ophthalmologist
glucose monitor 3. Cardiac: ECG q3-5y
- Counsel patients regularly & education to keep fasting 4. Foot exam: monofilament + examination
acting sugar readily available
at least yearly
Diabetic Ketoacidosis (mostly T1DM)
• Insulin deficit → volume depletion → potassium extracellular
→ metabolic ketoacidosis
• Sx: polyuria, polydipsia, weakness, air hunger/tripod
breathing, N/V, abdo pain, altered mental status
Investigations: BG, Cr, lytes + anion gap, blood gases, serum + urine
ketones, beta-hydroxybutyric acid if available
• Usually PG >14, pH <7.3, AG >12, (+) serum/ urine
ketones
• Normal/mildly ↑ BG does not r/o DKA if
pregnant/on SGLT2 inhibitor (euglycemic DKA)
Precipitants: ‘7- Is’ → infection, infarction, iatrogenic, incision,
intoxication, initial diagnosis, insulin missed
Management:
1. Fluid resuscitation 1-2L of NS
2. K replacement (20-30 meq K+ per L NS): DO NOT START
INSULIN UNTIL K+ >3.3
3. Insulin 0.1U/kg/hr IV
4. Bicarb controversial, consider if pH <6.9
5. Ongoing care:
- Recheck Na after bolus and correct for BG: adjust fluids
as appropriate
- Once BG <11.1
o Switch to D5 1/2 NS to prevent hypo
o ↓ insulin to 0.05U/kg/h until AG normalizes
- Continue with VBG, chemistry, POC BG q1h
HHS/HONK (mostly T2DM)
• DM Complication w/ ↑ BG & osmolarity w/o ketoacidosis
• Sx: dehydration weakness, cramps, vision changes, LOC
Initial Assessment:
- Assess severity of illness & need for rehydration
o Signs of dehydration in adults:
tachycardia, fain pulse, postural
hypotension, supine hypotension, dry
tongue, sunken eyes, reduced skin turgor
o Signs of dehydration in children:
▪ Mild/moderate: irritable, sunken
eyes +/- dry mucous membranes,
normal skin turgor
▪ Severe: sleepy/lethargic, sunken
eyes, dry mucous membranes,
sunken fontanelle, reduced skin
turgor, decreased tear production
- Maintain adequate intravascular volume & correct
fluid/electrolytes disturbances
- Identify likely causes from Hx/exam
Oral Rehydration: PO preferable- if not consider IV,
start food within 4h rehydration, frequent small meals,
avoid hyperosmolar fluids e.g. canned/sweetened juice
History:
- Amount, quality, volume, frequency
- Urgency, tenesmus
- Fever, abdo pain, N/V
- Weight loss, night sweats
- Cough, sore throat
- Arthralgias, myalgias, new rashes
- Diet, association with food
Red Flags:
- >50y
- B symptoms: fever, night sweats, weight loss
- Black/bloody stool
- Nocturnal symptoms
- Fever, arthritis, rash
Return to Work Instructions:
- Wait until no diarrhea for at least 48h
- Food handlers, daycare workers, healthcare
workers- may require negative stool sample x 2 at
least 24h apart dependent on workplace policy
Treatment of Acute Diarrhea:
DIARRHEA - Dietary modification (temporary): avoid high fat,
dairy (except yogurt)
Acute Diarrhea DDx: >3 stool/day for <14d, persistent o Minimal evidence for BRAT: banana, rice,
14-30d applesauce, toast
- Parasitic: giardia, amoebiasis, cryptosporidia - Symptomatic: e.g. Imodium if no fever & non-
- Bacterial: (CHEESSY) campylobacter, hemorrhagic bloody diarrhea for short-term use only
E. coli, enteroinvasive E. coli, entameoba - Probiotics: lactobacillus
histolytica, salmonella, shigella, yersinia - Do not routinely use Abx if self-limited
- Viral: hepatitis A, rotavirus, norovirus - Empiric Abx: indicated in
- Hospital: C. difficile o Severe (fever, >6/d, hospitalization)
- Traveller’s diarrhea: cholerna, ETEC, typhoid, hep
o Invasive e.g. bloody/mucous
- Daycare: rotavirus
o Host factors e.g. age >70y, comorbidities,
immunocompromised
Chronic Diarrhea DDx: >30d
- No Abx if causative pathogen is shiga-toxin
- Functional: IBS, overflow (constipation),
incontinence producing E. coli as risk of HUS
- Osmotic agents: lactose intolerance - Choice of therapy
- Inflammatory: Crohn’s, ulcerative colitis
- Metabolic: Addison’s disease, hyperthyroidism,
uremia, cystic fibrosis
- Malabsorption: celiac disease, short bowel
syndrome, bacterial overgrowth, pancreatitis
- Neoplastic: carcinoid tumour, medullary thyroid
carcinoma, colorectal cancer
- Iatrogenic: laxatives, magnesium excess, radiation
enteritis
Indications for Stool Testing:
- Severe illness: profuse watery diarrhea with signs
of hypovolemia, passage of >6 unformed stool per
24h, severe abdominal pain, need for
hospitalization
- Other concerns sx for IBD: bloody diarrhea, General Approach:
passage of many small volume stools containing
blood & mucous, temp >38.5C - In all patients with acute diarrhea, determine
- High risk host: age 70y+, medical comorbidities hydration status & treat appropriately
affected by hypovolemia, immunocompromised, - Look for C. difficile in recently hospitalized patients
IBD, pregnancy - Investigate elderly patients in a timely manner
- Duration > 1w - Do not over-investigate if IBS suspected in young
- Public health concerns: food handler, healthcare patient without any red flags
Condition Epidemiology Presentation Investigations Management
Infectious Recent Watery diarrhea +/- Stool C&S, O&P (blood/mucous or >7d, Rehydration: ORT vs IV fluids
colitis hospitalization, hematochezia, steatorrhea fever, sever pain, sepsis, foodborne Imodium PRN for short-term use only
recent travel to (giardia) outbreaks or PH concerns, consumption Consider probiotics
endemic area of raw meat or unpasteurized dairy, C. difficile: vanc +/- flagyl
Consumption of travel Hx, immunocompromised, age Consider empiric Abx if <3m, fever +
unsafe drinking >70y, IBD, pregnancy) severe sx, recent travel + fever
water C. difficile toxin if recent Abx,
hospitalization, elderly/NH
Blood cultures if very unwell

IBS F>M, Hx anxiety ROME III Criteria: >12 weeks
disorder or over past 12 months of
functional sx abdominal pain & 2 of:
- Relief with defecation
- Change in frequency
- Change in consistency
Negative for red flags
Exclude other diagnoses clinically e.g.
infectious, IBD, antibiotic associated,
malabsorption
*Do not over investigate
Dietary modification + referral to
dietician, consider FODMAP diet
Imodium PRN
Laxatives PRN
Bulking agents e.g. fibre supplement,
bran, psyllium
Antispasmodic for pain control e.g.
hyoscine

IBD Typically 15-40y, Diarrhea +/- bloody +/- Sigmoidoscopy +/- colonoscopy ASA maintenance
personal/FHx mucous CBC Steroids for flares
autoimmune Nocturnal sx, cramping, Cr, lytes Biologics e.g. infliximab, adalimumab
conditions or IBD weight loss, fever ESR/CRP Surgical intervention
Extraintestinal manifestations:
uveitis, iritis, myalgias,
arthritis, rash e.g. erythema
nodosum, aphthous ulcers

Malabsorption Family Hx celiac Steatorrhea Celiac: anti-TTg, IgA Gluten free diet, referral to dietician
e.g. celiac disease, T1DM, Weight loss, failure to thrive Endoscopy + biopsy (villous atrophy) Risk of T-cell lymphoma and small bowel
autoimmune disease in children adenocarcinoma if nonadherent
Sx of anemia
Nutrient deficiencies

Approach to the Difficult Patient
Reminders
- With difficult interactions, ask about the pt’s life
circumstances, current context, functional status
- Be compassionate and sensitive with seeing
patients with chronic illness
- Remain vigilant for new symptoms and physical
findings to ensure they receive adequate attention
- Take steps to end the physician-patient
relationship when it’s in the patient’s best interests
Interview Technique
- Identify your own attitudes and contributions to
the situation
- Set clear boundaries
o E.g. time limits, office hours, phone/email
communication, gifts
- Safely establish common ground to determine the
patient’s needs
Difficult Interactions
Patient Factors
- Life circumstances that generate emotions that
are transferred to the physician (transference)
- Undiagnosed or unrecognized psychiatric
problems/substance use/personality disorders
Physician Factors
- Desire for diagnostic certainty is challenging
with vague complaints
- Limited time, if patients feel rushed they don’t
feel heard and tend to repeat themselves
- Physician circumstances that trigger emotions
transferred to patient (countertransference)
DIFFICULT PATIENT
Terminating Physician-Patient Relationship
- Only when there has been significant breakdown in the relationship
o E.g. prescription fraud, frequently missed appointments without notice, behaviour
which disrupts the practice, abusive/threatening language
- Reasonable efforts to resolve the situation must be made in the best interests of the patient
o Communicate expectations for patient conduct
o Consider if isolated event vs pattern
o Discuss how situation is affecting ability to provide care
- Cannot end relationship if:
o Reason is that patient doesn’t follow advice
o Reason is that physician objects to treatments on the basis of conscious/religious beliefs
o Patient suffers from an addiction or dependence
o Prescribing high risk medication including controlled drugs, until another provider is
available
- How to end the relationship
o Notify patient: safely, give explanation unless risk of harm, provide written notification
in confidential method & retain a copy
o Provide interim care: prescribing, assistance finding a new physician
o Additional requirements
▪ Document termination & reasons in chart
▪ Inform patient they are entitled to copy of medical records & any fees
▪ Ensure timely transfer of medical records upon request
▪ Notify office staff
Personality Disorders
• An enduring pattern of inner experience and behaviour that deviated markedly from the
expectations of the individual's culture, manifested in 2 (or more) of the following ways:
• Cognition, Affectivity, Interpersonal functioning, Impulse control
• Pattern is inflexible and pervasive across broad range of personal and social situations
• Enduring pattern leads to clinically significant distress or impairment
• Pattern is stable and of long duration, onset can be traced back to adolescence or early childhood
Cluster A: ‘mad’- paranoid, schizoid, schizotypal
Cluster B: ‘bad’- antisocial, borderline, histrionic, narcissistic
Cluster C: ‘sad’- avoidant, dependant, obsessive compulsive
Disability: any condition of the body or mind (impairment)
that makes it more difficult for the person with the DISABILITY
condition to do certain activities (limitation) and interact
with the world around them (restrictions) Management
- 3 dimensions:
- Multidisciplinary individualized approach to minimize impact of disability & prevent further
o Impairment in body structure or function
functional deterioration
o Activity limitation
- Prevention strategies for those at risk including elderly, mental health conditions, those who work
o Restrictions in normal daily activities in manual labour
- Handicap: the disadvantage for an individual arising o Treat unstable medical conditions
due to disability
o Review polypharmacy
Screen for Risks Factors for Disability
o Pain management (WHO pain ladder)
- Falls: number of falls in past year, fractures o Early mobilization (involve PT)
- Cognitive impairment: MMSE, MOCA
- Immobilization: gait assessment, ‘get up & go’ o Balance training
(standard armchair, 3m/turn/3m, <30s) o Mobility aids (involve OT), orthotics, cane, walker, wheelchair, etc.
- Malnutrition: weight loss >5% in 1y
o Safety assessment with OT: grip rails, stair lifts, removal of loose carpets, address
- Visual impairment, hearing impairment
- Chronic illness, chronic physical problems inappropriate footwear, lifeline
o Foot problems o Vision & hearing assessment, provision of glasses, large print material, hearing aids, etc.
o Arthritis
o Cognitive impairment o Nutritional support (involve dietician), high protein diet, vitamin D, calcium, vitamin B12
o Cardiovascular disease o Hip protectors (prevent fracture if fall)
o Vision impairment
o Counselling when appropriate
- Mental health conditions
o Immunization (influenza, pneumococcal)
Functional Status o Social support (socialization, day care, volunteers)
- Spheres of functioning: emotional, physical, social
o Housing support: retirement home, nursing home, LTC
(including finances, employment, family)
o Financial support
- ADLs: (DEATH) o Employment:
o Dressing, eating, ambulation, transfer/toileting,
hygiene ▪ Work modifications when necessary
▪ If off work short-term discuss return to work (gradual, part-time, with
- IADLs: (SHAFT)
modifications, etc.)
o Shopping, housekeeping, accounting, food
preparation & meds, transportation & ▪ Part of comprehensive plan to minimize disability and optimize functioning
telephone
Etiology:
- Vertigo: rotational/linear/tilting movement of self/
environment, produced centrally or peripherally
o Peripheral: BPPV, labyrinthitis, vestibular neuritis,
DIZZINESS
Meniere’s, Ramsay Hunt Syndrome, cholesteatoma Vertigo
o Central: TIA/stroke, cerebellopontine angle tumour, - Peripheral: moderate-severe imbalance, severe N/V, common auditory sx, rare neuro sx, rapid compensation,
migrainous vertigo unidirectional nystagmus (horizontal or rotary) + fatigueability
- Presyncope/syncope - Central: mild-moderate imbalance, variable N/V, rare auditory sx, common neurologic sx, slow compensation,
bidirectional nystagmus (horizontal or vertical) + not faitugeable
o Serious causes: arrhythmia, stroke, seizure, PE, MI,
o Vertebrobasilar insufficiency: 5Ds (drop attacks, dysarthria, diplopia, dizziness, dysphagia)
AAA, sepsis, GI bleed
o TIA, cerebellar infarction
o Common: orthostatic, vasovagal, situational o Migrainous vertigo- episodic vertigo with signs of migraine
- Disequilibrium o Multiple Sclerosis
o Peripheral neuropathy, MSK disorder, Parkinson’s, o Inflammation- meningitis, cerebellar abscess
visual or hearing impairment, cervical spondylosis o Trauma- cerebellar contusion
- Medication induced
- Psychiatric
o Anxiety, panic disorder, somatic symptom disorder
Syncope: sudden transient LOC due to global cerebral hypotension
Pre-syncope: prodromal symptoms prior to syncope including
dizziness, nausea, visual changes, faint feeling, lightheadedness,
sweating, panic, difficulty maintaining posture
- Cardiogenic causes: arrhythmias (palpitations, often no Investigations: hearing tests, imaging if suspicious of central cause
prodrome e.g. heart block, sick sinus syndrome), structural • r/o cardiogenic causes, structural heart disease, syncope, cerebrovascular disease
(↓CO, with exertion, SOB, murmur, e.g. AS, PE, HOCM), other- Treatment:
carotid sinus syndrome, pulmonary HTN • BPPV: Epley maneuver + vestibular rehabilitation, trial betahistine (poor evidence), antiemetics
- Noncardiogenic causes: • Meniere's disease: bed rest, antiemetics, betahistine, low salt diet, diuretics, surgical, local gentamicin-
• Orthostatic: hypovolemia, autonomic dysfunction, results in complete SNHL
adrenal insufficiency, meds e.g. antiHTN, alpha blockers • Vestibular neuritis: bed rest, antiemetics, vestibular rehabilitation
• Vasovagal: stress, pain, phobias, straining, urination, • Labyrinthitis: IV Abx +/- drainage of middle ear +/- mastoidectomy
usually with lightheaded prodrome • Migrainous vertigo: prophylaxis with anticonvulsant, TCA, propranolol, candesartan
• Cerebrovascular disease: TIA or CVA, vertebrobasilar • Acoustic neuroma: definitive surgical excision, consider expectant management if small tumour + elderly
insufficiency, subclavian steal syndrome
Investigations: Physical Exam: for dizziness Meds: orthostatic
- CBC and ECG for all patients - General: ABC /vitals, orthostatic vitals, GCS - Cardiac: alpha blockers, beta
- Echocardiogram is risk of structural disease - CN: II/ IV/ VI- nystagmus, tracking, saccades, visual fields blockers, ACEI, clonidine,
- Consider carotid doppler - Visual acuity, fundoscopy- high ICP hydralazine, diuretics,
- Stress test if risk for CAD - ENT: canal + TMs, Webber & Rinne's, sign of OM/URTI, neck masses / LN nitrates
- Holter/loop if risk for arrhythmia - HINTS: head impulse, nystagmus, test of skew - CNS: antipsychotics, EtOH,
- Tilt table test if unexplained recurrent syncope or no other - Cerebellar exam: finger to nose, heel to shin, tandem gait, caffeine, opioids,
causes identified dysdiachokinesis, dysmetria Parkinsonism meds
- CT/MRI if neuro sx, symptoms of TIA/CVA - Rhomberg test (bromocriptine,
Treatment: - Gait: slow, wide based indicative of cerebellar dysfunction cyclobenzaprine) , muscle
- Orthostatic: lifestyle changes (getting up slowly, adequate - Screen for peripheral neuropathy relxants, TCAs
hydration, fall prevention, muscle strengthening), optimize - Dix-Hallpike - Urologic: PDE5 inhibitors,
underlying disease e.g. DM/Parkinson's, trial - CV exam urinary anticholinergics
midodrine/fludrocortisone - Trial reproducing hyperventilation (oxybutynin)
Approach to Domestic Violence:
- Screen those at risk opportunistically (e.g. at
PHE, visits for anxiety/depression, ER visits)
- Assess level of risk & safety of children, advise
about impact on children
- Advise about escalating nature and cycle of
domestic violence
- Collaborate with patient to develop
appropriate emergency safety plan
Epidemiology:
- Intimate partner violence most common
violence in women
- Annual prevalence 6-8%, ↑in adolescence/
pregnancy, lifetime prevalence 25-30%
Risk Factors:
- Pregnancy, higher risk if unplanned pregnancy
- Adolescent & young women
- Native populations
- Immigrant populations, women of colour
- Disabilities
- Lower socioeconomic status
- Women in homosexual relationships
Clinical Presentation:
- Physical/mental health: ↑ risk substance
abuse, mental health disorders, chronic
physical disorders, sexual health complaints
o Multiple visits, vague complaints,
injuries inconsistent with injury
- Maternal/fetal health:
o More likely to result in depression,
suicidal ideation, pregnancy
complications, poor fetal outcomes
including fetal death
- Children:
o ↑ risk developmental difficulties &
experiencing abuse themselves
DOMESTIC VIOLENCE
Cycle of Abuse
- Pretends things are normal
- Builds up anger
- Acts out with violence
- Rationalizes & justifies actions → Repeat
Intervention
- Safest approach to screen all at risk patients
- Woman-Abuse Screening Tool (WAST)
o In general, how would you describe your
relationship? (a lot/some/no tension)
o Do you and your partner work out
arguments with: (great/some/no
difficulty)
- HITS: How often does your partner? (score each
1-5, >10 if significant)
o Hurt you physically?
o Insult you?
o Threaten you with harm?
o Scream or curse at you?
- Make clear notes using woman’s own words and
diagrams when appropriate, consider use of
body map & photograph of injuries with
permission
- Document date & time of assessment, time
lapsed since incident, investigations ordered
- Provide professional support e.g. community
resources, shelter/helpline number, social work
Safety Risk
- High risk for homicide when attempting to leave
home or following separation
- Ensure appropriate follow up
- Safety/emergency plan with clear exit strategy
- Not reportable without victim’s permission,
unless child(ren) is involved
Emergency Plans
- Either hide items or give them to secure
friend/friend
- Passports, birth certificates, immigrations
papers, SIN cards, health card
- School and immunization records for children
- Bank cards, credit cards, as much cash as
possible, cheques
- Lease/rental agreements, house deeds,
mortgage papers
- Insurance documents
- Divorce or custody papers
- Keys of house, car, safety deposit box
- Photos of spouse/partner and children
- Address or telephone book
- Suitcase with at least 1 change of clothes
- Toys or items of comfort for children
Children
- Any suspicion of child involvement must be
reported to CAS
- RF:
o Caregiver: criminal Hx, psychiatric Hx,
misconceptions about child
care/development, substance abuse
o Child: behavioural problems, medically
frail, non-biologic relationship,
prematurity, special needs
o Family/environment: low SES, intimate
partner violence, social isolation & lack
of support
- Impact:
o Aggressive behaviour
o 2x risk anxiety disorders
o Increased predisposition to be target of
abuse themselves
o Men 2x more likely to abuse their
partners if previously witnessed IPV
Dyspepsia: symptoms on indigestion
- 25% underlying organic cause, 75% functional
Differential:
- Peptic ulcer disease
- GERD
- Meds: NSAIDs, antibiotics, CCB, bisphosphonates,
potassium supplementation
- Biliary colic
- Esophageal motility disorder, gastroparesis
- Malignancy
- *Consider ACS/cardiac chest pain
- Rare presentations of dyspepsia alone: chronic
pancreatitis, celiac disease, infiltrative (sarcoidosis,
lymphoma, amyloidosis)
History:
• Heartburn, regurgitation → GERD
• NSAID/ASA use → peptic ulcer disease
• Radiation to back, family/personal Hx
pancreatitis → chronic pancreatitis
• Weight loss, anorexia, dysphagia, odynophagia,
vomiting, family Hx GI cancer → cancer
• Severe episodic/epigastric/RUQ pain →
gallstones/biliary disease
• Relation to eating to help differentiate ulcers
Red Flags: require urgent EGD
• GI bleed: melena, hematochezia, IDA
• Weight loss: >5% of body weight in 6-12m
• Progressive dysphagia
• Odynophagia
• Persistent vomiting
• Palpable mass of lymphadenopathy
• Family Hx upper GI cancer
• New onset in patients 55-60y +
Mnemonics:
- ALARMS: Anemia/GI bleed, Loss of weight,
Anorexia/vomiting, Recent onset >60y, Mass on
exam, Swallowing difficulty
- VBAD: vomiting, bleeding, anorexia/abdo
mass/anemia, dysphagia
DYSPEPSIA
Approach
1. Identify who needs early endoscopy
2. Address modifiable risk factors
3. Consider testing for H. pylori
4. Offer symptomatic treatment
Diagnosis:
• Gastritis: inflammation from gastric mucosal injury,
many have unknown etiology as diagnosis requires
histopathologic evidence
• GERD: reflux of stomach contents past LES, erosive vs
nonerosive, usually clinical diagnosis but may need
additional investigation to r/o complications e.g.
Barrett's esophagus if any red flags/multiple risk
factors
o Screening for Barrett's recommended if GERD
>5-10y AND any of:
• Age 50y +
• Male
• Caucasian race
• Hiatal hernia
• Obesity
• Nocturnal reflux
• Tobacco use
• 1st degree relative- Barrett's or adeno-ca
• H-pylori: urea breath teat, serology, ECD + biopsy
• Peptic ulcer disease: definitive diagnosis by direct
visualization on EGD
• Functional dyspepsia: Rome IV Criteria (1+ of)
o Postprandial fullness, early satiation, epigastric
pain/burning, no evidence of structural disease
(including EGD)
o At least for last 3m, sx onset at least 6m prior
Investigations:
• EGD: if any red flags
• Esophageal manometry: if normal EGD, can use
manometry to r/o esophageal motility disorder
• Ambulatory esophageal pH monitoring: confirm
diagnosis of GERD if persistent sx despite trial PPI BID
• H.pylori: urea breath test, blood test, biopsy on EGD
o Consider test of cure 4 weeks after eradication
therapy completed, must be off PPI x 1-2 weeks
Treatment:
H. pylori: quadruple therapy
- CLAMET: Amoxicillin 1000mg PO BID +
clarithromycin 500mg PO BID +
metronidazole 500mg PO BID + PPI standard
dose PO BID x 14 days
- BMT: If penicillin allergy: bismuth salicylate
2 tabs PO QID + metronidazole 500mg PO
BID + tetracycline 500mg PO BID+ PPI
standard dose PO BID x 14d
Peptic Ulcer Disease:
- NSAID-induced: PPI for minimum 8 week, if
need to be on NSAID/ASA consider
maintenance therapy
o Non-NSAID: PPI for 4-8 weeks
GERD:
- Mild/intermittent symptoms: nonpharm &
lifestyle management
o Weight loss, elevate head of bed,
dietary modification, quit smoking,
reduce alcohol/coffee, avoid late
night meals, avoid large meals,
decrease acidic & spicy foods
• Antacids: Al-hydroxide, calcium
carbonate
• H2 receptor antagonists
o Severe/frequent/erosive:
• PPI once daily x 4-8 weeks, take
30min before 1st meal of the day
• If above doesn't work, adjust dose
of PPI (e.g. split dose, double
dose, switch PPI) and consider
further workup e,g, EGD,
ambulatory pH monitoring
Functional dyspepsia
o Trial of PPI x 8 weeks
o If no improvement with PPI, trial of low
dose TCA (e.g. amitriptyline) can be
used in combination
o Prokinetic agents third line e.g.
metoclopramide
Differential Diagnosis for Dysuria
• Urethritis: most commonly due
to STIs, young/sexually active
patients
• Prostatitis: history of
instrumentation, acutely ill with
fever/chills, malaise, myalgia,
cloudy urine
• Epididymitis: scrotal
pain/swelling +/- hydrocele,
fever rigors
• Vaginitis (e.g. yeast, BV,
trichomonas): PV discharge,
odour, pruritus, dyspareunia
• Interstitial cystitis/painful
bladder syndrome: increased
discomfort with bladder filling,
relief with voiding, sterile culture
• PID: lower abdo/pelvic pain and
fever, cervical motion
tenderness & mucopurulent
endocervical discharge, STI Hx
• Chemical irritation: lubricants,
spermicides, soaps
• Atrophic vaginitis: post-
menopausal, superficial
dyspareunia, topical estrogens
are controversial
• Bladder outlet obstruction e.g.
BPH, stricture
• Overactive bladder:
o Neurogenic (e.g. CVA, MS)
o Non-neurogenic (2⁰ BPH)
DYSURIA
Urinary Tract Infection
• UTI triad: dysuria, frequency, urgency
• Clinical Decision Aid (MUMS)
o Scoring criteria: burning/pain on urination (1), presence of >trace leuks (1), presence of any nitrites (1)
o Score of 2-3, >70% risk of positive culture, treat empirically
• Choosing Wisely:
o Negative dipsticks do not need microbiology/culture!
o Do not culture adults who lack symptoms unless pregnant or undergoing GU instrumentation
o Don't use a bag for collection of urine cultures
• Complicated UTI
o Extending past bladder (with any of the following features)
• Fever, chills, rigors, significant fatigue/malaise, flank pain, CVA tenderness, pelvic/perineal pain in men
o Risk factors
• Male (especially with recent instrumentation)
• Immunocompromised (neutropenia, HIV, poorly controlled DM)
• Structural abnormalities of urinary tract (strictures, nephrolithiasis, stents, indwelling catheter)
• Recurrent UTI:
o Two uncomplicated UTIs within 6 months or 3 positive urine cultures within 12 months
o Reinfection: different organism after 2 weeks of completing Abx
o Relapse: same organism, within 2w of completing Abx, bacteriuria may persist (normal)- look for symptoms
o Post-coital UTI: may consider postcoital prophylaxis e.g. single dose macrobid or septra
Treatment
• Acute uncomplicated female >12y
o Septra 2 tabs PO BID or 1 DS tab PO daily x 3d
• Caution re: hyperkalemia
• Contraindicated in 1st trimester and last 6 weeks of pregnancy
o Macrobid 100mg PO BID x 5d
• Avoid if CrCl <30mL/min
• Contraindicated in term pregnancy
o Fosfomycin 3g PO x 1
• Save for multidrug resistant isolates to avoid resistance
o Amoxicillin 500mg TID x 7d
• Preferred for pregnancy/paeds
o Cipro 250mg BID
• Reserve for pseudomonas, pyelonephritis
o Keflex 500mg BID x 7d
• Preferred for pregnancy/paeds
Earache DDx:
- Normal TM exam:
o Common: TMJ, pharyngitis, tooth abscess, cervical
spine arthritis
o Uncommon/serious: tumours, trigeminal
neuralgia, Bell’s palsy, temporal arteritis
- Abnormal TM exam:
o Common: EOM, otitis externa, FB, barotrauma
o Uncommon: cholesteatoma, malignant otitis
externa (DM, immunocompromised), Ramsay
Hunt syndrome, mastoiditis, Wegner’s
granulomatosis, tumour
Otitis Media
- In children, Eustachian tube shorter + more horizontal and
prone to obstruction by large adenoids
- Viral cause common, typical bacteria: S. pneumoniae, M.
catarrhalis, H. influenzae
Risk Factors: young age, prematurity, orofacial abnormalities,
not breastfed, daycare, household crowding, exposure to
cigarette smoking, immunodeficiency, first nations or Inuit
background
Presentation: otalgia, tugging ears, otorrhea, ↓ hearing,
irritability, fever, URTI symptoms, N/V
- O/E: vitals, HEENT including otoscopy (hyperemia, bulging,
loss of light reflex & landmarks, pus may be seen behind
TM, possible perforation)
Diagnostic Criteria:
1. Acute onset of symptoms (otalgia, otorrhea)
2. Signs of middle ear effusion: immobile TM, presence of
liquid in external ear canal from TM rupture
3. Signs of middle ear inflammation: bulging,
hemorrhagic TM, loss of landmarks
Complications: chronic TM perforation & drainage (Rx ciprodex
+ ENT), hearing loss, speech delay, mastoiditis (fever + ant
displacement of pinna- IV Abx), bacteremia, meningitis, abscess
EARACHE
Otitis Media Treatment
Children
- < 6 months:
o High dose amoxicillin 80mg/kg/day x 10
days (divided BID- TID)
- >6 months:
o Watchful waiting x 24-48h appropriate
when: otherwise healthy child, no
craniofacial abnormalities, mild
presentation (no perf, fever <39, <48h,
alert + responsive), reliable parents able
to follow up
o Delayed Rx for 24-48h if not improving
o 6 months- 2 years or frequent AOM:
▪ High dose amoxicillin
80mg/kg/day divided BID/TID x
10 days
o > 2 years:
▪ high dose amoxicillin
80mg/kg/day divided BID-TID x 5
days
- Perforated TM:
o High dose amoxicillin 80mg/kg/day x 10
days, ciprodex 4gtt BIDx 7d
nd
- 2 line (Rx failure):
o Amoxiclav 80mg/kg/day x 10d
- Penicillin allergy: clarithromycin 14mg/kg/day
Adults
- Abx over watchful waiting
- Amoxicillin 500mg TID x 7 days
- 2nd line: amoxiclav 875mg BID x 7d
- Penicillin allergy: clarithromycin 500mg BID x 7d
Tympanostomy Indications:
- Children w/ ≥3 episodes AOM in 6m ≥4 in 12m
- Breakthrough episodes while on Abx prophylaxis
or declined/not suitable for Abx prophylaxis
- Craniofacial abn, chronic retraction, conductive
hearing loss >20dB
Otitis Media with Effusion
- Presence of middle ear fluid without acute signs
-
of infection
Can result from recent viral infection, barotrauma,
allergy, or recent episode AOM
- Presentation: conductive hearing loss + fullness
o O/E: visible fluid (yellow) behind intact
TM, viscous bubbles, ↓ mobility of TM
- Rx:
o Often resolved with no Rx within 12w
o Intermittent autoinsufflation (pinch nose
+ gently exhale through nose, forcing air
back through Eustachian tube,
repressurizing ear)
o May trial nasal saline rinse,
antihistamines, nasal corticosteroids
o Referral to ENT for myringotomy
placement if > 12 weeks
- *Recurrent unilateral OME- nasopharyngoscopy
to rule out nasopharyngeal malignancy
Otitis Externa
- Inflammation of external auditory canal, usually
caused by infection
- RFs: swimming, trauma (cotton swabs), occlusive
ear devices (hearing aids, ear phones), derm
conditions (eczema, psoriasis)
- Presentation: otalgia, pruritus, discharge
o O/E: w/ pinna movement, erythema +
swelling of external canal
- Rx: clean out external canal (cerumen, debris)
o Ciprodex 4 gtt into affected ear BID x 7d
o Consider fungal culture if persistent (Rx
with topical clotrimazole)
Anorexia Nervosa
- Restriction of energy intake relate to
requirements, leading to significantly low body
weight
- Intense fear of gaining weight or becoming fat
despite being underweight
- Disturbance of body image, undue influence of
weight on self-esteem or denial or seriousness of
current low weight
- * types- restricting vs binge/purse, athletic triad
Bulimia Nervosa
- Recurrent episodes of binge eating (eating an
abnormal quantity of food in a discrete amount of
time, sense of loss of control during binge)
- Recurrent inappropriate compensatory behaviour
to prevent weight gain (vomiting, laxatives,
diuretics, fasting, exercise)
- Both above on average at least 1/w x 3 months
- Self-evaluation unduly influenced by weight
- Does not occur exclusively during periods of
anorexia nervosa
Avoidant/Restrictive Foot Intake Disorder: eating
disturbance w/ persistent failure to meet nutritional or
energy needs, interference in psychosocial function
Binge-Eating Disorder: recurrent episodes of binge-eating
with guilt feeling following, at least 1/w x 3 months, no
associated inappropriate compensatory behaviours
Risk Factors:
- History of dieting in childhood
- Childhood preoccupation with thin body + pressure
about weight
- Sports where thinness emphasized, scoring subjective
- 1st degree family member with eating disorder
- Psych:(e.g. suicidality, substance abuse, depression)
Presentation & Complications of Eating Disorders
- General: weak/dizzy, fatigue, syncope, hot flashes, cold, low HR/BP, seizures 2⁰ electrolyte disturbance
- Cardio/resp: palpitations, CP, SOB, arrhythmia, edema (↓albumin) → cardiomyopathy, sudden cardiac death- ↑K+
- Oral/dental: lacerations, erosions, cavities, parotid ↑
- GI: epigastric pain, early satiety, GERD, hematemesis 2⁰ to Mallory Weiss, hemorrhoids + constipation, pancreatitis
- Endo: amenorrhea, ↓ libido, infertility, ↓ BMD
- Derm: lanugo hair, hair loss, callus/scar (Russell’s sign), poor healing, brittle nails, yellow skin from high carotene
- Revanl: calculi, pre-renal failure from hypovolemia → renal failure, electrolyte disturbance, metabolic acidosis w/ emesis
EATING DISORDERS
Screening:
≥2 abnormal responses in either screen are very suggestive:
Mnemonic: SCOFF
• Do you make yourself sick because you feel
uncomfortably full?
• Do you worry you've lost control over your eating?
• Have you lost more than one stone (14lb) in 3 months?
• Do you think you are fat even though others say you
are thin?
• Would you say food dominates your life?
Assessment
History
• Rate and amount of weight loss
• Compensatory behaviour (vomiting, dieting, exercise,
insulin misuse, diet pills, laxatives, diuretics)
• Dietary intake + exercise
• Menstrual history (including HRT & OCP)
• Past psych Hx: including mood/anxiety sx, suicidality,
OCD, personality disorders, depression
• Family Hx including obesity, psych Hx, eating disorders
Physical
• Postural vitals: HR <60, BP <90/60, RR, temp
(hypothermia)
• Height, weight, BMI
• Cardiac + GI examinations
Investigations:
• CBC (anemia, leucopenia, thrombocytopenia)
• Extended lytes, FBG, bicarb/BUN/Cr, LFTs
• TSH (low normal TSH + T4)
• Beta-hCG
• ECG (arrhythmia, prolonged QTc, T wave inversion)
• Bone mineral density
Management: (AN & BN)
• Outpatient vs inpatient program
Inpatient hospitalization
- Rare: for acute medical complications of disease
or concurrent emergent psychiatric risk, consider
admission to med ward:
o <65% standard body weight, or <85%
for adolescents
o Hypovolemia requiring IV fluids
o HR <40bpm
o Abnormal labs/electrolytes, risk of
arrhythmias
o Actively suicidal
- Agree on target body weight on admission
Outpatient:
- Start at 30-40kcal/kg/day, aim to increase 0.5-1lb
per week
- Consider pharmacotherapy for comorbid dx,
fluoxetine approved for BN
- Psychotherapy (individual/group/family): address
food and body perception, coping mechanisms,
health effects, relearning normal eating patterns
- Monitor for complications of disease including
refeeding syndrome
Refeeding Syndrome:
- Potentially fatal metabolic response to refeeding
in severely malnourished patients, shift of fluids
& electrolytes
- RF:
o Little to no intake >10d
o Abnormal electrolytes (epseically
phosphate) prior to refeeding
o Profound/rapid weight loss, Hx of
diuretic use, laxatives, insulin misuse
- Prevention: inpatient unit if at risk, slow
refeeding with regular monitoring of fluid status,
extended electrolytes, vitals & cardiac status
- Complications:
o Hypophosphatemia
o Congestive heart failure, arrhythmias
o Delirium
o Death
Approach to Geriatrics:
- Regularly assess functional status
o ADLs: DEATH: dressing, eating, ambulation,
toileting, hygiene
o IADLs: SHAFT: shopping, housekeeping,
accounting & prescriptions, food rep,
telephone/transportation
- Regularly assess medications
o Side effects, dose, interactions, indication
o Non-prescription: herbal, cough drops,
OTC, vitamins
- Screen for modifiable RFs: vision, hearing
- Discuss advanced care planning
- Discuss suitable living environment/social supports
- Geriatric PHE:
o Cognition
o Functional status
o Visual acuity, hearing
o Meds review
o Ulcers & mobility
o Pain
o Mood
o Bowel/bladder function
o Safety RISKS: roaming, imminent danger,
self neglect/suicide, kinship, safe driving &
substances
Sensory Deficits:
- Vision: low risk 65y+ (q2y), high risk 65y+ (annually)
o RFs: DM, thyroid disease, rheumatological
disease, African/Hispanic descent,
tendency towards high IOP, FHx glaucoma,
cataracts, macular degeneration, retinal
detachment, previous eye injury
- Hearing:
o No evidence to screen in asymptomatic
adults, regularly inquired about concerns
Falls:
- Gait & balance assessment: get up & go test (armless chair, stand up & walk 3m, turn & walk back, sit down → >12s
significant), Berg Balance scale, Performance Oriented Mobility Test
- Multifactorial assessment: meds, vision, OP, incontinence, CVD & orthostatic hypotension, environment, lower
extremity function & gait, balance, feet & footwear, functional assessment
- Falls prevention: minimize high risk meds, exercise program (strength, balance, gait, flexibility), treat OP, treat visual
impairment, treat postural hypotension/arrhythmias, OT home assessment, footwear (low heel, anti-slip)
ELDERLY
STOPP Criteria:
➔ Screening tool of older person’s prescriptions
- CV: loop diuretics for edema only, BB if COPD, CCB if
constipation, ASA with PUD, antiplatelets if bleeding
disorders, digoxin >0.125 with CrCl <50
- Resp: theophylline monoRx for COPD, systemic
steroids/ICS as maintenance COPD, atrovent if glaucoma
- CNS: TCAs, opioids if urinary retention, long term benzos
& neuroleptics, anticholinergics, SSRIs in ↓Na
- GI: Maxeran in PD, PPI >8w, anticholinergics constipation
- MSK: NSAIDs if Hx GI bleed/HTN/CKD, longterm steroids,
longterm NSAIDs/colchicine for gout
- Endo: BB if hypoglycemia, estrogens with breast ca/DVT,
estrogens w/o progesterone if intact uterus
- GU: antimuscarinics in dementia/glaucoma/constipation,
a-blockers in men with incontinence or longterm catheter
- Analgesics: long term opioids *except in palliative care,
regular opioids >2w if constipation
Falls Risk Meds: benzos, neuroleptics, 1st gen antihistamines,
vasodilators, long-term opioids
Also see START Criteria)
➔ screening tool to alert right treatment
Other Considerations for Elderly Patients
-
-
Abdo pain: include group-specific surgical causes
Anemia: consider in elderly using NSAIDs
- Appendicitis: less inflammatory response & more
likely to present with perforation, early CT
- Dementia:
• Behavioural problems can be due to
adverse med effects
• Delirium/treatable medical conditions
e.g. sepsis/depression
- Dehydration: assess using vital signs in elderly
- Depression
• Atypical presentation
• Somatic complaints, cognitive/
functional/sleep problems, complaints of
fatigue or low energy, social withdrawal
- Diarrhea: pursue investigations sooner as more
likely pathological
- Disability
• Screen elderly for risks (e.g. cognitive
impairment, immobilization, decreased
vision)
• Recommend primary prevention strategies
(e.g. exercises, braces, counselling, work
modification)
- Fever: no correlation fever & serious pathology
- Fracture: escalate to CT/bone scan if x-ray neg
- Grief: atypical reactions (e.g. behaviour change)
more common
- Pneumonia/immunization:
• Discuss benefits of immunization
(pneumococcus, flu)
• 1/3 can be afebrile
• Can present as nonspecific functional
decline or exacerbation of comorbidities
- Infection: often cause of ill-defined problems
- MI:
• Mild or no CP
• Confusion, weakness, dizziness
- Osteoporosis: older men need screening too!
- Parkinsonism: r/o in deteriorating functional
- Thyroid: elderly are higher risk
- UTI
• BPH increases risk
• Suspect if nonspecific abdo
pain/fever/delirium
Incontinence:
- Risk factors:
o Age, female, multiple vag deliveries, prostatic hypertrophy, obesity, DM, neurological disease, dementia/functional impairment, restricted mobility, polypharmacy
- Etiology:
o Chronic: see table
o Acute/reversible causes: DRIP → delirium/drugs, restricted mobility/retention, infection/inflammation/impaction, polyuria

Type Stress Urge Overflow Functional Mixed

Etiology Weakened pelvic floor
muscles and/or impaired
bladder neck sphincter tone
due to: advancing age,
multiple vaginal deliveries,
inadequate estrogen levels,
pelvic surgery, neurologic
insult
Inappropriate bladder
contractions from hyperactive
detrusor muscle. 2⁰ to stroke,
spinal stenosis, bladder
inflammation acutely (e.g. UTI,
stone) or chronic (e.g. tumour)
Obstruction to urine outflow (e.g. Cognitive/physical Combined stress and urge
tumour, pelvic organ prolapse, BPH, impairment mechanisms
fecal impaction, scar tissue from ↓ mobility (e.g. PD, Frail elderly patients may also
past surgery) arthritis) have detrusor hyperactivity with
Underactive bladder muscle due to Cognitive decline incomplete contractility (DHIC),
nerve damage (e.g. DM, alcoholism, (e.g. Alzheimer's characterized by urgency but also
B12 deficiency, spinal cord injury, severe depression) retention, despite the absence of
hip fracture, previous colorectal outlet obstruction
surgery)

Clinical Intermittent small volume Sudden need to urinate. Most Overdistension, leaking small Variable Mixed features, most common
presentation incontinence with increased common found in elderly- volumes, dribbling, and hesitancy form of incontinence in women
intra-abdominal pressure known as 'overactive bladder
syndrome'

High yield Do you ever leak urine when Are you unable to hold urine Are you unable to fully empty your Do you have trouble •
questions you laugh, cough, sneeze, or after having the urge to bladder? Is the urine stream getting to the
light something? urinate? weaker than in the past? washroom?

Physical Presence of chronic cough, Nonspecific exam, prostate Bladder distension, abdominal Cognitive + mobility Mixed findings
Exam signs of fluid overload enlargement masses, uterine prolapse/ cystocele assessment
DRE to assess for fecal impaction
Abnormal strength, sensation or
reflexes of lower extremities may
suggest neurologic insult
- Management: nonpharmacological
o Stress: weight loss in obese patients, manage constipation, smoking cessation, dietary changes: reduce alcoholic/caffeinated/carbonated beverages
▪ Pelvic floor exercises (Kegel's): contractions of pelvic floor, 3 set of 8 contractions, ideally 10s each, pelvic floor physiotherapy
▪ Pads & protective garments: as adjunct to incontinence therapy
▪ Vaginal pessaries: for pelvic prolapse & stress incontinence in women, useful if preference for non-surgical treatment/poor surgical candidate
▪ Surgical intervention: urethral sling, bladder neck sling, mesh sling/retropubic suspension
o Urge: as for stress incontinence + pelvic floor exercises & behaviour training: for urge incontinence, scheduled voiding (q2h during day, before bed, q4h when asleep if
nocturnally incontinent), positional change to minimize PVR (bending forward, suprapubic pressure, voiding twice consecutively)
- Pharmacotherapy: manage chronic conditions
o Antimuscarinics: e.g. oxybutinin/solifenacin (SE- dry mouth, blurred vision, somnolence, h/a, constipation), CI in acute glaucoma, urinary retention, pregnancy
o B3 adrenergic agonist e.g. mirabegron (SE- HTN, h/a, constipation, UTI), CI in severe uncontrolled HTN/bladder outlet obstruction
- When to refer: suspected neoplasm, unresolving hematuria, suspected fistula, neuro conditions, abnormal prostate/PSA, surgical management, persistent elevated PVR
Classification: Management Algorithm:
- Anterior bleed (most common, 90%)
o Within Kiesselbach’s plexus (Little’s area) EPISTAXIS
- Posterior bleeds
o Posterolateral branches of the Etiology:
sphenopalatine artery and carotid artery - Mucosal trauma or irritation
o Can result in significant hemorrhage, o Nose picking
brisk bleed despite nasal packing is o Facial trauma/impact
suggestive o Dry cold air
o *Emergency → Needs ENT consult o Allergic or viral rhinitis
o Foreign body
Initial Assessment: o Intranasal drug use (e.g. cocaine)
- ABCs: ensure hemodynamically stable, airway
patent, IVF resuscitation as required - Medications: ASA, anticoagulants,
- Emergency ENT consultation in severe epistaxis intranasal glucocorticoids
- Bleeding disorders: hereditary
hemorrhagic telangiectasia, platelet
History: disorders, von Willebrand disease,
- Predisposing factors, medical conditions, hemophilia
medications e.g. anticoagulants - Neoplasm (nasopharyngeal cancer more
- Timing, frequency, severity of epistaxis episodes common in Chinese or southeast Asian
- Other signs of bleeding or easy bruising heritage)
- Hypertension
Physical Examination:
- Assess hemodynamic stability Management → see algorithm
Disposition:
- Vital signs, mental status - Reassure patient & family
- Anterior packing usually d/ home with packing in pace,
- Signs of coagulopathy: ecchymoses, petechiae, - Consider pre-treatment with swab soaked in
f/u with ENT in 24-48h
telangiectasias anesthetic + vasoconstrictor, clear clots with
- Admit patients with posterior packing
- Examination of the nose gentle blow
- Silver nitrate → merocele tampon +/- TXA
→ balloon Home Management/First Aid:
Investigations: - Continuous pressure on the anterior soft cartilaginous
- Generally not indicated, investigate if Antibiotics: portion of the nose distally for 15 mins
hemodynamically unstable, suspicious of bleeding - Controversial: not given routinely, only in
- Sit upright
diathesis, use of anticoagulation certain high risk cases (e.g. diabetes,
- Head tilted forward
immunocompromised, advanced age)
- CBC, cross & type in massive hemorrhage - Humidifier in room
- If given should be anti-staph (clavulin, 1st
- INR/PTT if patient is anticoagulated - Vaseline applied until healed
gen cephalosporin, topical mupirocin) to
- ER if does not stop within 15 mins, heavy bleed/clots
prevent toxic shock
Approach to ‘Family Issues’
FAMILY ISSUES
- Ask about family issues to understand their impact on
patient’s illness, and the impact of the illness on family
- Assess periodically
o At important lifecycle points (after birth, when
Mandatory Reporting (relating to family issues)
children’s move out, relationship breakdown, after
family member’s death)
o When problems not resolving despite appropriate
therapeutic interventions
Inquiring about Family Issues
- Use open ended questions
- Focus attention as needed on important family issues
which may not be directed related to the patient’s medical
condition but may significantly affect their illness or
treatment
- Analyze potential conflicts between patient and family
members, general family functionality, and the impact of
the sick role on the family structure and function
- May be helpful to have both the patient & family be
participants in the patient’s treatment plan
Resources for Family Issues
• Abuse: victim services organizations, family physician,
friends/family, hospital, legal services, police, shelters
• Counselling: SW, psychologist, religious organizations
Family Violence
- Types: intimate partner violence, psychological &
emotional abuse, financial abuse, child abuse & neglect,
elder abuse, forced marriage, female genital mutilation
- Safety Plan
• Suitcase with essentials: keys, cash, IDs, health insurance,
cheques/credit cards, financial docs, photos
• Clothes for self + children
• Separate bank account, statements to another address
• Teach children safety plan/meeting point, essential
numbers including police
• Talk about situation with trusted family/friends,
considering having code word
Family
- Individual support system, beyond traditional family
- Understand important roles of each family member,
taking cultural context into account
• Child abuse or neglect
• Mandatory reporting to Children's Aid Society if any suspicion of neglect, physical
abuse, emotional abuse, sexual abuse
• Impaired driving ability
• Report to ministry of transportation
• Cognitive impairment, sudden incapacitation, motor/sensory impairment, visual
impairment, substance use disorder, psychiatric illness
• Long-term care & retirement homes
• Report to Registrar of the Retirement Homes Regulatory Authority or long-term care
home director
• Suspected harm to resident of nursing home or retirement home or at risk of harm due
to improper treatment/care/abuse/neglect
• Suspicion of misuse/inappropriate use of resident's money
• Sexual abuse of a patient
• Must report to appropriate licensing authority, within 30d
• Births/stillbirths, deaths
• Notice of birth/still-birth to Registrar General within 2 business days
• Must also provide medical certificate of stillbirth
• Death certificate by physician in attendance during last illness of deceased person or
sufficient knowledge of illness
• Notification of coroner:
• Death is result of violence, misadventure, negligence, misconduct, malpractice
• By unfair means
• During pregnancy or following pregnancy in circumstances that might be
reasonably attributed to the pregnancy
• Suddenly and unexpectedly
• From disease or sickness for which he or she was not treated by a legally qualified
medical practitioner
• From any cause other than disease
• Under circumstances that may require investigation
• Privacy breaches
• Must notify patient & advise about entitlement to make a complaint to the Information
and Privacy Commissioner
• Must include details of breath, steps taken to address, contact information
Definition: O/E: general (LOC, psychomotor agitation/retardation)
- Difficulty or inability to initiate activity (subjective weakness) - Evidence of thyroid disease (HR, goitre, ophthalmopathy)
-
-
Reduced capacity to maintain activity (easy fatigability)
Difficulty w/ concentration, memory, emotional stability (mental fatigue)
FATIGUE -
-
Lymphadenopathy, hepatosplenomegaly
CVS (CHF), resp (COPD), neuromuscular exam + cognition if relevant
- Sleepiness or uncontrollable need to sleep History:
Characteristics: onset including relationship to event, course, duration & daily pattern, alleviating +
Classification: exacerbating factors, impact (work, social, family)
- Acute: <1 month Quantity & quality of sleep
- Subacute: 1-6 months Meds: benzo, antidepressants, muscle relaxants, 1st gen antipsychotics, antihistamines, BB, opioids
- Chronic: >6 months Social: changes or stressors in home/work environment
Patient survey instrument: brief fatigue inventory, fatigue symptom inventory
Etiology: PS PS VINDICATE, 50% associated with psychological problem Associated Sx:
P: psychogenic- depression, stressors, anxiety, chronic fatigue, fibromyalgia - CHF: exertional dyspnea, orthopnea, PND, peripheral edema
S: sleep disturbance- OSA, poor sleep hygiene, BPH, shift work, pain - COPD: dyspnea, chronic cough, sputum production
P: physiologic: pregnancy, excessive caregiving demands - OSA: snoring, interrupted breathing during sleep
S: sedentary: deconditioning/sedentary lifestyle - Hypothyroidism: cold intolerance, weight gain, constipation, dry skin
- Hyperthyroidism: heat intolerance, weight loss, diarrhea, clammy skin
V: vascular: stroke
- Chronic renal disease: N/V, mental status change if severe, oliguria
I: infectious: viral (EBV, hep, HIV), bacterial (TB), fungal, parasitic
- Chronic hepatic disease: abdo distention, GI bleed, gynecomastia, edema, spider nevi
N: neoplastic, nutrition (anemia), neurogenic (myasthenia, MS, Parkinson’s) - Adrenal insufficiency: weight loss, GI complaints, salt craving
D: drugs: B-blockers, antihistamines, benzos, antiepileptics, antidepressants - Anemia: dizziness, weakness, palpitation, dyspnea
I: idiopathic: chronic fatigue syndrome - Occult malignancy: fever, night sweats, weight loss
C: chronic illness: CHF, COPD, sarcoidosis, renal failure, chronic liver disease - Infectious: fever, night sweats, child, lymphadenopathy, weight loss
A: autoimmune: SLE, RA, mixed connective tissue disease, PMR - Fibromyalgia: chronic diffuse muscle pain, comorbid mood Sx
- PMR: aching/morning stiffness of shoulders/neck/hips, comorbid GCA
T: toxin: substance abuse (e.g. alcohol), heavy metal
- Depression: low mood, anhedonia, insomnia/hypersomnia, ↓ concentration/cognition
E: endocrine: hypothyroidism, DM, Cushing’s, adrenal insufficiency - Anxiety: general nervousness, panic attacks, phobias
Chronic Fatigue Syndrome Investigations:
- Unexplained persistent & relapsing fatigue >6 months, Dx of exclusion Labs: CBC, glucose & A1c, lytes, Ca, Cr, TSH
Dx: both of Consider: liver enz, CK, hep/HIV serology
1. New or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not relieved by rest, which If indicated: inf (TB, monospot, cultures, rheum
results in occupational, education, social, or personal dysfunction. (ESR, RF, ANA), CV (CXR, echo, sleep study), endo
2. Concurrent presence of 4+ of the following symptoms for a minimum of 6 months: (T4, cortisol), psych (GAD-7, PHQ-9)
o Impairment of short term memory or concentration severe enough to cause significant decline in function, sore throat, Age appropriate screening (CRC 50-74y, cervical
tender cervical or axillary lymph nodes, muscle pain, multi-joint pain with no swelling or redness, new headache, 21-70y, breast 50-74y, lung 55-74y + 30 pack y )
unrefreshing sleep, post-exertion malaise lasting >24h
- Exclusion criteria: medical conditions that may explain the fatigue, certain psychiatric disorders (depression with psychotic or Management:
melancholic features, schizophrenia, eating disorders), substance abuse, severe obesity (BMI >35) - Supportive relationship, establish
Clinical Presentation therapeutic goals (ADLs, relationships, work)
- Easy fatigability, difficulty concentrating, headache, sore throat, tender lymph nodes, myalgia, arthralgia, insomnia, mood Sx - Brief regular appointments
Management - Address underlying medical conditions, trial
- Supportive- focus on treating comorbidities (pain, depression, anxiety, sleep disorders) antidepressant if co-morbid mood Sx
- Establish rapport: real illness, not malingering, no diagnostic test, address concerns about specific dx, work modifications - Cognitive behavioural therapy
- Graded exercise therapy, CBT - Exercise therapy
Approach to Fractures in Trauma Setting
- Stabilize the patient with ABCs before dealing with #s
- Life threatening injuries: usually due to blood loss,
manage during primary survey
o Direct pressure
o Pelvic #- binders
o Traumatic amputation
o Massive lone bone injuries- grossly reduce &
splint
o Vascualr injury proximal to knee/elbow
- Orthopedic emergencies: VON CHOP
o Vascular compromise: 5Ps
o Open #, crush injuries
o Neurological compromise/cauda equina
o Compartment syndrome
o Hip dislocation, ankle dislocation
o Osteomyelitis/septic arthritis
o Pelvic # unstable
Examining Suspected Fractures
- General joint/MSK exam: look, feel, move
- Assess NV status:
o 5Ps: (vascular compromise) pallor,
poikilothermic, pulseless, paresthesia, paralysis
o Hand nerve exam: radial (thumbs up), median
(okay sign), ulnar (spread fingers)
- Examine joint above & below, palpate area around #site
- SEADS & signs of open #
Reduction & Immobilization
Closed Reduction
- Apply traction in the long axis of the limb
- Reverse the mechanism that produced the #
- Reduce with IV sedation & muslce relaxation
- Pre & post reduction x-rays, recheck NV status
Open Reduction:
- Indications (NO CAST) non-union, open #, compromised
NV, intra-articular #, Salter Harris 3-5, polytrauma
o Others: failed closed, unable to cast/traction
due to site (e.g. hip, pathology 3)
- Recheck NV after reduction + post-reduction x-ray
Immobilize
- Maintain reduction, external (splint, case, external
fixator) vs internal (pins, screws/plates/rods)
Rehabilitation: after period of immobilization
FRACTURES
Fractures Not Obvious on X-ray
1. Scaphoid #
- Mechanism: FOOSH with wrist extended
- Sx: tenderness in anatomical snuffbox, pain on axial loading on thumb pain with palpation scaphoid tubercle
- Ix: wrist x-ray with scaphoid views
o If positive: thumb spica splint x 6 weeks, repeat x-ray in 2 weeks, risk of non-union/AVN if not immobilized
o If displaced >1mm or significant change in scapholunate angle- immobilize & referred to ortho
o If negative consider CT/bone scan or thumb spica splint + repeat x-ray in 1w
2. Elbow #
- Supracondylar most common in kids, radial head # in adults
- Suspect proximal radial # with lateral elbow pain after FOOSH
- Obtain AP & lateral x-ray, if no # evident- radiocapitellar view
- If no obvious fracture, look for elevated ant/post fat pads (sail sign- occult #)
- Immediate reduction +/- surgical intervention critical if radial head/neck # and elbow dislocation- risk of AVN
- Isolated nondisplaced # can be managed with posterior splint flexed to 90 degrees + sling
3. Salter Harris #
4. Stress #
- # after bone subjected to repeated tension/compression
- Common sites: tibia > metatarsals > fibula
- Risk factors: hx prior stress #, low physical fitness, sudden increased intensity physical activity, female, obesity, OP
- Sx: insidious onset localized pain within days to weeks beginning of strenuous activity, focal tenderness at site
- Ix: x-ray, consider MRI/bone scan if negative
- Rx: pain control, protection of # site with reduced weightbearing or splinting, activity modification → gradual
resumption, rehabilitative exercises
o Risk factor modification: biomechanics, bone health, weight management
Hip Fractures
- Sx: new inability to weight bear, hip pain on axial loading, inability to SLR
- With insufficiency # there may be no obvious Hx trauma and pt have vague knee/buttock/groin/thigh pain
- O/E: abducted externally rotated leg, shortened, localized tenderness, limited active/passive ROM
- Classification: intracapsular (femoral neck/head) vs extracapsular (intertrochanteric/subtrochanteric)
• Intracapsular have high rates nonunion, malunion, and avascular necrosis of femoral head
- Ix: AP view of hip with max internal rotation, lateral view, AP pelvis --> CT/MRI (consider bone scan, US) if x-ray neg
& clinical suspicion high
- Rx: analgesia + ortho consult, DVT prophylaxis
o Crossmatch in pts with 2 of: >75y, initial Hb <120, peritrochanteric #
High Risk Complications of Fractures
Life-Threatening:
- Severe hemorrhage (femur or pelvic #)
- Rhabdomyolysis secondary to immobilization in elderly
- Pulmonary contusion with rib #
- Thromboembolism secondary to immobilization
- Fat embolism: associated with closed long bone # of lower
extremity & pelvis

Serious Complications:
- Arterial injury
- Nerve injury
- Compartment syndrome: pain out of proportion, paresthesia,
pain with passive stretching
- Open #: tetanus prophylaxis, surgical irrigation &
debridement, antibiotics
- Osteomyelitis: risk with open # + soft tissue injury, cefuroxime
+/- vanc, immunocompromised
- Non-union/malunion
- Complex regional pain syndrome
- Post-traumatic arthritis

Ottawa Knee Rule

Ottawa Ankle & Foot Rules

Ankle radiographs only required if pain in malleolar zone & any of:
- Bony tenderness at A
- Bony tenderness at B
- Inability to bear weight both immediately and in ER

Foot radiographs only required if pain in midfoot & any of:

- Bony tenderness at C
- Bony tenderness at D
- Inability to bear weight both immediately and in ER
Etiology: UGIB Treatment: (immediate management)
- Ulverative/erosive:
o Duodenal/gastric ulcer (H. pylori, NSAIDs, stress
ulcer, Zollinger Ellison), esophagitis (GERD, pill
GASTROINTESTINAL General Management:
- ABCs, resuscitate
esophagitis, infection), gastritis/duodenitis (H. - Supplemental O2 + ETT if massive bleed or LOC
pylori, NSAIDs, alcohol, radiation, weight loss BLEED - 2 large bore IVs, consider central line
surgery, anticoag) - NPO
- Portal HTN complications: Approach to GI Bleeding - Ix: CBC for Hb, cross match & type, Cr, lytes, LFTs,
o Esophageal varices, ectopic varices, portal UGIB vs LGIB coagulation studies +/- ECG to r/o MI
hypertensive gastropathy - Upper GI bleed: proximal to ligament to treitz - Transfusions PRN:
- Vascular lesions: o Hematemesis, coffee ground emesis, o pRBC if Hb <70 & consider transfusion if Hb
o Angiodysplasia (ESRD, AS, HHT, von Willebrand, melena, BRBPR if brisk <80 & active bleeding
radiation), Dieulafoy’s lesion, gastric antral - LGIB: distal to ligament of treitz o FFP if INR >1.5
valve ectasia, congenital venous malformations o Hematochezia, unexplained anemia o Platelets if <50
- Traumatic/iatrogenic: Risk Factors - Reverse coagulopathies:
o Mallory-weiss, FB investion, post-surgical - Prior Hx GI bleed o Vitamin K- warfarin
anastomotic bleeding, post- - Admission to hospital/ICU o Protamine- heparin
polypectomy/endoscopic resection, - NSAIDs, EtOH o Praxbind- dabigatran)
aortoenteric fistula - Cirrhosis
- Tumours: Gastric Cytoprotection UGIB:
o Adenocarcinoma, GI stromal tumour, - Sucralfate, Cytotec (misoprostol) - IV PPI bolus if non-variceal
lymphoma, Kaposi sarcoma, carcinoid, Consider other Causes of Discoloured Stool o Pantoprazole: 80mg IV x 1, then 8mg/h
melanoma, metastatic - Beets, berries continuous infusion x 72h, alternatively 40mg
- Iron supplementation, pepto-bismol IV BID
Etiology: LGIB - Variceal bleeding: somatostatin analog
- Anatomic: diverticulitis/diverticulosis Clinical Prediction Tool- Glasgow Blatchford Score o Octreotide 50mcg bolus x 1, then 50mcg/h
- Vascular: angiodysplasia, hemorrhoids, ischemic, post- - Predicts safe discharge from ER, any abnormal infusion
biopsy/polpectomy, radiation induced telangiectasia results indicated high risk for bleed, >6 points - Endoscopy within 24h
- Inflammatory: infectious, IBD, ulcer indicated 50% risk of requiring intervention o If hemodynamically unstable- resuscitate then
- Neoplastic: polyp, carcinoma - Hb, BUN, initial systolic BP, sex, HR ≥100bpm, emergent endoscopy
- Anorectal: hemorrhoids, fissure, fistula melena, recent syncope, hepatic disease Hx, o Consider balloon tamponade in interim
cardiac failure present - TIPS
Investigations: o If endoscopy fails (transjugular intrahepatic
UGIB: hematemesis or melena portosystemic shunt)
- Hemodynamically unstable: resuscitate & emergency endoscopy (when stable), no source → colonoscopy - Abx: ceftriaxone 1d IV daily as prophylaxis
o If no source & improving → evaluate for small bowel bleeding
o If no source & ongoing bleeding → deep small bowel enteroscopy, consider additional testing e.g. LGIB:
angiography, CTA, Meckel’s scan, laparoscopy/laparotomy with intraoperative enteroscopy - Colonoscopy within 24h
- Hemodynamically stable: upper endoscopy within 24h → no source: colonoscopy → no source: evaluation for o 4-6L PEG over 3-4h +/- NG tube
small bowel bleeding - Consider mesenteric angio or CT angio first if bleeding
LGIB: hematochezia is severe
- Hemodynamically stable: colonoscopy, no source → if isolate, expectant management, if ongoing → endoscopy - If negative, consider small bowel investigation
- Hemodynamically unstable: resuscitate & consult surgery/IR, upper endoscopy once stable, if no source & - May consider outpatient sigmoidoscopy/colonoscopy
ongoing bleeding → angiography, if bleeding improving → colonoscopy if young, self-limited, and likely anal source

Terminology:
- Gender: a social construct which varies
depending on time, location, and culture
- Gender roles/expressions vary greatly
e.g. across generations, culture
Sexual Attraction: attraction on
the bases of sexual desire of
interest (e.g. to women, to men,
asexual, pansexual, heterosexual,
homosexual)
Sex: refers to physical aspects
of our body, including genitals,
hormones, etc. (e.g. XX, XY,
intersex)
Difference in Health by Sex:
- Men traditionally used as a prototype for older research, results may not be generalizable across sexes
- e.g. statins: decreases CV events in women, but not all cause mortality
- e.g. ASA: reduced CVA in women, but not MI
GENDER SPECIFIC ISSUES
Gender Identity: your internal
experience of gender (e.g. woman,
man, agender, genderfluid)
Gender Expression: the
way you publicly present
your gender identity,
including dress &
behaviour (e.g. feminine,
masculine, agender,
androgynous)
Differences in Health by Sex:
CV:
- Higher mortality in males, angina
prevalence higher in women, cardiac CP
more likely to be atypical in women, men
typically diagnosed with CV disease 10y
earlier than F, CVD risk 4x after menopause,
men more likely to have sudden cardiac
death
Resp:
- Women more likely to develop lung cancer
per cigarette smoked
Depression:
- Higher prevalence in women, higher
completed suicide rate in men, men present
less frequently and often do not disclose
emotional distress, more often masked by
substance abuse in men
CNS:
- Women more likely to recover speech after
stroke, women more likely to experience
pain from pressure/electrical stim,
adolescent boys likely to take life-
threatening risk & die in violent manner
Immune:
- Women more likely to recover better from
viral infections, males more susceptible to
parasitic infections
GI:
- Women more likely to have IBS
MSK:
- Women more likely to have hip fractures
Meds:
- Women clear erythromycin, prednisolone,
and diazepam better than men
Triggers to Grief Reactions
- Death of family/friend, miscarriage
- Moving homes/cities/schools
- Loss of job, retirement
- Loss of pet
- Diagnosis of serious illness
- Relationship breakdown
Types of Reactions
- Emotional: disbelief, denial, bargaining,
guilt, anger, depression, acceptance/hope
- Physical
- Behavioural
Risk Factors for Poor Bereavement Outcome
- Poor social supports
- Unanticipated death, lack of preparation
- Highly dependent relationship with
deceased individual
- High initial distress
- Other concurrent stresses and losses
- Death of a child
- Pre-existing psychiatric disorders, especially
depression and separation anxiety
Complex Bereavement Disorder
• Severe and persistent grief and mourning reaction ≥ 6 months
• ≥ 1 of:
o Intense and persistent yearning for deceased
o Frequent preoccupation with deceased
o Intense feelings of emptiness or loneliness
o Recurrent thoughts that life is meaningless or unfair without deceased
o A frequent urge to joint the deceased in death
• ≥ 2 of: (for at least 1 month)
o Feeling shocked, stunned, numb
o Feeling disbelief o inability to accept loss
o Rumination about circumstances of death
o Anger or bitterness about death
o Experiencing pain that deceased suffered or hearing/seeing the deceased
o Trouble trusting or caring about others
o Intense reactions to memories or reminders of deceased
o Avoidance of reminders of deceased or seeking out reminders to feel close to deceased
Grief: natural response to loss, characterized by emotional/
GRIEF physical/behavioural disturbance
Bereavement: time spent adjusting to loss
Major Depressive Disorder vs Grief
- Complex/atypical grief reaction may present with features of MDD
Characteristic MDD Grief
Affect Persistent depressed mood Predominantly feelings of emptiness
and loss
Symptom pattern Symptoms persistent Symptoms decrease in intensity over
days to weeks, occur in waves
Association Symptoms pervasive Symptoms related to
thoughts/reminders of deceased
Thought content Self criticism and pessimistic Thoughts and memories of the
ruminations deceased
Self-worth Feelings of worthlessness, self-loathing Self-esteem preserved unless perceived
feelings about deceased (e.g. guilt)
Thoughts of death Focused on ending life because of Thoughts of death focused on deceased
feelings of worthlessness, undeserving, and about joining the deceased
unable to cope with pain of depression
Function Often impaired social/occupational Generally preserved unless complex
functioning reaction, may have temporary
sleep/appetite concentration issues
Adjustment Disorder
DSM Diagnostic Criteria
A. Development of emotional/behavioural Sx in response
to identifiable stressor(s) within 3 months
B. Clinically significant Sx: excess of expected or
social/occupational impairment
C. Does not meet criteria for another mental disorder
D. Do not represent normal bereavement
E. Once stressor terminated, Sx persist < 6 months
Treatment
- Psychotherapy: group, individual, family
- Crisis intervention
- Pharmacological: short-term low-dose benzo, SSRIs
for mood + anxiety Sx
Common Benign Headaches
Migraine
- Sx: POUND (pulsatile, onset with photo/phono-phobia +/- visual aura,
unilateral, nausea, disabling, duration 4-18h)
HEADACHE
- Triggered by stress, hormones, hunger, dehydration, weather, sleep, Serious Pathology Headaches
odours, neck pain, lights, alcohol, heat, exercise, sex Condition Presentation Investigations Management
- Rx: (abortive): tylenol/NSAIDs, triptans, metoclopramide, ergotamine Meningitis & Severe pain, rash, neck CT/MRI, LP, Urgent empiric Abx: ceftriaxone 2g
o ER: 1L NS bolus, maxeran 10mg IV, +/- sumitriptans 6mg SC, Encephalitis stiffness, photophobia +ve septic workup, IV q12h + vanc 1g IV q12h, +/-
+/- dex 10-25mg IV/IM to prevent recurrence Kernig or Brudzinski, fever, Rx before Ix if ampicillin 2g q4-6h IV for listeria
- Prophylactic: if >3d/m or impacting QoL confusion, +/- focal neuro suspected coverage
o Propranolol, topiramate, amitriptyline, gabapentin, deficits
candesartan Temporal >60y, temporal h/a, severe CRP/ESR, No visual loss: pred 1mg/kg/d PO
arteritis +/- jaw claudication, scalp temporal artery (max 60mg) x2w then wean
Tension: tenderness, vision loss biopsy, Rx Visual loss: methylpred 1g IV x 3d
- Sx: bilateral pressing/tightening, mild-moderate intensity before Ix if Urgent ophthalmology consult
- Infrequent episodic (<1d/m), frequent (1-14d/m), chronic (15+d/m) suspected
- Acute rx: NSAIDs/tylenol, nonpharm supportive management Subarachnoid Thunderclap onset, severe CT head, LP Urgent neurosurgical consult
including lifestyle change e.g. alcohol ↓, sleep, caffeine, stress hemorrhage pain/neck pain, +/- transient
LOC
Medication Overuse: Subdural, Hx head trauma, h/a, CT head Urgent neurosurgical consult
- Hx PRN analgesic use >2-3d/w for 3+ months, temporary/partial relief epidural bleed anticoagulation, emesis
- Can occur with all analgesia, opioids > ASA/tylenol/caffeine > triptans Cervical artery Recent head/neck trauma, MRA or CTA Thrombolysis if acute stroke,
> tylenol > NSAIDs dissection prominent neck pain, antiplatelets therapy
- Rx: Stop Rx, gradual withdrawal +/- bridge with another therapy e.g. Horners, new acute Urgent neurosurgical consult
naproxen, prednisone, or ergotamine/metoclopramide dizziness, tinnitus
Carbon Hx CO exposure, h/a Elevated Removal from source, high flow
Cluster: monoxide resolved when away from carboxy-Hb on O2 → hyperbaric O2 in LOC or
- Unilateral orbital/temporal attacks lasting <3h, conjunctival toxicity exposure, nausea, dizziness, ABG/VBG severe metabolic acidosis
injection/lacrimation, rhinorrhea, eyelid edema, facial sweating, LOC if severe
miosis/ptosis, agitation Acute narrow- Eye pain, red or tearing eye, IOP, slit lamp IV acetazolamide, timolol +
- Episodic (2+ cluster periods with pain-free intervals >1m), vs chronic angle glaucoma N/V, ↓ vision, fixed mid- w/o dilation, pilocarpine drops
(1+ year without remission or remission <1m) dilated pupil, IOP ↑ urgent optho Surg: peripheral iridectomy
- Acute Rx: triptans, high flow O2, ergotamine, consider prophylactic Cerebral vein & VTE RF, h/a, papilledema, +/- CT → CT/MRI Early anticoag- therapeutic
dural sinus seizure venography, D- heparin +/- endovascular- neuro
treatment (verapamil, lithium)
thrombosis dimer. LP Assess for thrombophilias
Red Flags for Headaches Hypertensive Severe HTN, N/V, Fundoscopy, CT Lower MAP 10-20% in first hour,
• New onset >50y encephalopathy papilledema + retinal head, ECG + then 5-15% over next 23h (CI acute
• Thunderclap headache (subarachnoid) hemorrhage, cardiac w/u ischemic stroke, AAA, ICH
• Trauma (ICH) hematuria/proteinuria (IV labetalol)
• Fever/constitutional Sx (meningitis) Brain tumour Hx cancer, ↑ w/ cough, CT +/- MRI Urgent neurosurgical referral
• Vision loss (temporal arteritis, glaucoma) Valsalva, N/V, neuro deficits
• Focal neurologic deficits (CNS malignancy, encephalitis) Brain abscess h/a with recent Hx CT head Urgent neurosurgical consult
• Severe neck pain (meningitis, cervical artery dissection) bacteremia, fever, neck
• Morning emesis (increased ICP, CO poisoning) stiffness
• Significant worsening frequency/intensity IIH Obese female, visual sx, ↑ MRI → LP, Weight loss, carbonic anhydrase
• Scalp tenderness, jaw claudication (temporal arteritis) with Valsalva, resolves lying optho consult inhibitor (acetazolamide)
• HTN (ICH, hypertensive encephalopathy, pre-eclampsia) flat, 6th CN nerve palsy Rarely CSF shunts
*Drugs causing ↑ enzymes: acetaminophen, chlorpromazine,
isoniazid, methotrexate, amiodarone, azoles, statins, methyldopa,
phenytoin, PTU, rifampin, sulfonamides, tetracyclines, herbs
(chaparral, germander, comfrey, bush tea)
Hepatocellular vs Obstructive
Hepatocellular
Liver AST/ALT > ALP
enzymes AST:ALT 2:1 in alcohol, ↑GGT
DDx Viral hepatitis, EBV/CMV, drugs*, liver
abscess, alcohol, ischemia, Budd-Chiari,
fatty liver, malignancy, yellow
fever/malaria, a1 antitrypsin deficiency, Q
fever, autoimmune hepatitis, Wilson’s,
hemochromatosis
Ix Viral hep serology
Autoimmune: anti-SMA, anti-LKM, RF +
ANA, biopsy
Drug levels if appropriate
Wilson’s: ↓ceruloplasmin, ↑ urine
copper, ↑ copper on liver biopsy, ATP7B
Hemochromatosis: ↑ferritin, HFE gene
Alcohol: AST:ALT 2:1, CBC, GGT
Fatty liver: echogenic liver texture on US
Hepatitis B Serology*
HBsAg Anti-HBs
Acute HBV + -
Chronic- high infectivity + -
Viral Hepatitis
Hepatitis A
HEPATITIS - Transmission: fecal-oral, food borne, contagious
during incubation (2-3w) + 1w after jaundice
- RF: travel, rarely blood borne (MSM, IVDU)
- Sx: self-limited, N/V, malaise, fever, abdo pain, dark
Cholestatic
urine + pale stool, arthralgia, jaundice
ALP>AST/ALT
ALP 4x ULN - Ix: hepatocellular ,rare cholestatic, IgM & anti-HAV Ab
CBD obstruction: pancreatic cancer, lymphoma, - Rx: supportive, stop hepatotoxic meds
choledocholithiasis, ascending cholangitis, cholangiocarcinoma, - Complications: cholestasis, can trigger autoimmune
sclerosing cholangitis, helminths - Prev: inf-lifelong immunity, vaccination (Havrix 0/6m,
Primary biliary cholangitis Twinrix 0/1/6m), post-exposure prophylaxis
Bile acid transporter defects, intrahepatic cholestasis of preg
Liver infiltrations: mets, lymphoma, granulomas, amyloidosis Hepatitis B
*ALP raised alone: bone disease, pregnancy - Transmission: parenteral, sexual (anal>vaginal>oral),
CBC, bili (direct + total), enzymes + LFTs, amylase, lytes, BC x 2 household contact- horizontal, vertical
- PSC: ↑ALP, + p-ANCA, ERCP - RF: multiple sexual partners, MSM, incarceration,
- PBC: ↑ALP/GGT, + AMA, ↑ lipids, no duct narrowing tattoos, healthcare work, IVDU, transfusion <1992
on ERCP, biopsy - Sx: 70% acute inf ASx, N/V, malaise, fever, RUQ pain,
*Prompt US/CT for evidence of bile duct obstruction dark urine + pale stool, jaundice, pruritus, stigmata of
Abdo US: (duct dilation) chronic liver disease, encephalopathy
- Extrahepatic: ERCP- relive obstruction/MRCP- diagnosis - Ix: hepatocellular, serology*, chronic HBsAg >6m, HIV
- Intrahepatic dilation: AMA, MRCP, viral hep, EBV/CMV, - Rx: acute (supportive), chronic 5+ y treatment
liver biopsy (interferon, entecavir, tenofovir, lamivudine,
Percutaneous transhepatic cholangiography (definitive
adefovir)- consider if HBeAG +/↑HBV DNA
management liver obstruction if ERCP failed)
o Counsel (alcohol, vaccines, transmission)
o Screen: for HCC w/ abdo US q6m
HBeAg Anti-Hbe Anti-HBc Liver enzymes - Complications: 5% acute → chronic in adults, 90% in
children, HCC, cirrhosis (↑ w/ hep D)
+ - IgM Elevated - Prev: vaccine (0/1/6m, Engerix-B or Twinrix), post-
+ - IgG Elevated exposure prophylaxis HBIG + vaccine

Chronic- low infectivity + - - + IgG ALT ↑, AST N Hepatitis C

- Transmission: parental, sexual less commonly
Resolved infection - +/- - +/- IgG Normal - RF: multiple sexual partners, MSM, incarceration,
tattoos, healthcare work, IVDU, transfusion <1992
Immunization - + - - - Normal
- Sx: fatigue, N/V, abdo pain, arthralgia, weight loss,
Complications of Chronic Liver Disease/Cirrhosis diarrhea, extrahepatic (haem, renal, derm)
- Heme: pancytopenia, early thrombocytopenia from hypersplenism, ↑ INR - Ix: hepatocellular, acute + HCV RNA with neg antiHCV,
- Portal HTN: ascites, variceal bleeding, splenomegaly, caput medusa, umbilical hernia, hemorrhoids chronic + HCV RNA +antiHCV, HIV serology
- Renal failure: pre-renal from volume redistribution, ATN, hepato-renal syndrome - Rx: antivirals (pegylated interferon a + ribavirin +
- Hepatopulmonary syndrome protease inhibitor), counselling + vaccinations
- Encephalopathy: acute hepatic encephalopathy, Wernicke’s → Korsakoff’s syndrome o Screen for HCC with US q6 months
- Dupuytren’s contracture - Complications: 80% acute → chronic, HCC, cirrhosis
- Derm: loss of sexual hair, palmar erythema, spider angioma - Prev: no vaccine, post-exposure lab, +ve Rx within 3m
Who to Screen:
- Men & women ≥40y (or postmenopausal)
o Consider earlier in high risk ethnic
groups e.g. South Asian, First Nations
- All patients, regardless of age, if:
o Clinical evidence atherosclerosis
o Abdominal aortic aneurysm
o Diabetes mellitus
o Arterial hypertension
o Current cigarette smoking
o Stigmata of dyslipidemia (e.g. arcus
cornealis, xanthelasma, or xanthoma)
o Family Hx premature CVD (in 1st degree
relative, <55y in men, <65y in women)
o Family history of dyslipidemia
o Chronic kidney disease (eGFR <60 or
ACR >3mg/mmol x 3 months)
o Obesity (BMI ≥ 30kg/m2)
o Inflammatory disease
o HIV infection
o Erectile dysfunction
o Chronic obstructive pulmonary disease
o Hypertensive diseases of pregnancy
How to Screen:
- History & physical exam
o Modifiable underlying disease e.g.
thyroid disease, alcohol abuse
- Standard lipid panel (TC, LDL-C, HDL-C, TG)
nonfasting, consider fasting is TG >4.5mmol/L
- Non HDL-C (calculate from profile)
- Glucose
- eGFR
- Optional: ApoB, urine ACR (eGFR <60, HTN/DM)
Risk Assessment:
- Calculate FRS (validated 40-75y) or CLEM,
unless statin indicated conditions
- Repeat screening every 5y if FRS <5%, or yearly
if FRS ≥5%
HYPERLIPIDEMIA
Station Indicated Conditions
- Clinical atherosclerosis
- Abdominal aortic aneurysm
- Most diabetes, including:
o Age ≥40y
o Age ≥30y & 15y duration (type 1 DM)
o Microvascular disease
- Chronic kidney disease
- LDL-C >5mmol/L (genetic dyslipidemia)
Primary Prevention Indications
- High risk: FRS ≥20%
- Intermediate risk: 10-19% AND (one of)
o LDL-C ≥3.5mmol/L
o non-HDL-C ≥4.3mmol/L
o apoB ≥1.2g/L
o Men ≥50y/women ≥60y with one
additional RF:
▪ Low HDL-C, IFG, high waist
circumference, smoker, HTN
No Pharmacotherapy
- Low risk: FRS <10%
Secondary Testing
- Coronary artery calcium measurement (CT)
o Asymptomatic patients, FRS 10-20%
where treatment decisions uncertain
o Consider for low-risk middle aged
individuals with FHx premature CVD
- Lipoprotein-a measurement
o To aid risk assessment in pts with
intermediate FRS/ FHx premature CAD
o If >30mg/dL, CVD risk increases 2x
Treatment
Targets:
- LDL-C <2.0mmol/L or >50% reduction
- ApoB <0.8g/L
- Non-HDL-C <2.6mmol/L
Statin Therapy
- Dosing
o Pravastatin 10-20mg → 40-80mg
o Lovastatin 10-20mg → 40-80mg
o Simvastatin 5-10mg → 20-40mg
o Atorvastatin 5mg → 10-20mg → 40-80mg
o Rosuvastatin 2.5mg → 5-10mg → 20-40mg
Non-Statin Therapy
- Ezetimibe 2nd line if not at target and maximum
tolerated statin therapy
- Consider bile acid sequestrants if above target despite
statin +/- ezetimibe
- Consider PCS-K9 inhibitors for patient with familial
hypercholesterolemia when LDL-C above target
despite maximally tolerated statin therapy
o E.g. evolocumab, alirocumab
Health Behaviour Interventions
- Diet: Mediterranean, portfolio, DASH, high in nuts/
legumes/olive oil/ fruits & vegetables, high in total
fibre and whole grains, low glycemic load,
vegetarian/plant base diet, avoid trans-fats and
decreased saturated fats
- Recommend against omega3 fatty acid supplements
- Activity: at least 150 min moderate to vigorous
intensity aerobic physical activity per week
- Smoking cessation
- Reduce alcohol consumption
- Moderate sleep duration (6-8h/night)
Follow Up
- Assess compliance, monitor SE (myalgias, ↑ glucose)
- Labs: transaminases within 3 months, CK if myalgias
- Referral indications: unexplained atherosclerosis,
severe dyslipidemias, genetic, refractory to treatment
Measuring Blood Pressure:
4 methods: electronic ambulatory office BP preferred
1. AOBP: mean ≥135/75mmHg
2. (Manual) Non-AOBP: mean ≥140/90mmHg
3. Ambulatory monitoring: mean ≥135/85mmHg,
24h ≥130/80mmHg
4. Home monitoring: mean ≥135/85mmHg
Home BP Monitoring Technique
- Electronic meter, discard first day’s readings
- Resting comfortably for 5 mins with seats
position & back support, no talking
- Arm bare & supportive with cuff at heart level
- Check before breakfast & 2h after dinner, before
medication
- No caffeine or tobacco in the hour, no exercise
30 mins proceeding, not after using bathroom
Diagnosis:
- Mean Office BP ≥180/110 → HTN
- DM: AOBP/non-AOBP ≥130/80 → HTN
- Non-DM: AOBP ≥135/85 or non-AOBP ≥
140/90 → HTN
Investigations:
- Routine: urinalysis, CBC, electrolytes, creatinine,
fasting BG &/or A1c, lipid panel (fasting or non-
fasting), ECG
- Optional: Urine ACR in DM
- Routine echo/imaging not recommended unless
signs of CHF
Cardiovascular Risk: Framingham Score (see hyperlipidemia)
Health Behaviour Management
1. Physical exercise: 30-60min aerobic exercise 4-7d/w
2. Weight reduction: BMI & waist circumference
3. Limit alcohol: ≤2/d, and ≤14/w (M) or ≤9/w (F)
4. Diet: fruit, veg, low-fat dairy, whole grain, ↓
saturated fat & cholesterol, plant protein, DASH diet
5. ↓ Sodium intake: <2000mg/day
6. Calcium & magnesium: no supplementation
7. Potassium: ↑ dietary intake if no risk hyperkalemia
8. Stress management: individualized behaviour
interventions, relaxation techniques
HYPERTENSION
Pharmacotherapy
Indication:
- Consider if >140/90mmHg with RFs
- Recommended for >160/100mmHg w/o RFs
Target:
- <140/90mmHg, <130/80mmHg in DM
Choice of Therapy:
1. Monotherapy or single pill combination
- Monotherapy: B-blocker (<60y), ACEI (non-black),
ARB, long acting CCB, thiazide/thiazide-like diuretic
- Combo: ACE+CCB, ARB+ CCB, ACE/ARB+ diuretic
- Specific conditions:
o IHD: ACEI/ARB → + CCB/BB if MI/CHF
o Recent MI: BB + ACEI
o CHF: ACEI + BB → + mineralocorticoid
antagonist +/- other diuretics
o Stroke: acute ischemic- Rx if >220/120 &
avoid excess lowering >25%, if eligible for
thrombolytic therapy Rx prior if >185/110,
after acute <140/90 w/ ACE + thiazide,
hemorrhagic- permissive HTN- SBP <180
o LVH: ACE/ARB.long-acting CCB, thiazide
o Nondiabetic CKD: ACE/ARB if proteinuria
o Diabetes: ACE/ARB, target <130/80
2. st
Add on from 1 line choices
- Nondihydropyridine CCB + BB not recommended,
ACE + ARB not recommended
3. Add on additional agent & consider reasons for poor
response to therapy
- Poor adherence, associated conditions, drug
interactions, suboptimal regimen, volume overload,
2⁰ HTN (renovascular, primary hyperaldosteronism,
thyroid disease, OSA, pheo + rare endo conditions)
Vascular Protection: statin in HTN w/ 3+ CV RFs, smoking
cessation (+ NRT, pharmacotherapy)
Hypertensive Emergency/Urgency
- BP >180/120mmHg
- Emergency (end-organ damage) vs urgency
(asymptomatic, no damage)
- Reduce MAP by 10-20% in first hour, then further 5-15%
over the next 23h
o Exception: ischemic stroke, acute aortic
dissection, ICH
- Sx end-organ damage: delirium, visual disturbances,
focal neurologic sx, flame hemorrhages, N/V, CP, SOB
- Ix: ECG, CXR, U/A, labs for Cr/lytes, cardiac biomarkers,
consider CT head/chest if neuro sx or to r/o dissection
- Rx: labetalol 20mg IV bolus, repeat q10 mins
Secondary Hypertension:
Renovascular HTN:
- Consider if 2+ of: sudden onset worsening >55y or <30y,
presence of abdo bruit, resistant to 3+ drugs, ↑ Cr >30% w/
ACE or ARB, atherosclerotic vascular disease, recurrent
pulmonary edema w/ hypertensive surges
- Ix: captopril-enhanced radioisotope scan if GFR >60,
doppler sonography, MRA, CTA if N renal function
Fibromuscular Dysplasia related Renal Artery Stenosis:
- Consider if HTN + 1of: <30y, resistant to 3+ drugs, >1.5cm
asymmetry in kidney size, abdo bruit, FMD in another
vascular territory, FHx
- Ix: MRA or CTA
- If confirmed, screen for cervicocephalic lesions &
intracranial aneurysms, FMD in other vascular beds
Hyperaldosteronism
- Consider in unexplained hypoK <3.5 or makred diuretic
induced hypokalemia <3.0, resistant to 3+ meds, or
incidental adrenal adenoma
- Ix: screen- plasma aldosterone/renin/ratio in am,
confirmation w/ saline load test or plasma
aldosterone:renin ratio, or captopril suppression test
- Rx: medical adrenalectomy (spironolactone), surgical
Phaeochromocytoma
- Consider if: episodic/liable HTN, refractory, incidental
adrenal mass, h/a + palpitations/sweating, MEN/NF1/ VHL
- Ix: screen with 24h urine metanephrine/catecholamines, dx
w/ clonidine suppression test
- Rx: alpha blockage +/- antiHTNs, resection + genetic testing
Approach to Immigrant Patients
- Always assess vaccination status & provide
necessary updates
- Modify approach based on cultural context
o Inquire about alternative
medicine/healers, natural products,
medications from different countries,
spiritual healers
- Use a medical interpreter if there is a language
barrier & be aware of risks of family acting as
interpreter
- Screen for depression & past history of
abuse/torture, assess resources for support
- Consider infectious diseases for new/ongoing
presentations of disease
- Preventative Care Checklist for New Immigrants
& Refugees:
http://www.ccirhken.ca/ccirh/checklist_website/
Chronic Disease
T2DM:
- Screen immigrants >35y from ethnic groups at
high risk with fasting blood glucose
o South Asian, Latin American, African
Iron deficiency anemia:
- Screen immigrant women of reproductive age &
children (age 1-4y) with Hb
Dental Disease:
- Screen all immigrants for dental pain
- Refer patients to a dentist as needed
Vision:
- Screen all for visual impairment
- Refer to an optometrist as needed
IMMIGRANTS
Mental Health
Depression:
- Screen for depression using PHQ-2 (in
patient’s language)
PTSD:
- Do not conduct routine screening for exposure
to traumatic events
- Be alert for signs & perform clinic assessment
as needed
Child maltreatment:
- Do not conduct routine screening
- Be alert for signs & assess further when
evidence exists/after patient disclosure
Intimate partner violence:
- Do not conduct routine screening for intimate
partner violence
- Be alert for signs & assess further when
evidence exists/after disclosure
Women’s Health
Contraception
- Screen immigrants women of reproductive
age (15-44y) for unmet contraceptive
needs
Cervical Cancer
- Screen women 21-70y of age & sexually
active every 3 years with pap smear
- Routine vaccination for HPV for females &
males age 9-26y (may consider if >26y)
Infectious Diseases & Vaccination
MMR:
- Vaccinate all adult immigrants w/o immunizations using
1 dose of MMR
- Vaccinate all children with missing or uncertain records
using age-appropriate MMR
DTap-IPV:
- Vaccinate all adult immigrants without immunizations
using a primary series (3 doses)
- Vaccinate all immigrants children without
immunizations using age appropriate vaccination
Varicella
- Vaccinate all immigrant children <13y with varicella
vaccine without serologic testing
- Screen all immigrants >13y for serum varicella
antibodies and vaccinate those susceptible
Hepatitis B/C:
- Screen adults & children from countries where
seroprevalence of chronic hepatitis B is >2% (Africa,
Asia, E. Europe, parts of South America)
- Vaccinate those found to be susceptible to hepatitis B
(negative HBsAg, anti-Hbc, anti-HBs)
- Screen all immigrants for hep C if region prevalence >3%
Tuberculosis
- All screened for active TB in immigration exam w/ CXR
- Screen children & adults up to 50y from countries with
high incidence with TB skin test
HIV
- All immigrants screened during immigration exam
- Screen with informed consent in all children & adults
from countries where HIV is prevalent
Intestinal parasites: Strongyloides:
- Screen immigrants from SE Asia and Africa with
serologic testing & treat with ivermectin if positive
Malaria:
- Do not conduct routine screening, be alert for Sx if
lived/travelled in endemic regions within 3 months
Contraindications/Precautions to Vaccination
- Anaphylaxis to previous dose/vaccine component (egg,
gelatin, baker’s yeast, neomycin, streptomycin)
- GBS onset <6 weeks of immunization
- ‘Moderate/serious’ illness +/- Fever >38⁰C
- Severe asthma (on oral/high doses inhaled steroids,
actively wheezing) for LAIV (live attenuation influenza)
- Congenital GI malformation/intussusception for rot-1
- Pregnancy, severe immunodeficiency, active untreated TB
When to Vaccinate
- Infancy (routine schedule)
- Before pregnancy
- Before travelling
- New to country
- High risk groups- see table
High Risk Populations
- Asplenia
IMMUNIZATIONS - Transplant/cochlear implant recipients
- Immunocompromised (steroids, chemo,
Common Myths radiation, biologics), primary Ab deficiencies
• MMR- ASD; 1997 paper by Wakefield - IVDU, needlestick injuries, recipient of blood
(surgeon) discredited re: procedural products, HCPs
errors, financial/ethical conflicts, - Chronic liver disease
- MSM
violations, lost license
• Too many vaccines for system; millions of - Immigration, household contacts
antigens daily, capacity for 10k vaccines at - HIV, history of STIs, multiple sexual partners
once - Sickle cell disease/hemoglobinopathies
• Natural immunity > vaccine - Malignant neoplasms
• Toxins; minuscule amounts, FDA approved - Chronic disease: (pneu-23) e.g. cardiac, DM,
• ADR mistaken for the disease itself CKD, COPD, neuro, LTC/institution
• PRN vaccines, sched re: multiple dosing - Pregnancy (Tdap 27-32 weeks, flu shot)

12 months

15 months

18 months

34 years +
2 months

4 months

6 months
Why Vaccinate?

4-6 years

65 years
Grade 7

14-16

24-26
years

years
- Preventable hospitalizations and deaths
- Infants and young children have less mature immunity
- Ongoing waning immunity and new diseases
- Herd immunity for those who have not been/cannot DTap-IPV- IM IM IM IM
be/do not adequately respond despite being vaccinated Hib
- Required for school (immunization of school pupils at Pneu-C-13 IM IM IM
child care & early years act) re: Dtap-IPV, MMR, Men-C, Rot-1 PO PO
Men ACYW Men-C-C IM
MMR SC
- Specific vaccines:
Varicella SC
o Diphtheria: asphyxia (pharyngitis), heart damage
MMRV SC
o HiB: meningitis, epiglottitis, deafness (OM)
Tdap-IPV IM
o HepB: cirrhosis, hepatocellular cancer
HepB IM
o Measles: encephalitis Men-C- IM
o Meningococcal: meningitis, septicemia, ACYW
amputation, deafness HPV-4 IM
o Mumps: fertility: re orchitis/oophoritis, (9-26y, +/- >)
meningitis, encephalitis Tdap IM IM
o Pertussis: aspiration, choking, pneumonia, Td IM
encephalopathy q10y
o Polio: paralysis HZ (50y +) SC
o Rubella: encephalitis, miscarriage, stillbirth, Pneu-P-23 SC
malformation/delay Inf IM annually
‘Grade 7’ vaccines provided through school (Men-C-ACYW is single dose, Hep B is 2 dose series, & HPV-4 is 2 dose series)
o Tetanus: rigidity, spasms, death
Once a Tdap is given in adulthood (24-26y), adults should receive a Td booster q 10 years
Children 6 months – 8 years received an influenza vaccine for the first time should have 2 doses ≥4 weeks apart
Immunizations in High Risk Populations
Vaccine Age (Publicly Doses Eligibility Criteria
Funded)
Hib ≥5y 1 or 3 (1-2m apart, then 1-12m apart) 1 dose: asplenia, bone marrow or organ transplant, cochlear implant, immunocompromised, lung transplant, primary antibody deficiency
3 doses: HSCT
Hepatitis A ≥1y 2 (6-36 m apart) IVDU, liver disease (chronic) including hepatitis B/C, MSM
Hepatitis B ≥0y 2-4 (+ booster if required) 3 doses:
(1m apart, then 2-5 months apart *3rd - Children <7 whose families have immigrated from high prevalence countries and who may be exposed to HBV carriers through extended families
dose must be at least 16w after 1st - household & sexual contacts of chronic carrier & acute cases
and at least 24w old) - Hx of STI
- Infants born to HBV-positive carrier mothers (<2000g = 4 doses at 0/1/2/6m, >2000g = 3 doses)
- IVDU
- Liver disease (chronic), including hepatitis C
- Awaiting liver transplant (2nd & 3rd doses)
- MSM
- Multiple sexual partners
- Needle stick injuries in a non-healthcare setting
- Renal dialysis or diseases requiring frequent receipt of blood products (2nd & 3rd doses)
HPV-4 Males 9-26y 2 (6m apart) MSM
3 (1-2m apart, 3-4m apart *3rd dose - 2 doses if healthy <14y
must be 6m after 1st) - 3 doses if 14y+, immunocompromised, HIV
4CMenB 2m-17y` 2-4 Acquired complement deficiencies, asplenia, cochlear implant, complement/properdin/factor D/primary Ab deficiencies, HIV
Starting 2-5m: (2/4/6/12m)
Starting 6-11m: (6/8/12m)
Starting 1-10y: (12/14m)
Starting 11-17y: (1m apart)
Men-C-ACYW 9m-55y 2-4, +/- boosters Acquired complement deficiencies, asplenia, cochlear implant, complement/properdin/factor D/primary Ab deficiencies, HIV
Starting 9-11m: 10/12/14m, booster
q3-5y
Starting 12m-6y: 12/14m, booster q3-
5y
Starting 7-55y: 2m apart, booster q5y
Men-P-ACYW 56y+ 1 (5+y after last dose of Men-C-ACYW) Acquired complement deficiencies, asplenia, cochlear implant, complement/properdin/factor D/primary Ab deficiencies, HIV
MMR 6-11m, 18y+ 1, +/- repeat dose 18y+ Infants who will be travelling to areas where disease is a concern, must be followed by 2 further doses at appropriate intervals at 1y+
(1m apart, 3m apart if MMRV) Adults who have received only 1 dose of MMR are eligible for a 2nd dose if:
- They are healthcare workers
- They are post=secondary students
- If they are planning to travel to areas where disease is concern
- Based on the health care provider’s clinical judgement
Pneu-C-13 6w-6m 1 additional dose as 4th dose *See criteria for high risk infants for Pneu-P-23
- 2-6m: 2/4/6/12m 1 dose: asplenia, congenital immunodeficiencies, HIV, immunocompromising therapy, malignant neoplasms including leukemia/lymphoma, sick
- 7-11m: x3 2m apart cell disease or hemoglobinopathies, solid organ or islet cell transplant
- 12-13m: x2 2m apart 3 doses: HSCT recipient
- 24-59m: x1
50y+ 3: 1m apart, 3m post-transplant
Pneu-P-23 2-64y 1 +/- booster Asplenia, chronic cardiac disease, chronic CSF leak, cochlear implant, congenital immunodeficiencies, DM, HIV, immunocompromising therapy,
*Should be given 8w+ after last dose chronic liver disease, malignancy neoplasms including leukemia/lymphoma, chronic renal disease, chronic resp disease (excluding asthma unless
of Pneu-C-13 on high-dose steroids), sick cell disease & hemoglobinopathies, solid organ or islet cell transplant, chronic neuro conditions that may impair
*If Pneu-P-23 already received, Pneu- clearance of secretions, HSCT, residents of nursing homes
C-13 should be given after >1y

Booster >5y after 1st dose Booster: asplenia, sickle cell disease, hepatic cirrhosis, HIV, immunocompromised related to disease or therapy, chronic renal failure
IPV, Tdap-IPV, ≥18y 1 Travellers who have completed immunization series against polio & travelling to areas where polio virus is known or suspected to be circulating,
Td-IPV single lifetime booster dose
Varicella Born prior to Dec 2 (3m apart) Susceptible children & adolescents given chronic salicylic acid therapy, susceptible individuals with CF, susceptible household contacts of
31 1999 immunocompromised individuals, susceptible individuals receiving low dose steroid therapy or inhaled/topical steroids, susceptible
immunocompromised individuals
DDx of Common Presentations Injury Prevention
Abdo pain - Injury is leading cause of
-
-
Common: colic, gastro, mesenteric adenitis
Serious causes: intussusception (6-9
IN CHILDREN death in First Nations
children/youth, risk ↑ with
months), appendicitis (5-15y), obstruction Pediatric Preventative Care rural living, low SES
- Often missed: abuse, constipation, - Nutrition: vitamin D supplementation (400iu while breastfeeding, until dietary equivalent, - Drowning: bath safety (do
testicular torsion, intolerance, ulcer, consider continued supplementation into adulthood) not leave alone, no bath
mumps, pneumonia, EBV, UTI, gyne causes - Environmental health seats/rings), water safety
- Other: psychogenic, diabetes o Minimize 2nd hand smoke exposure (adult supervision, pool
o Sunscreen use fencing, swimming lessons,
Cough
o Insect repellent: no DEET <6 months, 6-24m once daily, 2-12y max TID boating safety)
- Acute (< 3 weeks): URTI (75%), asthma
o Lead exposure: screen if residence built <1978, living near point source - Choking: avoid small/hard/
(10%), pneumonia, croup, reactive airways
contamination, family members affected, refugees 6 months- 6 years round/ smooth food until 3y,
pertussis, FB, GERD
- Injury prevention (see box) sit while eating/drinking,
- Chronic cough (>8 weeks): postnasal drip,
- Oral hygiene safe toys
post-viral/ reactive airways, GERD, asthma
o RF carries: poor hygiene, parent carries, premature/LBW, no fluoridation - Burns: smoke detectors in
- High mortality: PE, pneumothorax, cancer,
o 1st dentist visit within 6m after 1st tooth or at 1 year home, hot water
TB, HIV, pertussis, pneumonia, FB
- Sleeping temperature <49⁰C
Earache o Counsel on SIDS ‘front to play, back to sleep’ avoid bed sharing, overheating - Poisons: meds + cleaning
- AOM (50%), otitis externa, FB, coryza o Duration: 12-14h (4-12 m), 11-14h (1-2 y), 10-13h (3-5 y), 9-12h (6-12 y), 8-10h (13- products locked up/out of
causing Eustachian tube blockage, mumps, 18y) reach, poison control #
TMJ, meningitis, dental pain, sinusitis o Positional plagiocephaly, crib safety - Falls: never leave alone on
o Swaddling x 2 months promotes longer sleep but increased risk hyperthermia/ change table, stair gates,
Fever (newborn) SIDS/ hip dysplasia if incorrect, ensure free movement hips/legs, head uncovered walkers not recommended,
- Bacteremia, UTI, meningitis, bacterial o Pacifier use may ↓ SIDS, wait until breastfeeding established, d/c if recurrent AMO stable furniture
gastroenteritis, pneumonia - Screen time - Firearm: remove from home
- Ask about vertical transmission: maternal o Encourage physical activity, read to children within first months - Helmet use: ↓ risk TBI,
fever, GBS, maternal STIs, prolonged ROM o Avoid screen time <2 years, 2+ years limit to 1h per day legally required <18y
- Ix: WBC, blood culture x 2, urine + stool, - Toilet training
CXR, LP o Child centered approach, 24-28 months, girls usually younger than boys - Car seat guidelines:
- Rx: empiric Abx (e.g. ampicillin + o Assess readiness, ability to communicate needs, positive reinforcement o Rear facing until
cefotaxime/gent), consider acyclovir o Encourage toilet use in morning, after meals, before bed 9kg (20lb)
o Forward facing 9-
Adolescent Interview (HEADSSS) Adolescent Confidentiality & Consent 18kg, tether strap
H: home & environment (parents/caregivers, siblings, home, arguments/conflicts, food) - All paeds interactions should involve to prevent forward
E: education & employment (grades, favourite classes, missed class, plans for future, part- communication directly with pt as movement
time work, bullying/peer pressure) well as caregivers where possible o Booster seats: 18-
A: activities (hobbies, extracurricular activities, religion, weekends, criminal activity) - No age of consent in Ontario 36kg (40-80lb),
- Pts 16y + capable of giving/refusing <145cm, <8 years
D: drugs (alcohol, smoking, recreational drugs, how these are paid for, family drugs/alcohol)
consent if competent, unless o Seat belts:
S: sexuality (relationship + safety, sexually active, orientation, contraception, pregnancy,
grounds to believe otherwise mandatory for all
STIs, menstrual Hx) ages, safe to use
S: safety (safe at home, friends, driving safety, helmet use, weapons in the home) - SDM must be at least 16y, unless
adult belt once >8y,
S: suicide/depression (mood, sleep, appetite, self-harm, conflict with parents/friends, SI/HI) they are parents of incapable patient
>36kg, >145cm
Approach to Infections
- Culture when appropriate to confirm organism & sensitivities
-
-
Consider infection with ill-defined sx in children & elderly
Antibiotics
• Use antibiotics judiciously and rationally
• Treat empirically in life threatening infections
• Treat empirically for presumed infections (e.g. candida
vaginalis, consider in strep pharyngitis)
- Use other treatments in addition to Abx (e.g. fluids, draining
abscesses, pain relief)
- Reasons of antimicrobial failure:
o Wrong Abx (may need culture)
o Resistant organisms, viral infection
o Wrong diagnosis (e.g. noninfectious- PE, malignancy)
o Complication (e.g. empyema, abscess)
o Inadequate source control (e.g. endocarditis)
o Host immunosuppression
Pharyngitis
- Inflammation of the pharynx/tonsils
- Viral (majority): parainfluenza, influenza, rhinovirus,
coronavirus, RSV, adenovirus, coxsackie virus, EBV
- Bacterial: GAS
Modified Centor Criteria (McIssac Criteria)
- Estimates probability of GAS pharyngitis:
o ≤1: no RST/Cx/Abx
o 2-3: RST +/- culture, Abx based on results
o 4+: RST +/- culture, Abx based on C&S, consider empiric
- Criteria: fever >38, hypertrophic tonsils +/- exudate, tender
anterior cervical LNs, absence of cough, age 3-14y (0)/ age 15-
44y (1)/ age >44y (-1)
Scarlet Fever
- Rash caused by GAS infection: diffuse erythematous blanchable
sandpaper exanthem, begins on face, after 24h generalizes,
circumoral pallor- spares around mouth
- Pastia lines- flexural accentuation
- Desquamation after 1 week
Management
- Fever & sore throat usually resolve within 4d
- Treatment to prevent complications: acute rheumatic fever and
suppurative complications (peritonsillar abscess,
retropharyngeal abscess, otitis media, sinusitis, mastoiditis)
- Acute rheumatic fever: autoimmune reaction- arthritis, carditis
with valve insufficiency, chorea, erythema marginatum, fever
- Antibiotic therapy does not prevent post-strep GN or PANDAS
- Abx: Children: amox 40mg/kg/day divided BID-TID x 10d, adults:
penicillin V 300mg TID x 10d (erythromycin if pen allergic)
Sepsis & Septic Shock
- Systemic inflammatory response syndrome (SIRS): 2 or more of
INFECTIONS • Temperature <36⁰C/96.8⁰F or >38⁰C/100.4⁰F
• Heart rate >90 beats per minute
Bronchitis • Respiratory rate >20/min or PaCO2 <32mmHg
- 90% viral, acute onset cough 1-3w, • WBC <4 x 109/L or >12 x 109/L or >10% bands
- No fever, tachypnea, N - Sepsis: SIRS + proven or provable infection
- Severe sepsis: sepsis + signs of end-organ dysfunction &
auscultation, no Hx COPD
hypoperfusion
- CXR- unlikely to change Rx but
- Septic shock: severe sepsis + hypotension (<90mmHg sBP),
indicated to distinguish pneumonia despite adequate fluid resuscitation
- Rx: pt education (Abx not required),
rest, fluids, throat lozenges, honey, - Presentation:
if cough bothersome- o History: fever, chills, dyspnea, cool extremities, fatigue,
dextromethorphan malaise, anxiety, confusion
o Physical: abnormal vitals (fever, tachypnea,
Pertussis
tachycardia, hypotension), local signs of infection
- Cough lasting 2+ weeks with 1 of:
• Paroxysms of cough
• Inspiratory whoop - Investigations
• Post-tussive emesis • CBC & differential, electrolytes, BUN, creatinine, liver
• Known close contact with enzymes, ABG, lactate, INR, PTT, FDP, blood C&S x3,
confirmed case urinalysis, urine C&S & cultures of any wounds/lines
• Pertussis outbreak • CXR (other imaging depends on focus of infection)
- Diagnosis: NP swab (culture & PCR)
for Bordetella pertussis - Treatment (BUFALO)
Treatment: • Respiratory support: O2 +/- intubation
• Adult: erythro 500mg QID x 7d • CV support: IV fluids +/- norepinephrine + ICU
• Children: erythromycin • IV antibiotics (empirical, depends on suspected source)
40mg/kg/d divided QID x 7d • Narrow once susceptibilities are known
Skin Infections:
Impetigo: acute purulent ‘honey-crusted’ lesions, often associated with eczema, surrounding erythema
- Consider culture: GAS, S. aureus
- Rx: remove crust with saline compresses/topical antiseptic soak, topical mupirocin/fusidic acid TID → PO
cephalexin 7-10d
Cellulitis: involves lower dermis/SC fat, flat erythematous lesion poorly demarcated, tender
- GAS, S. aureus, H. influenzae if periorbital, pasturella multocida if dog/cat bite
- Rx: 1st line cloxacillin or cephalexin → 2nd line/pen allergic: erythromycin/clindamycin, children- cefuroxime
Erysipelas: upper dermis, erythema with sharp raised edge, ++ pain, systemic sx if severe
- GAS, spreads via lymphatics → fat necrosis, streptococcal gangrene if severe
- Rx: 1st line penicillin, cloxacillin, cefazolin, 2nd line clindamycin or cephalexin, erythromycin if pen allergic
Superficial Folliculitis: superficial infection of hair follicle, dome shaped pustule at base
- Staph most common, pseudomonas- hot tub
- Rx: antiseptic wash, topical antibacterial (e.g. Fucidin, mupirocin) → PO cloxacillin 7-10d
Furuncle: red inflammatory nodule with central punctum, involving SC tissue & arising from hair follicle
- Usually S. aureus, carbuncle- deep abscess from multiple furuncles +/- systemic sx
- Rx: I&D, warm compresses + topical Abx, culture if febrile/cellulitis → cloxacillin 1-2w
Infertility: failure to conceive after one year of regular
unprotected intercourse in women <35y, and after 6 months
in women ≥35y
- 1⁰: couple has never been able to conceive
- 2⁰: couple has conceived at least once before
- Normal fertility: 85% couples conceive within 12m,
15% within following 12 months
Assessment: Male
- Duration of infertility
- Fertility in other relationships
- Medical and surgical Hx, including testicular surgery
and Hx of mumps
- Hx chemotherapy or radiation
- Smoking, alcohol, marijuana, other drug use,
environmental and occupational exposure, meds
- Sexual or erectile dysfunction
- Frequency of intercourse, use of lubricants (which
may be toxic to sperm)
- Previous infertility testing and therapies
- Family Hx birth defects, mental retardation, or
reproductive failure
Male O/E:
- Klinefelter's tall thin, gynecoid appearance
- BMI, masculinization
- Genital exam: varicocele, testicular, masses, hernias
Etiology: Male Partner
1. Idiopathic
2. Hypogonadotropic hypogonadism
• Congenital
• Acquired- tumour, infiltrative disease, head
trauma, chronic glucocorticoids, adrenal
hyperplasia, drugs
3. Hypergonadotropic hypogonadism
• Congenital: Klinefelter syndrome,
cryptorchidism
• Acquired: varicocele, infection (mumps, STI, TB)
drugs & radiation, environmental factors
(smoking, hyperthermia), antisperm antibodies
4. Sperm Transport Disorders
• Retrograde ejaculation
When to Refer: pt request/anxiety, couple (ovulation monitoring with timed intercourse x 3 months)
- Female: <35y with >12m infertility or >6m (if >35y), >40y at first visit, Hx endometriosis/PID/chemo or radiation,
premature ovarian failure, structural abnormalities
- Male: abn sperm studies, Hx STI, Hx urogenital pathology/surgery, adult mumps, sexual dysfunction, chemo/radio, >40y
INFERTILITY
Assessment: Female
- Duration of infertility
- GTPAL (including ectopic and miscarriages) w/ the
same or different partner
- Gyne Hx: including Hx of PID, fibroids,
endometriosis, cervical dysplasia, surgery of the
cervix/ovary/uterus/fallopian tube/pelvis/abdomen,
contraception use, diethylstilbestrol exposure in
uterus, uterine anomalies
- Menstrual Hx (age at menarche, cycle length,
regularity), presence of premenstrual sx or
vasomotor Sx, dysmenorrhea
- Changes in hair growth, body weight, breast d/c
- Other medical/surgical Hx, including medications
- History of chemotherapy or radiation
- Cigarette smoking, alcohol, marijuana, other drug
use, occupational and environmental exposures
- Exercise and dietary Hx
- Frequency of intercourse, use of lubricants (which
may be toxic to sperm). Presence of deep
dyspareunia suggestive of endometriosis
- Previous infertility testing and therapies
- Family Hx of birth defects, mental retardation, or
reproductive failure
o Symptoms of thyroid disease
Female O/E:
- BMI, thyroid exam
- Signs of hyperandrogenism: hirsutism, acne,
acanthosis nigricans
- Pap smear/STI swabs if indicated, bimanual exam
Etiology: Female Partner
1. Cervical: hostile mucous, cervical stenosis, structural
2. Uterine/tubal: septate uterus, Asherman's syndrome,
adhesions, PID, previous ectopic
3. Ovulatory dysfunction: premature ovarian failure,
PCOS, prolactinoma, thyroid disease, Cushing's
4. Peritoneal: endometriosis
Investigations:
Female
- Documentation of ovulation: basal body temp ↑ 2-
3d after ovulation, LH surge, mid-luteal
progresterone >3 (1w prior to period)
- Ovulatory dysfunction: FSH (↑ in ovarian failure),
prolactin, TSH, assessment for PCOS, 17a
hydroxyprogesterone & testosterone, rubella &
varicella serology, STI screening
o Exclude Cushing’s, CAH, androgen-
secreting tumours
o Rotterdam Criteria: 2/3 → PCOS
1. Oligomenorrhea
2. Clinical/biochemical
hyperandrogenism
3. Polycystic ovaries on TVUS
- Ovarian reserve (>35y): day 3 FSH (>20 suggests
poor ovarian reserve), day 3 estradiol (elevation
suggests poor ovarian reserve)
- Endocrinopathies: FBG, A1c
- Assessment of tubal patency & uterine cavity:
hysterosalpingogram +/- sonohysterogram
Male
- Semen analysis: collected on 2 occasions, after 2-
7d of abstinence (volume, pH, sperm
concentration & count, motility, morphology)
- Hypogonadism: (based on semen analysis)-
morning FSH & total/free serum testosterone to
different 1⁰ from 2⁰ hypogonadism
- Low volume: transrectal US (r/o duct obstruction),
evaluate for hydrocele &/or tumours, post-
ejaculatory U/A to r/o retrograde ejaculation
Management:
- Normal Ix: timed intercourse 5d prior to 2d after
ovulation, q1-3d, preconception counselling (see
pregnancy), avoid lubricants, home LH surge kit
- Treat cause of anovulation e.g. PCOS → consider
clomiphene if normogonadotropic, if
oligomenorrhea consider OCP x 2-3m, metformin
Family Planning: optimize natural fertility
- Adoption
- Assisted reproductive e.g. IVF, surrogacy
Insomnia: difficulty maintaining or initiating sleep, or
sleep that isn’t restorative
History: from pt & bed partner
- Onset: acute vs chronic (>3m for at least 3
nights/week)
- Precipitating factors: stressors, caffeine, EtOH
- Quality
- Relieving factors
- Severity e.g. impact on daily function, work, driving
- Time: what happens before, during, after sleep-
change in sx over time
- Mood: always screen for depression & anxiety
- Pertinent positive & negatives:
o Physical sx: asthma/COPS, CHF, dementia,
pain, GI/GU sx, menopause
o Behaviours during sleep: limb movements,
walking, talking, snoring
o Meds & PMH:
▪ E.g. stimulants, antidepressants
including SSRIs/SNRIs, mood
stabilizers, glucocorticoids, opioids
▪ Chronic pain +/- substance misuse
o Social factors: smoking, EtOH, recreational
drugs, usual schedule/work hours including
shift work
Investigations:
- Polysomnography generally not indicated except:
o Clinical suspicion for obstructive/central
sleep apnea, frequent periodic limb
movements of sleep, parasomnias e.g. sleep
walking or talking
o Chronic insomnia that is refractory to
multiple standard treatments
- Sleep diary x 2 weeks
o Time going to bed & waking up
o Number of episodes of nighttime waking
o Episodes of daytime naps
o Times of meals, alcohol, caffeine
o Significant daytime events e.g. stress,
exercise, work
o Rating of sleep quality
o Mood, sx of anxiety
INSOMNIA
Sleep Disorders:
Obstructive Sleep Apnea: obstructive pauses in breathing
pattern &/or respiratory effort, related arousals caused
by repetitive collapse of upper airway during sleep
- STOPBANG questionnaire to screen: low risk 0-2,
intermediate risk 3-4, high risk 5-8
- Snoring, tired in daytime, observed apnea,
pressure (HTN), BMI >34, age >50y, neck side
>43cm M or 41cm F inches, gender male
Sleep-related movement disorders: restless leg syndrome,
periodic limb movements
- Associated with IDA, 1st line Rx: gabapentin/
pregabalin, serotonergic agents may exacerbate
Parasomnias: sleep walking, sleep talking
Circadian rhythm disorders (poor sleep hygiene): jet lag,
shift work
Sleep Hygiene
Stimulus control
• Use bedroom only for sleep & sex
• Reduce noise, light, extremes in temperature
• Get out of bed if not asleep within 15-20 mins
• Exposure yourself to bright light in AM
• Moderate physical activity but avoid heavy
exercise in 3h before bedtime
Intake
• No caffeine after lunch
• No EtOH within 6 hours of bedtime (sedative but
impairs sleep maintenance)
• No nicotine close to bedtime (smoking cessation
aids can also impair sleep)
• No excess liquids or heavy meal before bedtime
Reduce anxiety
• At least one hour of unwinding before bedtime
• Consider worry journal/scheduling worry time
• No checking phone or watching clock
• Consider CBT for insomnia
Routine
• Bedtime routine to wind down
• Wake up & go to bed at the same time each day
• Avoid daytime napping
Pharmacotherapy
Indication/Method:
- Acute insomnia (<3 months), treat only if substantial
negative impact on function
- Use lowest effective dose and short term (<1 w)
- Can prescribed for longer duration but should only be
used intermittently/PRN (max 3/w to reduce
tolerance)
- Max 6 months prescription before follow up needed
Contraindications:
- Other underlying cause requiring more specific
treatment (e.g. OSA- CPAP)
- Elderly: nonpharmacological >> pharmacological
- Pregnancy/postpartum: conflicting evidence on
whether benzos and benzo receptor antagonists are
teratogenic
Pharmacological Choices:
- Melatonin
o 1-5mg
o Available OTC, some evidence but may also
have side effects e.g. dizziness, h/a, nausea
- Zopiclone
o 3.75-7.5mg (max 5mg in elderly)
o Metallic taste, risk of tolerance/dependence
but less than benzos, less rebound sx
- Doxepin
o 3-6mg
o May cause TVA like side effects at higher
doses (e.g. arrhythmias, hypotension,
seizures, anticholinergic effects)
- Temazepam
o 15-30mg
o Side effects of tolerance/dependence, affect
on cognitive or memory, avoid in elderly, CI if
substance use or sleep apnrea, increased falls
risk, withdrawal sx if >1m use, requires taper
- Trazodone
o 25-100mg
o risk of orthostatic hypotension and cardiac
conduction issues, but minimal tolerance,
decreased appetite, CI in eating disorders or
previous seizures
Others: (uncommon) amitriptyline, nortriptyline, nozinan
Ischemic Heart Disease: variable degrees of myocardial
ischemia, mismatch of supply & demand
Typical Angina:
1. Substernal chest pain- tight/full/ pressure/ squeezing,
+/- radiation in arms/ jaw/shoulder/ back, nausea,
SOB, diaphoresis, dizziness
2. Provoked by exertion or emotional stress
3. Relieved by rest and/or nitroglycerin
Atypical Angina: two of above
- More common in women, diabetics, elderly
Non-Cardiac Chest Pain: 0-1 of above, dyspnea,
belching/hiccups, indigestion, dyspepsia/epigastric pain,
nausea, lightheadedness, jaw pain
Modifiable Risk Factors
- Smoking → cessation
- Sedentary lifestyle → 150 mins aerobic
exercise/week
- Weight → reduction to BMI <27
- Dietary → DASH, Mediterranean
- Optimal control of HTN, dyslipidemia, DM
Nonmodifiable Risk Factors
- Age, sex, ethnic origin
- Family Hx premature established CV disease
o MI <55y in men, <65y in women
Investigations
- Labs: CBC, lipid, fasting glucose + A1c, renal function
- Resting ECG for baseline in all patients, negative test
does not rule out IHD
o Prior MI/LBBB/poor R wave progression/T
wave changes may increase pre-test
probability
o Changes during acute pain episodes may
have ST changes
- Stress testing: sensitivity 68%, specificity 77%
o Does not r/o IHD, useful to stratify re:
prognostications and need for angiography
- Other non-invasive: exercise myocardial perfusion
imaging, nuclear imaging (exercise vs persantine)
- Invasive: angiography
Differential Diagnoses
• CV: aortic dissection, CHF, pericarditis
Ischemic Heart Disease • Respiratory: PE, pneumothorax, pleuritis,
pulmonary HTN
• GI: esophagitis, esophageal spasm, biliary colic,
GB disease, PUD, pancreatitis
• Chest wall: costochondritis, fibromyalgia, rib #
• Neuro: cervical disease, herpes zoster
• Psych: anxiety/hyperventilation, panic disorder,
depression, somatoform disorder, thoughts
disorder (delusions)
Management of Stable Ischemic Heart Disease:
- ASA 81mg PO daily indefinitely
o Dual antiplatelet not require for routine
treatment or beyond period required for
stenting
o Clopidogrel 75mg PO daily is ASA intolerant
- ACEI if pt has HTN, DM, LVEF <40%, CKD
o Reasonable to consider ACEI in all pts with
stable IHD
- B-blocker if stable IHD & LVEF <40% +/- CHF or
previous MI
- Statin therapy
- Nitroglycerin spray- for PRN use
Revascularization Therapy
- Indicated early in patients with high risk non-
invasive tests
- Elective coronary angiography if medically
refractory sx or poor QoL on medical therapy
Clinical Follow-Up:
- Follow up visits:
o Hx to determine changes in sx, med
High Risk Features on Exercise Stress Testing:
adherence & SE, optimization of RFs
o 2+mm of ST segment depression at low workload or
o O/E: resting HR & BP, murmurs & aorta
persisting into recovery
o Ix: metabolic fitness (lipids, glucose,
o Exercise induced ST segment elevation/VT/VF
renal function), resting ECG
o Failure to ↑ sBP >120mmHg or sustained ↓ >10mmHg
- Cardiac rehabilitation
during exercise
- Repeat stress testing (exercise of
Angina Self-Management pharmacological) or stress cardiac imaging, if:
- Script for nitro spray/SL, lasting 2-3+ mins → stop activity, o Change in sx, ↓ exercise tolerance
remove from stressor, if pain persisting- call EMS o Revascularization suboptimal
- Monitor for changes in symptom pattern o High risk occupations (e.g. driver)
Acute Coronary Syndrome Post-MI Complications: Discharge Medications:
Initial Management of MI - Hypotension/shock: LV or RV 1. ASA 81mg daily
- ABCs dysfunction, arrhythmias, mitral 2. Clopidogrel/ticagrelor (1y
- MONA regurgitation from papillary muscle post-stent placement)
o Monitor: ECG q30 mins, troponin, CBC, lytes, INR/PTT, CXR rupture 3. Beta-blocker (start within
o O2 if saturation <90% - Septal rupture 24h)
o Nitro-spray 0.4mg SL q5min x 3 or morphine for sx relief - Ventricular wall aneurysm (persistent ST 4. Statin, high intensity (start
o Aspirin 160mg chewable tab AND Clopidogrel 300mg PO or elevation) within 24h)
Ticagrelor 180mg PO - Cardiac tamponade 5. ACE-Inhibitor (start within
24h) all pts with EF <40%,
o Anticoagulation: to start after PCI/thrombolysis, or - Hematoma post-CABG
CHF, HTN, DM, stable CKD
immediately if not receiving reperfusion therapy - In-stent thrombosis
6. Sublingual nitroglycerin PRN
- Pericarditis, Dressler’s syndrome
ST-Segment Elevation Myocardial Infarction (STEMI)
- Diagnosis: elevated troponin & relevant ECG changes Post ACS Care:
o ST elevation >1mm in 2 consecutive leads - Cardiac rehab, daily walking then graduated return, sex if comfortable with mod activity
o ST elevation >2mm in V2 & V3 in men or >1.5mm in women - Driving: wait 1 month if STEMI, 7 days if NSTEMI with no PCI or 2d if PCI
o New LBBB - Meds to avoid: hormonal therapy, NSAIDs, PDE5 with nitrates, TCAs, nifedipine (first few
- Treatment: see initial management above weeks), QT prolonging drugs, PPI (if using clopidogrel- decreased efficacy),
o Percutaneous coronary intervention (PCI) within 90 mins sympathomimetics (decongestants)
o If unavailable, fibrinolysis within 120 mins of contact
▪ CI: stroke <3m, head trauma <3m, Hx ICH, pregnancy, ECG Territories
BP >180/100, liver/kidney disease, aortic dissection, - Lateral: I, aVL, V5-6
surgery within 2-4w, thrombocytopenia, structural CNS o Left circumflex or diagonal of LAD
issue, active bleeding e.g. GI/GU hemorrhage - Inferior: II, III, aVF
o Right coronary artery &/or LCx
- Anterior/septal leads: V1-4
Non-ST-Segment Elevation Myocardial Infarction (NSTEMI & UA) o LAD
- Diagnosis: elevated troponin & relevant ECG changes
o New horizontal or downsloping ST depression ≥0.5mm in 2
contiguous leads
o T inversion >1mm in two contiguous leads with prominent R
wave or R/S ratio >1
- Treatment: see initial management above
o TIMI Scoring: (AMERICA)
o → age 65+, marker elevation, ECG changes, risk factors (3+ of
HTN, hypercholesterolemia, DM, FHx CAD, smoker), ischemic
CP/angina severe, CAD (known stenosis ≥50%), ASA in last 7d
▪ 0-2: admission for non-invasive testing (urgent)
▪ 3+: PCI/cath
Red Flags Osteoarthritis

- Septic joint: single swollen warm joint,
fever/constitutional sx
- Compartment syndrome: pain out of
proportion, known trauma/#
- Sarcoma/osteoma: pediatric bony pain,
limp, nocturnal/ rarely constitutional
sx, painless mass
Septic Arthritis
-Infection within joint, hematogenous spread
vs direct inoculation
RF: age, prosthetic joint, recent
surgery/injection, IVDU, ↓immunity
Micro:S.aureus, strep, gram neg bacilli
Sx: monoarticular arthritis * knee, hot swollen
joint, ↓ ROM, fever
Investigations: WBC, CRP, synovial fluid
analysis prior to Abx, blood cultures x 2, XR
joint +/- CT
Management: empiric IV Abx, ceftriaxone for
gram neg bacilli, vanc vs cefazolin for gram
pos bacilli, consider drainage- needle
aspiration vs arthroscopic, 4w- may stepdown
to PO after 2w
JOINT DISORDER
Ligamentous Injuries: clinical diagnosis, NO imaging
Shoulder: rotator cuff tear- supraspinatus most common, acute
(trauma) vs chronic (degeneration), Rx: pain management, PT
+/- glucocorticoid injection, surgical
-Adhesive capsulitis: ↓ active/passive ROM, Rx: rest + gentle
ROM, glucocorticoid injection
Elbow: medial (golf) + lateral (tennis) epicondylitis, pain with
wrist flexion/extension, overuse, Rx: activity modification,
brace, NSAIDs, PT
Wrist/Hand: de Quervain’s- APL & EPB tendinopathy, overuse,
radial wrist pain w/ thumb movement/grip, Finkelstein +, Rx:
thumb spica, NSAIDs → steroid injection
Knee: ACL/PCL- pivot or hyperextension w/ valgus stress,
MCL/LCL- valgus/varus stress, meniscal tear- twisting on planted
foot- Rx: acute (RICE, non-weight bearing, NSAIDs), immediate
surgical vs PT (depending on function, occupation, QoL)
Ankle: *ATFL strain most common, calcaneofibular, post
talofibular, inversion of plantar flexed foot, Ottawa ankle + foot
rules, Rx: RICE, NSAIDs, brace weight bearing as tolerated→ PT
-Degenerative destruction of articular surfaces
RF: obesity, age, muscle weakness, prior trauma
family Hx
Sx: asymmetric mono/polyarthritis, pain with
activity & relieved by rest, progressive, slow
onset, limited morning stiffness <30 mins,
reduced functioning
O/E: crepitus in joint, reduced ROM, bony
enlargement + muscle wasting, pain at end of
ROM, bouchard + Heberden nodes in hands,
hallux valgus in foot, valgus/varus deformity +
quadriceps wasting in knees, fixed flexion
deformity + limited abduction of hip
Investigations: XR (LOSS) loss of joint space,
osteophytes, subchondral sclerosis, subchondral
cysts, usually clinical Dx
Management: non-pharm (exercise- aerobic +
strength weight loss, PT, supportive footwear,
heat, splitting e.g. knee brace), pharm (tylenol,
PO + topical NSAIDs, topical capsaicin, intra-
articular steroids, opioids, joint replacement)

Gout Systemic Causes of Joint Pain:

-Precipitation of monosodium urate crystals in joint space, triggers inflammatory reaction
- Vasculitis: Granulomatosis with polyangiitis: (Wegener’s), Eosinophilic
DDx: septic arthritis, trauma, pseudogout (calcium pyrophosphate)
granulomatosis with polyangiitis (Churg Strauss), Microscopic polyangiitis,
RF: alcohol, purine rich diet, thiazides, CKD, African American, obesity, DM, chemo/rad Henoch-Schonlein purpura
Sx: monoarticular arthritis 1st MTP/ midtarsal/ ankle/ knee/ wrist/ elbow, acute - Connective tissue disease: Ehlers Danlos, Marfan’s
swelling/warmth/erythema - Systemic Lupus Erythematous
Investigations: joint aspiration & synovial fluid analysis- ↑WBC, urate crystals (negatively - Dermatomyositis/Polymyositis
birefringent), CBC, ESR + CRP, serum urate, XR, US- double contour sign + tophi - Scleroderma, Sjogren’s
- Sarcoidosis
Management: acute Rx within 24h, PO prednisone 30-40mg, NSAIDs, colchicine 1.2mg PO
then 0.6mg in 1h --> 0.6mg BID until resolved, intra-articular steroids →Rx comorbidities - Seronegative spondyloarthropathies: IBD, psoriatic, ankylosing spondylitis
- Cystic Fibrosis
- Allopurinol if 2+ flares/year, joint damage, tophi, renal insufficiency, recurrent uric
- Lyme Disease
acid nephrolithiasis- start 2w after flare –> continuous, monitor urate/CBC/LFTs/Cr &
lytes 2w, 3m, 6m, then annually annually, target serum urate <6ng/dL
- Bone metastases, multiple myeloma
-
 Condition Clinical Features Investigations Management
Rheumatoid Symmetric polyarthropathy of small >large RF, anti-CCP, ESR, CRP, Acute: NSAIDs, steroids
arthritis joints, morning stiffness >30 min, joint XR (LOSE)- loss of joint Maintenance: rheum referral, DMARDs e.g. methotrexate,
deformities- ulnar deviation, swan neck, space, osteopenia, soft hydroxychloroquine, biologics- anticytokine/TNF, IL1/6 receptor
boutonniere, extra-articular features* tissue swelling, erosions Preventative: exercise, PT + OT, reduce CVD risk, screen + treat
osteoporosis, immunizations
SLE MDSOAPBRAIN: malar rash, discoid rash, Suspect if 2+ systems Hydroxychloroquine +/- glucocorticoids & NSAIDs for flares
serositis, oral ulcers, arthritis/adenopathy, involved + unexplained Cyclophosphamide (nephritis, resp), biologic agents
photosensitivity, blood (anemia, ANA, Anti-ds DNA, anti- Manage CVD risk
leukopenia, thrombocytosis), renal smith, C3/4 ↓, urine, Contraception during active disease + 6 months after
dysfunction, ANA+, immunologic (anti CBC, lytes, Cr, ESR Prevent flares: sun protection, smoking cessation, immunizations
DsDNA, C3/4), neuro (seizures, psychosis)
Fibromyalgia Chronic widespread MSK pain >3months, Minimal testing, r/o Pt education + manage expectations, symptom diaries, sleep
fatigue, cognitive/psychiatric/somatic sx other conditions hygiene, exercise, CBT + stress reduction, pharm: Cymbalta,
pregabalin, amitriptyline, short duration muscle relaxants
PMR Symmetrical aching/morning stiffness of CBC, ESR/CRP, Ca, ALP, *Screen for GCA- temporal artery tenderness, headache/jaw pain,
shoulders/neck /hip girdle, age >50y, anti-CCP, RF, urine visual Sx → temporal artery biopsy
associated with GCA, fever, fatigue Oral corticosteroids: initial dose 15mg/day, adjust to Sx, duration 2y
Polymyositis/ Progressive proximal muscle weakness, Muscle + skin biopsy, PO/IV glucocorticoids, azathioprine vs methotrexate as steroid
dermatomyositis Gottron’s papules, heliotrope eruption EMG, CK + myoglobin sparing agent, PT, avoid UV light
Reactive arthritis Asymmetric oligoarthritis *knees, +/- Stool culture, urine Abx for concomitant infection
enthesitis, dactylitis, SI joint pain culture + swab for NAAT Treatment of STI- chlamydia/gonorrhea
-Post-infectious GI/GU G/C, ESR/CRP, WBC, NSAIDs/steroids for acute management of oligoarthritis
Conjunctivitis, urethritis, diarrhea, oral HLA B27+,
ulcers, rashes, nail changes
Ankylosing SI pain, arthritis, enthesitis, plantar BC, lytes, Cr, ESR/CRP, NSAIDs, TNF-a inhibitors, glucocorticoid injection to SI joints if
spondylitis fasciitis, dactylitis, costochondritis, posture HLA B27, SI imaging- isolated, non-biologic DMARDs e.g. sulfasalazine/methotrexate
changes, Sx relieved by activity bamboo spine
Psoriatic arthritis Oligoarthritis/ symmetric polyarthritis/ CBC, lytes, Cr, ESR/CRP, Exercise, PT, weight reduction, NSAIDs
arthritis mutilans/ spondyloarthritis/ distal, RF, anti-CP, ANA, HLA DMARD e.g. methotrexate, leflunomide, biologic if systemic Sx
nail lesions, +/- psoriasis rash B27, relevant imaging (TNFI), rarely steroids- can cause erythroderma/pustular psoriasis
Pediatric Hip Pain:
Extra-Articular Features: RHEUMATOIDS
SCFE: displacement of capital femoral epiphysis from femoral neck, adolescent/obesity/growth spurt, limited ROM +
R: risk of IHD & lymphoma
↓ weight bearing, aching dull pain + altered gait, knee pain → Ix: x-ray bilat hip → Rx: urgent ortho fixation + rehab
H: heme- anemia, neutropenia, thrombocytosis
E: eye- scleritis, episcleritis, sicca Transient synovitis: inflammation of joint capsule, acute join pain +/- preceding URTI, exclude septic arthritis → Ix:
U: unusual skin signs (nodules, lymphadenopathy) WBC/ESR/temp +/- US & arthrocentesis → Rx: NSAIDs
M: median nerve compression/myelopathy (c-subluxation) Legg Calve Perthes: partial interruption of blood supply to immature femoral head, vague hip pain + limp, knee pain,
A: atherosclerosis, vasculitis limited ROM, leg length discrepancy → Ix: x-ray bilat hip initial normal, bone scan → Rx: ortho for splint vs surgical
T: tenosynovitis, bursitis, Baker’s cyst
Osgood Schlatter: osteochrondritis of tibial tubercle, active adolescent, anterior knee pain + limp, ↑ with exertion →
O: osteoporosis
Ix: x-ray to r/o # → Rx: self-limited once growth plate ossified, NSAIDs, acetaminophen ice, PT, surgical if failure to
I: immunologic
respond of after closure of growth plate
D: deformities- ulnar deviation, swan neck, Boutonniere’s
S: systemic Sx- fever, malaise Others: septic arthritis, trauma +/- hemarthrosis- hemophilia, growing pains, JIA, Kawasaki, osteosarcoma,
Complicated Lacerations
3rd/4th Degree Perineal Tear
o 1: perineal skin & vaginal epithelium
o 2: extends into musculature of perineal body
o 3: extends into external or internal anal
sphincter (consider 1 dose ceftriaxone)
o 4: extends into rectal mucosa (consider 1
dose ceftriaxone)
- Complications: chronic pain, dyspareunia, urinary &
fecal incontinence
- Repair: (1st/2nd ⁰) start 0.5cm above apex → tie, loose
running suture → change planes at perineal body →
approximate perineal muscles, running suture →
come out to skin at inferior apex → close perineal skin
with subcuticular sutures, tie & bury knot
- Postpartum care: ibuprofen, sitz baths, stool softeners
Lip
- Approximate vermillion border first
- Inspect for damage to teeth
- Consider Abx (amoxicillin)
- Use regional blocks: mental nerve block for lower lip,
infraorbital nerve block for upper lip
Eyelid
- Visible fat = ocular injury
- Perform complete eye exam
- Exclude injury to globe- CT orbits if unsure
- Consider emergent ophthalmology referral
Arterial Lacerations
- Achieve hemostasis prior to wound closure via direct
pressure, elevation, topical anesthetic w/ epinephrine
- Avoid clamping vessels due to potential nerve injury
- Suspected vascular injury: deep injury, penetrating
trauma, in territory of major artery
- Ischemia (5Ps): pain, paresthesia, pallor, polar (cold),
pulselessness
Complications of Lacerations
- Flexor tendon laceration: inspect flexion & extension,
refer to plastics/hand clinic for tendon repair
- Open fracture: orthopedic emergency- immediate
irrigation & debridement in OR, Abx (cefuroxime)
- NV injury: test distal sensory & motor function
- FB: consider mechanism, visually explore all wounds,
consider x-ray, consider Abx
Pediatric Laceration Repair
- Topical anesthesia: LET (lidocaine, epinephrine,
LACERATIONS tetracaine) +/- additional injected lidocaine
- Consider buffering lidocaine with bicarbonate
High Risk for Infection - Consider warming ampoule prior to use
- Require secondary closure & prophylactic Abx - Inject slowly at perpendicular angle to skin
1. Puncture wounds - Conscious/procedural sedation if necessary to avoid
2. Bites (cats/dogs, human, on hands/feet) physical restraints
3. Grossly contaminated wounds
4. Crush injuries Rabies Post-Exposure Prophylaxis
5. Wound >12h old (24h on face) - Immediate gentle irrigation decreases likelihood of
6. Compromised host transmission
- PEP most effective within 48h
Prophylactic Antibiotics - Safe in pregnancy
- Most common skin pathogens: staphylococcus - http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_sta
aureus, streptococci ndards/docs/protocols_guidelines/Management_of_Potential_Rabies
- Most wounds respond to cephalexin 500mg PO q6h _Exposures_2019_en.pdf
- Puncture through shoe: pseudomonas coverage - Indications for PEP:
required e.g. ciprofloxacin 750mg BID o Dog/cat/ferret bite if animal suspected to be
- Animal/human bite wounds: amoxiclav x 3-5d to rabid (if possible, animal should be tested),
cover pasturella multocida unknown/escaped
o Skunk/bat/fox/coyote/raccoon: consider rabid
Suturing unless area known to be rabies free (if possible,
Duration of Sutures: animal should be tested)
- Eyelid: 3d o Livestock & rodents: 14d observation, low risk,
- Neck: 3-4d only if highly unusual behaviour/rabid
- Face: 5d - Method:
- Scalp: 7-14d o Prev immunization: rabies vaccines at 0, 3d
- Trunk & upper extremities: 7d o No prev immunization: rabies vaccine at 0, 3, 7,
- Lower extremities: 10d 14d +/- 28d if immunocompromised, & RabIg
on day 0 (20IU/kg) to site
Types of Sutures:
- Absorbable: synthetic (monocryl, vicryl, POS) vs
natural (collagens- chromic/fast absorbing gut) Tetanus Prophylaxis
- Non-absorbable: synthetic (ethilon, prolene) vs
natural (silk) Clean/minor wounds:
- Appropriate vaccination Hx (≥3 doses): Td if last
dose >10y ago, TIG not indicated
Techniques
- Unknown/incomplete vaccination Hx: give Td, TIG
not indicated
All other wounds:
- Appropriate vaccination Hx: (≥3 doses): Td if last
dose >5y ago, TID not indicated
- Unknown/incomplete vaccination Hx: give Td & TIG
Learning Disability
- Intrinsic cognitive difficulty resulting in
academic achievement at a level less than
expected for the individual’s intellectual
potential
- E.g. reading (dyslexia), writing, math
(number sense, calculation, visual-spatial),
nonverbal (social reasoning, higher order
reading comprehension), language-based
- Consider if:
o Parental concern
o Report card indicated possible
learning difficulty
o FHx of learning difficulty
o Behavioural or mental health
conditions
o Intellectual/developmental disorder
o Neurologic or genetic condition, Hx
CNS insult
o Prematurity
- Assess impact of learning disability on family
& child
- Ensure patient and family have access to
available community resources
- Explain information clearly to family &
patient, matching complexity to their level
of understanding
Approach to Self-Learning
- Continuously assess your learning needs &
effectively address them
- Incorporate your new knowledge into your
practice to provide up to date evidence-
based care
LEARNING
Medical Evaluation
- Hx of learning problems, school performance, attendance
- Psychiatric/behavioural conditions
- Prenatal/perinatal health
- Sleeping habits
- Medications
- Neurological issues, developmental history
- Family Hx (inc parental education), social Hx
Examination
- Growth parameters
- Dysmorphic features
- Hearing/vision
- Neurologic exam
Management:
- Informal testing (skills by grade 1)
o rhyming, decode 3-4 letter word, language skills, number sense, math facts
- Refer for formal audiometry
- Support formal psychoeducational assessments
o Free through school board, often lengthy wait lists
o Available privately often %1.5-3k, may be covered through insurance
- if >21y, psychoeducation testing through Developmental Services Ontario
Signs of a Learning Disability
Cognitive Signs Behavioural Signs
Spelling the same word differently in a since Not wanting to go to school
assignment
Trouble with open-ended questions on tests Complaining about the teacher
Poor reading & language comprehension Reluctance to engage in reading/writing activities
Weak memory skills Saying the work is too hard
Difficulty in adapting skills from one setting to another Not wanting to show you schoolwork
Slow work pace Avoiding assignments/homework
Difficulty grasping abstract concepts Saying negative things about his or her academic
performance, such as ‘I’m dumb’
Inattention to details or excessive focus on details Disobeying teacher’s direction
Frequent misreading/misinterpreting information Cutting class & skipping school (adolescents/teens)
Trouble filling out applications or forms Bullying
Poor organizational skills, easily confused by Manifestation of mental health problems like
instructions depression or anxiety
Approach to Lifestyle Changes STI Counselling & Screening
- Regularly ask about changes in behaviour/lifestyle
that can improve health
LIFESTYLE - Prevent transmission through
abstinence or condom use
o Periodically review these as they may change - Screen for STIs in high risk
Alcohol populations:
o Regularly reinforce advice
- Case finding: CAGE (2+ yes)/AUDIT questionnaire o Sexually active youth <25y
- Explore patient’s readiness to change o Have you ever felt the need to cut down on your drinking?
- Explore patient’s context before making o Have people annoyed you by criticizing your drinking?
o Sex workers & partners
recommendations to ensure they are compatible o Have you ever felt guilty about drinking? o New sexual partners or >2
o Have you ever felt you needed a drink first-thing in the partners in the last year
Diet morning to steady your nerves or to get rid of a hangover?
o Serially monogamous
- Prevention of coronary artery disease, CRC - Counselling for problem drinking, advise of alcohol
individuals
- Decrease total fat/saturated fat/cholesterol, ↑ fibre related health complications & to ↓ consumption
o Not using contraception
- Consider referral to dietician if at increased risk - 1 unit = 17.2mL pure alcohol, safe limits 0-2u/day
o IVDU
women or 0-3u/day men, up to 10u/w for women
o Substance use, especially in
and 15u/w for men
Exercise association with sex
- DO NOT DRINK if:
- 30 minutes/day without two consecutive sedentary o Unsafe practices
o Driving, using machinery/tools, pregnancy or
days OR o Homeless populations
planning on becoming pregnant,
- 150 minutes/week cardiovascular/aerobic exercise o Anonymous sexual partnering
breastfeeding, <19y, living with mental or
o Victims of sexual
physical health problems or alcohol
Smoking abuse/assault
- Screen school age children for smoking & second dependence, responsible for the safety of
- Method:
others, using medications or drugs that
hand smoke exposure (5-18y) o Syphilis: serology
interact with alcohol
- Discuss smoking cessation at all appropriate visits o Chlamydia/gonorrhea: if
- Discuss NRT, other pharmacotherapy Poverty asymptomatic NAAT or
- Eat average of 7 portions of green leafy - Screening: do you ever have difficulty making ends cervical swab/urine in women
vegetable/fruit per week to lower risk of lung cancer meet at the end of the month? & urine in men, if
- Refer to validated smoking cessation program symptomatic both culture &
Counselling NAAT, culture for
Skin Cancer Prevention oropharyngeal
- Readiness to Change/States of Change:
- Avoid excess sun at mid-day o HBV: HBsAg serology
o Precontemplation
- Use protective clothing o HIV: serology
o Contemplation
- Use sunscreen, and reapply regularly every 4h or
o Preparation
after swimming Personal Safety
o Action
o Maintenance +/- Relapse - Always wear seatbelt, appropriate car
Oral Hygiene
seat orbooster seat for children’s age
- Prevent periodontal disease & oral cancer with - Motivational Interviewing
o OARS: open ended questions, affirmations, & weight
regular brushing & flossing
reflections, summarizing - Wear helmet- bicycle, motorbike,
- Daily use to fluoride toothpaste
- 5Rs: relevance, risks, rewards, roadblocks, repetition skateboard
- Smoking cessation
- Noise control/hearing protection
Approach to the Unconscious Patient
Resuscitation
- Airway: prone, assess for trauma, airway
assessment + consider intubation if GCS <8
- Breathing: equal breath sounds, O2, RR
- Circulation: appearance, warmth, pulses, ECG leas
for shockable rhythms --> ACLS, 2 large IVs, fluids
- Drugs: D50W 50cc IV bolus, thiamine 100mg IV,
naloxone 0.4mg IM
Sample Hx
- Signs/symptoms, allergies, medications, PMH, last
oral intake, events leading up
- Abrupt onset (SAH, seizure) vs gradual (tumour),
fluctuating (metabolic, 2+ seizures), initial
hemiparesis (structural/stroke/mass effect), vision
(posterior ischemia), recent confusion/delirium
(metabolic/toxic), fever (infection), increasing
headache (intracranial mass, infection, CO2, sinus
thrombosis)
Physical Exam
- Mydriasis/miosis, fundoscopy
- Breath (EtOH, ketones)
- Tongue laceration (seizures)
- Meningeal signs (SAH, meningitis)
- Focal neuro findings (stoke, encephalopathy)
- Asterixis (CO2)
- Trauma
- Medication/substances in pockets
GCS (3-15/15)
- Eyes: spontaneous (4), speech (3), pain (2), none(1)
- Verbal: oriented (5), confused (4), inappropriate
(3), incomprehensible (2), none(1)
- Motor: obeys commands (6), localizes pain (5),
withdraws from pain/flexion (4), abnormal flexion
(3), abnormal extension (2), none (1)
Driving Restrictions
- No restrictions if single vasovagal event
- Wait 1 week if : diagnosed & treated (e.g. bleed),
or situational (e.g. micturition), single episode
unexplained, or recurrent vasovagal
- Wait 3m if recurrent episode of unexplained LOC
- Seizures: all require reporting, no driving until
investigated & assessed by MoT
LOSS OF CONSCIOUSNESS
Differential: Mnemonic: AEIOU TIPS
- A: alcohol, abused substances, acidosis (DKA), arrhythmia
- E: epilepsy, encephalopathy, endocrine (adrenal, thyroid),
environment, electrolytes
- I: infection (encephalitis, meningitis, sepsis)
- O: oxygen deficiency (hypoxemia, PE, MI)
- U: uremia (renal failure, CHF, urinary obstruction)
- T: trauma/TBI/tumour
- I: insulin, intracranial bleeds
- P: psychogenic/poison
- S: stroke/syncope/shock: (see types)
- Hypovolemic: bleeding, diarrhea, burns
- Cardiog: CHF, arrhythmia, valvular insufficiency, MI
- Obstructive: tamponade, tension pneumo,
constrictive pericarditis, PE
- Distributive: anaphylaxis, sepsis, neurogenic
Syncope
- Transient LOC resulting in loss of postural tone, caused by
inadequate blood flow to brain
Classification:
- Neurally mediated: sudden unexpected sight/smell/pain,
vasovagal e.g. prolonged standing, exertion
- Orthostatic: positional change, autonomic e.g. Parkinson's
- Cardiovascular syncope: structural heart disease,
arrhythmia, heart block, bradycardia, nonsustained VT, MI
Presentation:
- Prodrome: lightheadedness, temp instability, sweating,
palpitations, nausea, vision change, pallor- LOC <1 min
o Followed by fatigue, feeling cold/clammy, N/V, +/-
confusion/injury
- O/E: vital signs, neuro + cardiac exams, postural vitals
Investigations:
- ECG, consider labs, consider echo to r/o structural heart
disease if suspected or Holter is arrhythmias suspected
Management:
- Lie/sit down w/ onset of prodromal Sx, adequate
hydration, elevation of legs above head
- Avoid rapid postural changes if orthostatic
o Consider fludrocortisone/midodrine if nonpharm
ineffective & persistent orthostatic hypotension,
with no supine HTN
- Avoid triggering sites/smells where possible
Intracranial Bleeds
Epidural hemorrhage
-
-
Blunt trauma to temporal/temporoparietal, skull #
Altered LOC, headache, vomiting, confusion/seizure
- Biconvex (lentiform) hyperdensity on CT
Subdural hemorrhage
- Sudden acceleration-deceleration, shearing;
elderly, alcoholics
- Can be acute <14d or chronic >14d
- Lucid interval, progressive decline into coma
- Crescent, hyperdense (acute) vs hypodense (late)
Subarachnoid hemorrhage
- Ruptured aneurysm or head injury
- Thunderclap h/a (sudden > maximal intensity)
- Retinal hemorrhage, sentinel bleed headache
- Confirm with xanthochromia in LP
Rx:
- Stabilize + urgent neurosurgery consult
- Anticoagulation reversal
- Lower intracranial pressure (elevate head of bed,
hyperventilate, hypertonic saline, mannitol)
Concussion
- Head injury with post-concussive sx following
o SCABS: somatic (headache), cognitive
(fog), affective (lability), behavioural
(irritability), sleep/wake
o Consider CT head if required (see below)
- SCAT 5 to assess
- Return to work/play
o Rest during acute phase 24-48h
o Gradually/progressively increase activity
while avoiding cognitive/physical
exacerbation; reduce activity back to
previous threshold if symptomatic
o Usually improved after 10-14d, consider
PT/CBT/rehab if not
- Prevention:
o Helmets, mouth pieces, advocate for rule
changes to reduce contact and head-to-
head, protective equipment e.g.
shoulder/elbow pads
Canadian CT Head Rules
• Avoid Driving if you Get SSmashed And Vomit
o Amnesia >30min before impact
o Dangerous mechanism (ejection, pedestrian
struck by vehicle, fall from >3 feet/5 stairs)
o GCS <15 2h post-injury
o Suspected open/depressed skull #
o Signs of basilar skull #
o Age >65y
o Vomiting >1 episode
• Exclusion criteria: ABRUPT MONS
o Age <16y
o Bleeding disorder or anticoagulant use
o Return for reassessment of same head injury
o Unclear Hx of trauma
o Pregnant
o Trauma (major with unstable vitals)
o Minimal head injury (no LOC, amnesia, or
disorientation)
o Obvious penetrating skull injury
o Neurologic deficit
o Seizure prior to ED assessment

PECARN Rule (<16y)

Clinically Relevant Weight Loss:
- >5% unintentional weight loss compared to
baseline body weight, within 6 months
- Predicts: morbidity & mortality, illness severity,
undiagnosed illness
Natural Aging
- Peak body mass in 50-60s, then stabilizes
- Normal to lose 1-2kg/10y afterwards
Weight Maintenance: caloric intake, absorption,
utilization, losses
Approach to Unintentional Weight Loss
1. Organic
o Cancer: (most common) GI, lung,
breast, prostate, hematologic
o GI: oral cavity disease, gastritis, PUD,
IBD, chronic constipation, celiac disease
o Endocrine: thyroid, DM, adrenal
insufficiency
o Other: CVD, alcoholism, neurologic
disease, chronic pulmonary disease,
acute/chronic infectious process, CKD,
med side effect, eating disorders
2. Psychosocial (better prognosis)
o Psychiatric: depression, dementia,
o Apathy, decreased self care, decreased
recognition for need to eat + appetite
o Social isolation, poverty, functional ↓
3. Idiopathic
o Multiple comorbidities, polypharmacy,
psychological & social factors
Follow-Up:
- Dependent on diagnosis
- If idiopathic unintentional weight loss: 3 months
to monitor weight & look for new symptoms
- Stable/improving: f/u 6 months
- Counsel on signs/symptoms that should trigger
patient to return earlier
- If weight decreasing: continue to explore
organic or psychosocial causes
Investigations:
- Watchful weight is appropriate for up to 6
LOSS OF WEIGHT months if no other concerning features
History: - Ensure provincial cancer screening up to date
- Duration & pattern of weight loss (past fluctuations - Targeted investigations if specific diagnosis
in weight, progressive or stabilized) suspected
- Intention, change in caloric intake, physical activity - Standard investigations if no diagnosis suspected
- ROS: GI, anorexia, N/V/D, dysphagia, odynophagia, • Labs: CBC, renal function, electrolytes,
swallowing issues, constitutional symptoms glucose, HbA1c, calcium, phosphate, TSH
- PMH, past psych Hx (high yield), liver function, ESR/CRP
- Meds, tobacco/EtOH use, recreational drug use • Chest x-ray
- Social Hx: access to food, finances, function • Urinalysis
- Elderly: the Ds- dentition, dysgeusia, dysphagia, • FOBT (high yield)
diarrhea, depression, dementia, disease, drugs
Physical Exam: - Consider if clinically indicated
- Document weight loss, BMI + calculate percentage • Ferritin, B12, folate
lost from baseline • SPEP
- HEENT: check oral cavity, LN • HIV serology
- CVS/resp, abdo exam • GI investigations: if clinical suspicion or
- Breast/prostate exam as indicated screening BW positive: celiac screen ,
- Mental status exam abdominal imaging , endoscopy (high yield,
- MMSE/MoCA if indicated based on Hx/physical)
Management:
- All patients: involve dietician, consider SLP, monitor at regular intervals
o Acute management including correcting dehydration and electrolyte abnormalities
- Organic: treat underlying cause, ensure timely investigations + follow-up if malignancy suspected
- Psychosocial: treat underlying cause e.g. involve SW, dietician, psychiatry as appropriate, consider if meets
criteria for form 1 under mental health act if neglecting self care
- Idiopathic: obtain advice from dietician to improve caloric intake and treat vitamin deficiencies
- Nutritional therapy:
o Dietary education
o Dietary supplementation: supervised by dietician
o Decreased dietary restriction
o 30-35kcal/kg/day
o >30% protein content
o Daily multivitamin
- Pharmacologic:
o Appetite stimulants: steroids, growth hormone, mirtazapine if comorbid depression
• Used more commonly in palliative care
o No studies showing improvement or change in long term survival excepts in AIDS
o Serious potential adverse effects
Approach to Back Pain:

LOW BACK PAIN

Red Flags for Back Pain: Yellow Flags:
Mnemonic: NIFTI → potential underlying serious pathology Mnemonic: ABCDEFG → psychosocial
- Neurological: diffuse motor/sensory loss, progressive neurological factors for chronic pain
deficits, cauda equina syndrome, bladder/bowel dysfunction,
saddle anesthesia - A: attitudes (believes harmful)
o Urgent MRI indicated, surgical emergency
- B: behaviours (illness role)
- Infection: fever, IV drug use, immunosuppression
o X-ray & MRI indicated - C: compensation (financial gain)
- Fracture: trauma, osteoporosis, risk/fragility fracture - D: diagnostic/treatment
o Xray indication, +/- CT scan expectations
- Tumour: Hx cancer, unexplained weight loss, significant night pain,
severe fatigue, constitutional sx - E: emotions (mood, withdrawal)
o X-ray & MRI indicated - F: family overprotective, or
- Inflammation: chronic low back pain > 3m, age onset <45y, lacking supports
morning stiffness >30 mins, improves with exercise,
disproportionate night pain - G/J: job problems
o Rheumatology consultation

Management:

Physical Examination:
Causative Organisms:
- Bacterial:
o 0-4w: GBS, E.coli, Listeria, klebsiella
o 1-23m: GBS, E. coli, S. pneumoniae, N.
meningitides, H. influenza
o >2y: S. pneumoniae, N. meningitidis,
Listeria (>50y, alcoholism,
immunocompromised)
- Viral: HSV1/2, VZV, enteroviruses, west nile
- Fungal: cryptococcus, coccidiodes
- Other: lyme disease, neurosyphilis, TB
Risk Factors:
- Immunocompromised: corticosteroids, asplenia,
malignancy, diabetes, hepatic/renal failure, HIV
- Penetrating head trauma
- Anatomical meningeal defect e.g. CSF leaks
- Lack of immunization
- Hematogenous spread e.g. from oropharynx
- Parameningeal infection e.g. otitis media, sinusitis
- Students living in a residence
- Previous neurosurgery, shunt
- Alcoholics, elderly, neonates, Native populations
- Contact with colonized or infected person
Clinical Features:
- Neonates & children: fever, vomiting, lethargy,
irritability, poor feeding
- Older children & adults: fever, h/a, neck stiffness,
confusion, N/V, lethargy, photophobia, altered
LOC, seizures, focal neurological signs, papilledema
Physical Exam:
- Nuchal rigidity: passive or active flexion of neck →
positive if chin can’t touch chest
- Petechial rash in meningococcal meningitis
(bacterial), seen more on trunk/lower extremities
- Full neurological exam
- Special tests:
o Jolt accentuation of h/a: worse when
head turned horizontally 2-3 rotations
o Brudzinski’s sign: passive neck flexion
causes involuntary flexion of hips & knees
o Kernig’s sign: resistance to knee extension
when hip flexed to 90⁰
MENINGITIS
Investigations:
- CBC, WBC usually high (severe infection can be low)
- Cr, lytes, VBG/ABG, lactate
- Blood cultures x 2, before Abx
- LP
o Abx have minimal effect on LP, can reduce utility
of gram stain/culture a few hours after given
o Opening pressure, cell count, glucose, protein,
gram stain & culture, viral PCR, consider
fungi/parasites/ mycobacteria + AFB if
immunocompromised, suggestive travel Hx,
known TB exposure
- CT head: to screen for raised ICP/mass before LP if any of:
o Immunocompromised (e.g. transplant pt, HIV), Hx
of CNS disease (e.g. stroke, mass), new onset
seizures (within 1 week), papilledema, abnormal
LOC, focal neuro deficit
o Delay LP if any signs of herniation: GCS <11,
brainstem signs (pupillary changes, posturing,
irregular respiration, recent seizure) → start
empiric Abx + dex then send for CT first
Management:
- Empiric Abx:
o <1 month: ampicillin + cefotaxime
o 1-23m: vanc + ceftriaxone/cefotaxime
o 2-50y: vanc + ceftriaxone/cefotaxime
o >50y: vanc + ampicillin + ceftriaxone/cefotaxime
- Blood cultures
- Culture pending: empiric Abx +/- empiric antivirals
o +/- dexamethasone (within 20 min prior to or
with 1st dose Abx)
Prevention:
Immunization
- Children: immunization against H. influenzae
(Pediacel), S. pneumoniae (Prevnar-13), N.
meningitidis (Menjugate, Menactra)
- Adults: immunization against N. meningitidis in
selected circumstances (outbreaks, travel, epidemics)
& S. pneumoniae (Pneumovax) for high-risk groups
o Pneumococcal Polysaccharide Vaccine (e.g.
Pneumovax)
o >65y
o >2y, w/ chronic
cardiovascular/respiratory/hepatic/rena
l disorders, asplenia, sickle cell, or
immunosuppression (8w after
pneumococcal conjugate if <18y)
o Meningococcal Quadrivalent
Vaccines(Menactra)
o Healthy young adults in gr. 7
o Asplenia
o Travellers to high-risk areas
o Military recruits or laboratory personnel
o Complement, factor D, or properdin
deficiency or acquired terminal
complement deficiency through receipt
of eculizumab
Contact tracing through public health
Prophylaxis:
- Chemoprophylaxis for all close contacts of pts w/
invasive meningococcal disease (meningitis,
meningococcemia, pneumonia, septic arthritis,
pericarditis) 7d before onset to 24h after initiation of
treatment, regardless of immunizations
o Affected individuals:
• Household contacts (highest risk)
• Children & staff (e.g. in daycare setting)
• Direct nose/mouth contact
• Health care workers with unprotected
contact e.g. no mask when intubation,
resuscitation, examining oropharynx
• Airline passengers
- Agents:
• H. influenzae: rifampim
• N. meningitidis: rifampin, cipro, ceftriaxone
Menopause: cessation of the menstrual cycle/end of
reproductive years, 12m after final menstrual period
- Premature <40y (offer HRT until natural age of
menopause), average age 51y in Canada
Presentation:
1. Vasomotor symptoms
o hot flashes +/- sweating/palpitations, lasting
2-30 mins
o sleep disturbances 2⁰ to night sweats
o 10% persistent 10y after final period
2. Menstrual irregularities
3. Genitourinary Sx:
o Vaginal dryness/discomfort, dyspareunia,
pruritus, burning, ↓ libido
4. Dysuria, ↑ UTIs
o Vulvovaginal + urogenital atrophy
o Loss of pelvic tone, prolapse, urinary
incontinence
5. Mood disorder
o Depression, anxiety, irritability
6. Cognitive disturbances
o Insomnia, forgetfulness
Other sx: skin changes (↓ elasticity, somatic complaints-
back pain, headache, decreased breast density), weight
gain, bloating, loss of BMD (fragility #s)
Atypical sx: weight loss, changes to bowel pattern or blood
in stool, drenching night sweats → r/o med side effect,
thyroid, prolactinoma, carcinoid syndrome, malignancies
Nonpharmacological Management:
- Prev care/lifestyle: healthy diet, ↓ sodium/sugar/
saturated fats, vit D supplement, exercise, stop
smoking, BP control + Framingham risk assessment
- Vasomotor sx: smoking cessation, ↓ alcohol, exercise,
weight loss, mindfulness + stress reduction, CBT,
dressing in layers, ice pack under pillow, use fan
**Limited evidence: black cohosh, evening primrose,
chasteberry, dong quai, fennel, clover, accupuncture
- Urogenital: vaginal moisturizer or lubricant, regular
sexual activity, Kegels, consider pessary
- Psychological: counselling + education, exercise,
muscle relaxation techniques
MENOPAUSE
Investigations:
- Not done routinely/required for diagnosis, especially if
>45y, *clinical diagnosis
- Consider investigations if diagnosis unclear e.g.
atypical sx or <45y, any vag bleeding after 12 months
amenorrhea should be investigated
- Hormone: neg panel does not r/o menopause
o FSH >30mIU/mL, best done on day 3- do not
test if on OCP
o ↑LH, rises after FSH
o TSH, prolactin, B-hCG
o Estradiol <20, if OCP test after 7d pill free
o Endometrial biopsy if AUB/post-menopausal
bleeding
Differential Diagnoses:
Vasomotor sx (hot flashes, night sweats)
- Panic attacks, stress, alcohol, thyroid, infections,
carcinoid syndrome, leukemia, pheochromocytoma
Menstrual irregularity
- Thyroid disease, pregnancy, reproductive tract
pathology (vaginal, cervical, endometrial), OCP,
hyperprolactinemia, virilizing tumour,
hyperandrogenism
Dysuria/incontinence
- UTI, vaginitis, STI, prolapse, urge vs stress incontinence
Menopausal Women Preventative Health
- Mammo 50-74y q2y, Pap smears 21-70y q3y
- OP screening for all menopausal women, & 50-64y if:
o Fragility # >40y
o Prolonged steroid use, other high risk med
o Parental hip #
o Vertebral or hip #, osteopenia on XR
o Current smoking
o High alcohol intake
o Low body weight <60kg or weight loss >10%
o Rheumatoid arthritis
o Other disorder associated with OP (including
premature menopause)
Pharmacological Management:
Genitourinary
- Topical estrogen (vagifem, Premarin), progestin
co-therapy not required
- Antimuscarinic for urge incontinence, kegels or
pessaries for stress incontinence
Sexual dysfunction
- Treat genitourinary sx, pelvic PT, CBT +
relationship counselling or sexual therapy
Vasomotor sx
- HRT: combined OCP or low dose continuous
progestin if perimenopausal
- Non-hormonal: SSRIs e.g. fluoxetine/venlafaxine,
gabapentin/pregabalin, clonidine
Osteoporosis
- HRT only if treating other sx
- Calcium 1200mg/d, vitamin D 100U/d
- Weight bearing exercise + balance
- Smoking cessation, moderation of alcohol
Hormone Replacement Therapy
- Oral E (Premarin, estrace), topical, patch, ring
- Oral P e.g. medroxyprogesterone acetate or
prometrium, progesterone required if uterus
present for endometrial protection
- Contraindications
o Unexplained vaginal bleeding, known or
suspected breast ca, acute liver disease,
acute CV disease, uncontrolled HTN,
recent CVA, active thromboembolic
disease, pregnancy
o Relative: migraine w/ aura, CAD/IHD
- Monitoring: 6-8w for improvement, reassess q1y,
typical duration 2-3y or maximum 5y
- Side effects:
o Breast tenderness, nausea, h/a,
bloating, mood changes, skin irritation,
gallstone disease, VTE/stroke
- Discontinuation: gradual taper, consider non HRT
alternative, individual approach
Endometrial Cancer RFs: (OLD AUNT): obesity, late
menopause, DM, age & FHx ovarian/breast/colon ca,
unopposed estrogen, nulliparity, tamoxifen
Approach to Mental Competency
- Assess competency when there are subtle signs
of cognitive decline e.g. family concerns,
medication errors, repetitive questions, decline
in personal hygiene)
o Use a standardized tool
- Consider assessing competency when a patient
is making big decisions e.g. code status, and
when they have a diagnosis that may predict
cognitive impairment (e.g. dementia, recent
stroke, severe mental illness)
Consent
- Must be related to individual decisions
- Valid if informed, voluntary, and competent
- Physician must provide patient with
information about nature of treatment,
expected benefits, risks & side effects, as well
as alternative courses of action and
consequences of not having treatment
- Evidence of consent: express or implied, best
practice to document rather than verbal alone
Emergency Treatment
- May be given without consent to an apparently
capable person in an emergency if in the
opinion of the physician:
o It is not possible to communicate
relevant information to patient
because of language, disability, or
situation
o Steps have been taken to find means of
communicating but no such means
have been found
o The delay required to find a means to
communicate will prolong suffering or
put patient at risk of bodily harm
o No reason to believe that person does
not want treatment
MENTAL COMPETENCY
Capacity
- Ability to both understand information relevant to a decision and to appreciate the reasonably foreseeable
consequences of a decision or lack of a decision
o Context: can patient understand the situation they are facing?
o Choice: does patient understand the options?
o Consequences: understand the possible ramifications of choosing various options
o Consistency: no fluctuation in their understanding or choice
- Consider use of a structured tool:
o MacArthur Competency Assessment Tool for Treatment
o Assessment of Capacity of Everyday Decisions
o Aid to Capacity Evaluation: (ACE)
- CPSO Principles:
o Best interests of patient are central to all interactions
o Respect for autonomy and dignity of the patient is central to ethical care, fundamental right of
patient to decide which interventions will be accepted and which will not
o To exercise autonomy, patient must be capable & competent of making informed decisions
o Physicians have obligation to secure consent and patient has legal right to reduce/consent
- Competency: legal ability e.g. to make healthcare decisions
- Capacity assessment:
o What is your understanding of your condition?
o What options are available for your situation?
o Do you understand the option of not treating?
o How will the treatment help you, and what are the odds that it will work?
o What are the risks of the treatment and odds that you may have a bad outcome?
o What is important to you in making this decision? What are you hoping for in terms of your care?
- Approach
o Assess frequently: family concerns, abrupt changes in mental status, psychiatric process, refusal of
recommended treatment, risk factor for impaired decision making including very young & elderly
o CURB: communicate decision, understand information, retain information, balance pros & cons
Substitute Decision Maker
- When deemed not capable, SDM will make decisions
- Hierarchy of who becomes SDM, unless a POW for health & welfare has previously been decided upon:
legally appointed guardian → POA for personal care → representative appointed by consent & capacity
board → spouse -> child or parents (shared among all) → brother or sister (shared among all) → other
relative → public guardian & trustee)
Approach to ‘Multiple Medical Problems’ **Also consider:
o Take an appropriate history to determine the
- Illness anxiety disorder
primary reason for the consultation
• Opportunity to ask about patient's ideas,
Multiple - Body dysmorphic disorder
- Conversion disorder
concerns, and expectations
Medical Problems - Factitious disorder & factitious disorder by proxy
- Malingering
o Prioritize problems e.g. most bothersome to
patient, most concerning medically
o Somatic Symptom Disorder
Develop an agenda, agreed upon between pt and
Suggestive diagnostic features:
healthcare practitioner
o • Multiple Sx, often occurring in different organ systems
Professional & pt-centered approach
o • Symptoms that are vague or exceed objective findings
Determine common ground
• Chronic course
o • Presence of psychiatric disorder
Set limits when appropriate: e.g. if recurrent visit
• History of extensive diagnostic testing
for unchanging symptoms
• Rejection of previous physicians
• Duration of visits
• Frequency of visits
Comorbidities:
o • Depression (60%)
Always consider depression (& secondary
• Anxiety disorders (50%)
depression due to multiple medical problems)
• Personality disorders (60%)
• Consider anxiety & abuse (physical, mental,
• Substance abuse
drug abuse)
• Sexual/physical abuse
o Periodically re-assess management:
Diagnostic Criteria:
• Simplify management
• >1 somatic symptom that is distressing/significant disruption of daily life
• Limit polypharmacy
• Excessive thoughts/feelings/behaviours related to somatic symptom manifested by at least 1 of the
• Minimize drug interactions
following
• Update therapeutic choices (due to changing
• Disproportionate/persistent thoughts re: seriousness of symptoms
guidelines and/or patient situation)
• Persistently high level of anxiety about health symptoms
• Excessive time/energy devoted to health concerns
Polypharmacy
• Although any one somatic symptom may not be continuously present, the state of being symptomatic
- Includes all prescribed meds, OTC, herbal products is persistent (typically more than 6 months)
- Particular concern in older adults: Beers Criteria (relevant to FM)
- ↑ risk ADEs & hospital admission (irrespective of - Potentially inappropriate meds for older adults due to drug-disease or drug-syndrome interactions
age) ↑risk in older adults due to metabolic changes,
↓ drug clearance
- ↑risk drug interactions and risk potentially
inappropriate medications
- Problems with adherence (especially elderly)
- Associated with ↓ physical & cognitive capability
History: Interpreting C-Spine X-rays:
- Acute (<5w) vs subacute (6w-3m) vs chronic (>3m) Mnemonic: AABCs
- Neck (sub-occipital, trapezius, parascapular) vs arm
(upper arm, forearm, hand), vs shoulder dominant
NECK PAIN A: adequacy C7/T1 must be visible
(deltoid, anterior shoulder) Management:
- Trauma/injury - Nonpharmacologic A: alignment x 4 (ant + post
- Site, onset, characteristics, radiations, o Patient education, reassurance of prognosis & recovery, early return longitudinal lines, spinolaminal,
alleviating/aggravating factors, timing, severity to non-painful ADLs & work spinous processes)
- Referred pain from headache e.g. pseudotumour o Give instructions for independent stretches/exercise
cerebri vs referred from cardiac source o Referral to physiotherapy B: bones, examine each vertebrae
- Function → r/o yellow flags - Pharmacologic for #/collapse/avulsion
- Prolonged morning stiffness >30 mins o Acetaminophen, NSAIDs
- Cardiac sx: CP, SOB, presyncope, and cardiac Hx o Muscle relaxant (e.g. baclofen, cyclobenzaprine) for short duration C: cartilage (disk spaces) symmetry
o If chronic: consider antidepressants, antiepileptics (pregabalin, of intervertebral disks
Red Flags: gabapentin)
- Neuro: cervical cord compression, demyelinating o Routine use of opioids not recommended S: soft tissue, prevertebral swelling
process, progressive neurological deficits → MRI - Surgical referral <7mm anterior to C2, <2cm anterior
- Infection: fever, meningism, history of o If red flags, failure to respond to conservative treatment within 12 to C7
immunosuppression or IVDU → x-ray +/- MRI, CSF weeks
- Fracture: OP #, traumatic fall → x-ray +/- CT Canadian C-Spine Rule
- Tumour: Hx cancer, unexplained weight loss, • Indicated for: alert (GCS 15) and stable trauma patients
significant night pain, severe fatigue → x-ray & MRI • Rule NOT applicable if:
o Non-trauma case, GCS <15
- Inflammatory: RA, PMR, giant cell arteritis →
o Unstable VS
inflammatory markers + rheum consult
o Age <16
o Acute paralysis
Yellow Flags: o Known vertebral disease
- Do you think your pain will improve or get worse? o Prior C-spine injury
- Do you think you would benefit from activity, • If any high risk factor- C-spine immobilization & x-ray
movement or exercise? • If not high risk factors, 1+ low risk factor- can safely check ROM
- How are you emotionally coping w/ your neck pain? o Check if patient can actively rotation neck 45 degrees left & right
- What treatments or activities do you think will help o If able- no radiography
you recover? o If unable- C-spine immobilization & x-ray

Examination: • High risk factors

o Age 65y +
- Inspection: gait/neck posture
o Dangerous mechanism (fall from >3ft/5 stairs), axial load to head, MVC high speed >100km/h, rollover,
- Palpation for spinal tenderness, lymphadenopathy
ejection, motorized recreational vehicle, bicycle
- ROM: active + passive, flexion/extension, rotation,
o Paresthesias in extremities
lateral flexion, shoulder ROM
• Low risk factors
- Neuro: o Simple rear-end MVC
o Myotomes: C4 trapezius, C5 deltoid, C6 o Sitting position in ED
bicpeps, C7 triceps, C8 finger flexion o Ambulatory at any time
o Dermatomes, DTRs o Delayed onset neck pain
o Spurling’s compression test o Absence of midline C-spine tenderness
o Upper motor neuron: plantar, Hoffman test
Neonatal Examination:
General appearance:
-
-
Well or septic appearing, alertness, vitals, weight, length, HC
APGARs: at 1 & 5 mins
HEENT:
- Head appearance (dysmorphic features), head (shape, size,
fontanelles), eyes (red reflex), ears & nose (shape, size,
position), lips & palate
- Head swelling:
o Caput succedaneum: ‘cone head’ swelling of scalp +/-
bruising, diffuse & crosses suture lines, present at
delivery- days to resolve
o Cephalohematoma: subperiosteal hemorrhage, does
not cross suture lines, appears hours after birth &
resolved in 2-12w
o Subgaleal hemorrhage: blood accumulation between
periosteum & skull, diffuse fluctuant head swelling-
can expand over time, tachycardia + pallor, ↑HC- may
require fluids +/- blood products
- Red reflex: absent- cataracts, retinoblastoma, structural
abnormality, glaucoma
- Ophthalmia neonatorum: purulent conjunctivitis within 1st
month of life- G/C > viral/other bacterial, Rx topical Abx-
erythromycin, screen mom & baby for STIs, ophtho consult
- Ankyloglossia- tongue tie (refer if feeding affected)
- Cleft lip/palate: refer- surgical repair (lip at 3m, palate < 1y)
- Congenital neck masses: thyroglossal duct cyst, cystic hygroma,
branchial cleft cyst
CVS/Resp
- Inspect for chest deformity, cyanosis, accessory muscle use, RR
- Observe for signs of increased work of breathing
- Palpate for femoral pulses, capillary refill
- Auscultate for breath sounds, crackles, heart rate, murmurs
NEWBORN
Newborn Examination Continued:
Abdomen
- Size, shape, masses, herniations, anus (imperforate, prolapsed)
- Gastroschisis: defect ant abdo wall lateral to umbilicus, herniated intestine/no covering sac/associated abn
- Omphalocele: incomplete closure of anterior abdominal wall after return of midgut, herniated
bowel/stomach/liver/spleen in peritoneum covered sac, high association with other abnormalities
- Umbilical hernia: mostly in premature/F /dark skinned infants- most resolve spontaneously, repair if >3-4y
Neuro/spine:
- CNS/PNS system: movement symmetrical + all 4 limbs, bilaterally, jitters vs seizure activity, tone
- Reflexes: DTRs (positive babinski normal), primitive reflexes
• Primitive reflexes
o Galant: stroke back approx 1cm from midline when prone, trunk curves toward stroked side
o Placing: baby upright, gently touch top of foot to table edge, mimics walking onto table
o Rooting: stroke cheek, head turns to same side
o Palmar/plantar grasp: fingers/toes grasp object placed in palm/sole
o Moro: startle with loud noise or sudden drop when supine, arms extend/abduct then adduct
o Asymmetric tonic neck: turn head to one side, arm/leg on that side extend, flex on opposite
side (fencing position)
o Spine/back- skin changes, lower back hair tuft or dimple
o Neural tube defects
o Spina bifida occulta: usually no consequences
o Spina bifida aperta:
• Meningocele: herniated meninges with no spinal cord involvement
• Myelomeningocele: herniated meninges and spinal cord
o Screening: MSS or IPS & US, prevent w/ folic acid prior to conception (75% risk reduction)
MSK
- Screen for congenital hip abnormalities with Barlow and Ortolani maneuvers
• Barlow: supine, stabilize pelvis, flex knees & hips, apply posterior pressure, +ve if unstable/dislocatable
• Ortolani: supine, flex knee & hips, abduct & apply anterior pressure, +ve if audible/palpable clunk
- Check for birth injury: clavicle fracture, brachial plexus injury
• Erb's: C5/6/7, arm extended & hand medially rotated/write flexed, pronation (water’s tip)
• Klumpe's: C8/T1, forearm supinated, wrist & fingers hyperextended, flexion at IPs, +/- Horner's
Genitalia
• Male: check for normal genital anatomy, bilateral descended testes, hernias, hydrocele
• Female: check for normal anatomy, swollen labia and scant bloody or white discharge from maternal
estrogen withdrawal
Skin (see chart)
• Birth marks, rashes
• Vascular lesions
Newborn Feeding: Neonatal Resuscitation
- Encourage breastfeeding but support decision to formula feed without PPV Corrective steps: Mnemonic- MR.SOPA → mask readjustment, reposition head to open airway,
judgement suction mouth & nose, open mouth & jaw life, pressure increase, alternative airway e.g. LMA/ETT
- Contraindications to breastfeeding: Compression to ventilation ratio- 3:1
o Galactosemia (baby): unable to metabolize galactose, lactose-
can lead to liver failure
o Maternal HIV, human lymphotrophic virus, ebola virus, active
herpetic lesions on breast, active untreated TB
o Medications: chemo, immunosuppressants, lithium,
bromocriptine, iodides
- Frequency of feeds: q2-3h, 10-12 feeds during first week then 8-10/14h
- Output:
o Urine: minimum 1 wet diaper per day of life until >5/d
o Stools: 1-2 meconium stools on day 1-2
- Weight:
o May lose up to 10% but shoulder be regained by day 13
o Average 20-30g/d
Prior to Discharge
- Ensure newborn able to feed, void, stool
- Advise parents: seek immediate assessment if poor feeding, decreased
wet diapers, lethargic, fever, signs of respiratory distress
- Follow up with GP for newborn visit within 3d-1w to check weight,
feeding, voiding, stooling, address concerns, & full physical exam
Neonatal Sepsis
- Systemic inflammatory response to infection, early 0-7d vs late 7-28d
- Etiology: GBS, E.coli, listeria, GAS, staph aureus, HSV, enteroviruses
- RF:
o Prolonged rupture of membranes (>18h)
o Intrapartum fever
o Chorioamnionitis: fever, tenderness, foul amniotic fluid
o Maternal GBS colonization
o Prematurity: delivery at <37w GA
o Perinatal asphyxia
o Male gender
- Sx: nonspecific/subtle: low APGAR, poor feeding, lethargic, vomiting,
diarrhea, respiratory distress/apnea, grunting, fever
- Investigations: full sepsis work-up
o Labs: CBC, Cr, lytes, blood cultures
o Urinalysis + culture
o LP: CSF for cell count, glucose, protein, culture, PCR
o +/- CXR if respiratory sx
o +/- stool culture if GI sx
- Treatment:
o Empiric ABx: amp + gent/amp + cefotaxime, + vanc if >30d
o Newborns of GBS +ve mom’s- observe min 48h if prophylaxis
• Adequate prophylaxis: IV penicillin/amp/cefazolin >4h
before delivery
Routine Prenatal Care Neonatal Skin Conditions:
1. Erythromycin ointment: applied to both eyes for prophylaxis of ophthalmia neonatorum Vasomotor Response: (cutis marmorata, acrocyanosis) transient mottling when
2. Vitamin K IM: prophylaxis against HDNB exposed to cold; usually normal, particularly if premature
3. Newborn screening tests in Ontario
- Metabolic disorders (amino acid/organic acid disorders, fatty acid oxidation defects, biotinidase deficiency,
galactosemia)
- Blood disorders (SCD, other hemoglobinopathies)
- Endocrine disorders (CAH, congenital immunodeficiency) Vernix caseosa: soft, creamy, white layer covering baby at birth
- Other (CF, severe combined immunodeficiency)
- Congenital hearing loss
4. Rh- if mother Rh negative: send cord blood for blood group and direct antiglobulin test
5. Hep B- if mother hepatitis B surface antigen positive: HBIg and start hepatitis B vaccine series
Jaundice: Congenital Dermal Melanocytosis: (monoglian spot/slate gray nevus) slate gray
- Jaundice in the first 24 hours or >2w or conjugated hyperbilirubinemia are always pathological macules over lower back & buttocks (may look like bruises), common in darker skin
- Visible at serum bilirubin levels of 85-120 umol/L; visual assessment is often misleading → look at
sclera, tip of nose in natural light
- Jaundice more severe/prolonged (due to increased retention of bilirubin in the circulation) with:
Capillary hemangioma: raised red lesion, which increases in size after birth &
prematurity, acidosis, hypoalbuminemia, dehydration, hemolysis involutes, 50% resolved by 5y and 90% by 9y

Erythema toxicum: yellow-white papules surrounded by erythema, eosinophils

within lesions, common rash which resolves by 2 weeks

Milia: lesion 1-2mm firm white pearly papules on nasal bridge, cheeks, and palate,
self-resolving

Investigations:
- Unconjugated hyperbilirubinemia
o Hemolytic workup: CBC, reticulocyte count, blood group (mother and infant), peripheral Pustular melanosis: brown macular base with pustule, seen more commonly in
blood smear, Coombs test African American infants, may be present at birth
o If baby is unwell or has fever: septic workup (CBC and differential, blood and urine cultures,
LP, CXR, +/- stool culture )
o Other: G6PD screen (especially in males), TSH
- Conjugated hyperbilirubinemia must be investigated without delay
Nevus Simplex: (salmon patch) transient macular vascular malformation of the
o Consider liver enzymes (AST, ALT), coagulation studies (PT, PTT), serum albumin, ammonia,
eyelids and/or neck (‘Angel kiss’ or ‘Stork bite’), most lesions disappears by 1 year
TSH, TORCH screen, septic workup, galactosemia screen (erythrocyte galactose-1-phosphate
uridyltransferase levels), metabolic screen, abdominal U/S, HIDA scan, sweat chloride
Treatment: (unconjugated hyperbilirubinemia)
- Treatment to prevent kernicterus
- Breastfeeding does not usually need to be discontinued, ensure adequate feeds and hydration Neonatal acne: inflammatory papules & pustules mainly on face, self-resolving
- Lactation consultant support, mother to pump after feeds
- Treat underlying causes (e.g. sepsis)
- Phototherapy (blue-green wavelength, not UV light) use monogram
- Exchange transfusion, usually for hemolytic disease/G6PD deficiency → IVIg
Obesity: condition of being overweight, imbalance in
amount of energy expended vs consumed
BMI: poor predictor of obesity, specific cut-offs for
different ethnicities
Classification:
- <18.5 = underweight
- 18.5-24.9 = normal
- 25.0-29.9 = overweight
- 30.0-34.9 = obesity class I
- 35.0-39.9 = obesity class II
- >40 = obesity class III
Medical Consequences of Obesity
- Type 2 DM (CANRISK Score)
- Coronary artery disease
- Congestive heart failure
- Hypertension
- Dyslipidemia
- Stroke
- Non-alcoholic steatohepatitis
- Gallbladder disease
- Osteoarthritis
- Low back pain
- Obstructive sleep apnea
- Certain cancers
- Increased total mortality
Readiness to Change
OBESITY
Assessment: exclude secondary causes of obesity &
obesity related health risks & complications
History: non-judgemental approach
- Diet & exercise, screen time
- Sleep habits, screen for sleep apnea
- Smoking, alcohol
- Work, stress
- Mood: screen for depression, eating disorders,
psychiatric disorders
- PMH, medications
Examination: BP, HR, weight height, BMI
- Signs of hyperlipidemia: xanthoma, tendinous
xanthoma, corneal arcus
- Waist circumference (>102cm in men, >88cm in
women)- measured at iliac crest
Investigations:
- Fasting glucose, A1c, lipid profile (total
cholesterol, triglycerides, LDL & HDL, ratio of
total to HDL)
- LFTs, TSH
- Sleep study if appropriate
Childhood Obesity
- Obesity directly proportional to screen time, activity should be
fun/recreational, tailor to strength of child & family
- Exclusive breast feeding until 6m as prevention
Management
- Family oriented behaviour therapy
- Limit consumption of energy dense snacks foods
- Limit screen time to <2 hours per day
- Physical activity:
o Infants <1: interactive active play
o 1-4y: 180min activity any intensity spread throughout day
o 5-17y: 60 mins moderate/vigorous activity 6+ days/week
Management: Lifestyle Modification
- Goal of 0.5-1kg per week weight loss
Nutrition: reduce energy intake by 500-1000kcal
kcal/d than total daily energy expenditure
- Adherence level more important than type of diet
- Should be developed with qualified health
professional, dietician referral if available
- Food journals, CBT, mindfulness counselling
- E.g. Atkins, weight watchers, zone diet
Physical activity: initially 30 mins moderate/vigorous
intensity 3-5x/week, increasing to >60 mins most days
Management: Pharmacological Therapies
- Task force recommends against pharmacotherapy
as 1st line management, consider as adjunct if no
adequate weight loss 3-6 months after lifestyle
changes + BMI >30 or >27 + RF (DM2 or CVD risk)
1. Orlistat (Xenical)
- (Xenical), lipase inhibitor- reduces fat absorption
- SE fatty stools/diarrhea, CI in IBD, maximum 2y
- 120mg PO TID with meals, omit if non-fatty meal
2. Liraglutide (Saxenda, Victoza)
- GLP-1 agonist, ↓ appetite & glucose, ↓ glucagon
secretion & stimulate insulin secretion
- Starting dose 0.6mg/day, gradual ↑ to 3.0mg/day
3. Naltrexone + Bupropion (Contrave)
- Works to control hunger + cravings
- 1 tab (naltrexone 8mg/bupropion 90mg) once
daily x 1w, increase q1w until 2 tabs BID
- D/c if 5% baseline weight not lost after 12w
Management: Surgical
- Only considered if other methods failed & BMI
>40 or >35 w/ RF, needs lifelong monitoring
- Methods: gastric bands, sleeve gastrectomy,
bypass/roux-en-y, bili-pancreatic diversion
Osteoporosis
-
-
T score ≤ - 2.5 OR
Presence of fragility fracture
Osteopenia
- T score -1.0 to -2.5
Fragility Fracture
- # due to fall from standing height or less
without major trauma
- Excludes # in skull, C-spine, hands, feet, ankles
- Excludes stress #
Assessment:
History: RF for low BMD, fractures, falls
- Prior fragility fractures
- Parental hip fracture
- Glucocorticoid use
- Current smoking
- High alcohol intake (≥3 units/day)
- Rheumatoid arthritis
- Inquire about falls in the previous 12 months
- Inquire about gait & balance
Physical Examination:
- Weight: >10% loss since age 25y is significant
- Vertebral fracture screen: height annually
(loss >2cm or historical loss >6cm), rib to
pelvis distance (≤2 finger’s breadth
significant), occiput to wall distance (>5cm
significant for kyphosis)
- Get up and go test (stand, walk 10 ft, turn,
walk 10ft, sit: >30s significant)
Labs:
- Calcium (corrected for albumin): hyper
(primary hyperparathyroidism or malignancy)
vs hypo (malabsorption or vit D deficiency)
- CBC (anemia- MM), Cr, ALP (liver disease,
Paget’s), TSH, SPEP if vertebral #s (MM), 25-
hydroxyvitamin D (after 3 months adequate
supplementation, do not repeat if ≥75)
Bone Health: encourage for all individuals
- Regular active weight bearing exercise
- Calcium 1200mg daily (diet + supplements)
- Vitamin D 800-2000IU daily after age 50y
- Fall prevention strategies
OSTEOPOROSIS
Indications for BMD Testing
1. All women & men age ≥65y
2. Menopausal women & men aged 50-64y with clinic
RF for fracture:
- Fragility fracture after age 40y
- Prolonged glucocorticoid use (≥3 months in prior
year at prednisone equivalent dose ≥7.5mg
daily)
- High risk med use: aromatase inhibitors,
androgen deprivation therapy
- Parental hip fracture
- Vertebral fracture or osteopenia on x-ray
- Current smoking
- High alcohol intake
- Low body weight (<60kg) or major weight loss
(>10% of weight loss at age 25y)
- Rheumatoid arthritis
- Other disorders strongly associated with OP:
hyperparathyroidism, T1DM, osteogenesis
imperfecta, uncontrolled hyperthyroidism,
hypogonadism or premature menopause (<45y),
Cushing’s, chronic malnutrition or
malabsorption, chronic liver disease, COPD &
chronic inflammatory conditions (e.g. IBD)
3. Younger adults (<50y) with:
- Fragility #
- Prolonged use of glucocorticoids
- Use of other high-risk medications
- Hypogonadism or premature menopause
- Malabsorption syndrome
- Primary hyperparathyroidism
- Other disorders strongly associated with rapid
bone loss and/or fracture
Risk Assessment: FRAX Score
- Theoretical risk of patient who is treatment naiive
- Estimated 10 year risk of major osteoporotic # & hip #
- Calculation: age, sex, height, weight, prior fragility #,
parental hip #, smoking, alcohol, corticosteroids, RA,
2⁰ causes of osteoporosis, femoral neck BMD
Risk Assessment: CAROC Score
- Low risk: 10y # risk <10%, unlikely to benefit from
pharmacotherapy → reassess in 5y
- Moderate risk: 10y # risk 10-20%, repeat BMD in 1-3y,
consider pharmacotherapy if:
o Vertebral # on VFA or lateral spine x-ray
o Previous wrist # in individuals older than age 65y or
those with T-score <2.5
o Lumbar spine T-score << femoral neck T-score
o Rapid bone loss
o Men on androgen-deprivation for prostate cancer
o Women on aromatase-inhibitor for breast cancer
o Long-term or repeated systemic glucocorticoid use
(oral or parenteral) that does not meet the
conventional criteria
o Recurrent falls:2 or more times in the past 12m
o Other disorders strongly associated with
osteoporosis, rapid bone loss, or fractures
- High risk: 10y # risk >20% or prior fragility # hip/spine or >1
fragility #, benefit from pharmacotherapy
Treatment:
Nonpharm: d/c smoking, ↓ alcohol, ↓ caffeine, weight bearing
exercise, falls assessment, calcium 1200mg/day (calculator OP
website), vit D 400-1000U (low risk) 800-2000U (high risk)
Pharmacological
Bisphosphonates: inhibit osteoclast bone remodeling
- Dose: zolendronic acid 5mg IV q1y, alendronate 10mg od or
70mg q1w, risedronate 5mg od or 35mg q1w or 150mg q1m
- Method: first thing in am, empty stomach, full glass of water,
upright & NPO x 30 mins following
- CI: eGFR <30, uncorrect hypo-Ca, inability to sit up,
esophageal disease, pregnancy/feeding (zolendronic)
- SE: GI, osteonecrosis of jaw, atypical femoral #
- Drug holiday: none in high risk, consider in mod risk if no
vertebral/fragility # & femoral T-score > -2.5, low risk
discontinue after 5y & re-evaluate after 2y
Denosumab: (prolia) monoclonal Ab to RANKL, inhibits osteoclast
activation, dose: 60mg SC q6m, no drug holiday
- CI: pregnancy, uncorrected hypo-Ca, SE: cellulitis, hypo-Ca,
osteonecrosis of jaw, atypical femoral #
Raloxifene: SERM, 60mg PO daily, SE: DVT/PE, risk stroke, flushing
Teriparitide: recombinant PTH, 20mg SC od, SE: hypotension, ↑Ca
Estrogen: hormone therapy: only if vasomotor sx & OP
-
Approach to Palliative Care
- Reason for referral/consideration of palliative care
-
-
Past medical history
Medications: including past opioid use & side effects
PALLIATIVE CARE
- Social Hx: Palliative Performance Scale
o Living situation
o Social supports: family, friends, caregivers,
etc.
o Social background, occupation, finances,
insurance coverage
o Smoking, EtOH, recreational drugs
o Spirituality & religious beliefs

- Illness course: HPI

o Date of diagnosis
o Treatments (e.g. chemo, radiation, surgery)
o Dates of recurrence, disease progression

- Physical and emotional symptoms:

o Any complications secondary to cancer
(e.g. effusions, emboli, DVT, infectious sx,
fistulae)
o ESAS: pain, appetite, N/V, bowel
movements, dyspnea, cough, secretions,
delirium, seizures, mood
o Function: e.g. ADLs, IADLs
o Palliative performance score →
o Characterize nature of sx, timing,
aggravating & relieving factors, effect of
function, treatments & effect
- Response & coping: how patient/family are coping
- Advanced care planning: goals of care, code status,
POA/SDM
- Physical exam
- Investigations
o Most recent bloodwork
o Imaging
o Cancer staging
- Disposition: outpatient follow up, home with
supports, palliative care unit, hospice, alternative
facility e.g. long-term rehab (less common)
- Summary & recommendations/plan
Goals of Care Opioid Starting Doses & Equivalents:
- Clarify if goal is palliation or prolongation of life, balance, or both - PO PRN (q4h) starting doses: morphine (5-10mg),
- Clear mind (not depressed, confused, pressures, in pain) codeine (8-15mg), oxycodone (2.5-5mg),
hydromorphone (1-2mg)
- Wishes for care e.g. treatment of infection, reversible issues,
active Rx
- Code status- CPR, intubation/ventilation, ICU, vasopressors
- Artificial nutrition e.g. TPN, NG feeding, PEG tube, aspiration risk
- Preferred place of care & preferred place of death
Pain Ladder: Opioid Prescribing:
- Acetaminophen/NSAIDs - PRN dosing → monitor frequency of use & add routine, titrate to pain & side effects
(avoid in elderly, renal dz, o Titration: PRN dose = 10% of 24h dose, q1-2h PRN
GI bleed- add PPI) - Prescribing details: quantity of dose & quantity of tabs in numbers & spelled
- Weak opioid (codeine) - Prescribed with laxative (PEG, senna 1-6 tab BID, lactulose 15-45mL OD-TID)
- Strong opioids (morphine, - Prescribed with anti-emetic (metoclopramide 5-10mg PO/IV/SC TID-QID), haloperidol
hydromorphone, oxy) 1mg PO q4h PRN, dimenhydrinate 50-100mg PO/IV/PR q4h PRN
- Adjuvant therapy: bone - Adverse effects:
pain (NSAIDs, o Constipation (prevent by prescribing laxative w/ opioid)
dexamethasone, o Somnolence/sedation (switch agent, consider psycho-stimulant)
bisphosphonates), o Nausea (prevent by prescribing with antiemetic)
neuropathic (nortryptline, o Neurotoxicity (adjust doses in renal impairment, good hydration)
gabapentin, duloxetine) o Respiratory depression (rare, careful titration + naloxone available)
- Opioid toxicity: sedation, confusion, hallucinations, myoclonus, seizures, ↓RR
Symptom Management:
Anorexia
- Megestrol 400-800mg (10-20mL suspension) OD
- Dexamethasone (Decadron) 4-8mg PO qAM, plus PPI
- Domperidone or metoclopramide 10mg PO TID
- Consider cannabinoids (e.g. nabilone 0.5-1mg QHS)
Bleeding
- Cyklokapron 1000mg PO TID
- Also consider midazolam 0.5-1mg SC q4h for sedation
Bowel Obstruction
- Partial obstruction
o Prokinetic: maxeran10-20mg SC/IV q4-6h
o Anti-emetic: haloperidol 0.5-1mg SC q8-12h
o Anti-spasmodic: hyoscine butyl bromide
(Buscopan) 10-20mg SC/IC q4-6h
o Steroids: dexamethasone 2-4mg SC/IV OD-BID
- Complete obstruction
o Avoid/stop prokinetic
o Anti-emetic, anti-spasmodic, steroid
o Octreotide 100-300mcg SC BID (↓ secretion)
Constipation
- Optimize diet & hydration
- Sennoside (Senokot) 2-4 tabs PO OD-BID
- Bisacodyl tablets (Dulcolax) 5-10mg PO OD-BID
- Milk of magnesium 15-45mL PO OD-BID
- Docusate sodium 200mg OD-BID (plus stimulant)
- Lactulose 15-45mL PO OD-BID
- Bisacodyl (Dulcolax) suppository q2-3d if no BM
- Phosphate enema (Fleet), if suppositories fail
- Citromag 250mL/day
- Oral fleet 45mL
- Polyethylene glycol 3350 17g/d
Delirium
- Treat reversible causes (infection, urinary retention,
constipation, dehydration, electrolytes, drug interaction)
- Rotate/reduce opioids, avoid benzodiazepines
- Haloperidol 0.5-1mg SC BID-QID PRN
- Nozinan 5-12.5mg PO q4-6h OR 6.25-12.5mg SC q4-6h
- Risperidone 0.5-1mg Po/SC BID-TID
- Olanzapine 2.5-15mg PO OD
- Quetiapine 50-100mg PO BID
Dyspnea
- Morphine 2.5-5mg SC, hydromorph 0.5-1mg SC q1h PRN
- Bronchodilators +/- diuretics
- Dexamethasone (Decadron) 4-8mg PO/SC/IV OD-BID
- Lorazepam (Ativan) 1-2mg SC/SL q1h PRN (anxiety)
- Nebulized saline +/- ventolin + atrovent q4-6h PRN
Hypercalcemia
- Corrected: calcium + (40-albuminx0.2) or add 0.02mmol
per g albumin below normal
- Hydration with normal saline
- Pamidronate 90mg IV in 500mL normal saline at
125mL/h q4w PRN
- Zoledronic acid 3-4mg IV over 15min q3-4w
Intractable Hiccups (>1m or persistent >48h)
- Metoclopramide 10-20mg PO/SC/IV QID
- Domperidone or PPI
- +/- gabapentin
- 1nd line: chlorpromazine, haloperidol, nozinan,
nifedipine, valproic acid, dexamethasone, sertraline, +/-
midazolam
Mouth Care
- Thrush
o Nystatin (5mL) swish + swallow QID x 7d
o Ketoconazole (nizoral) 200mg PO OD x5-7d
o Fluconazole (diflucan) 100mg PO OD until clear,
then once weekly for maintenance
- Ulcerations & stomatitis
o Benzydamine HCl (Tantum) 15mL QID
o Lidocaine (Xylocaine) 2% viscous (15mL) or 10%
spray q4h
o Benzocaine (Orajel) apply directly to lesions
- Debris-Crust
o 3% hydrogen peroxide (diluted 1:10) apply by
gentle brushing TID prn, wait several minutes,
then rinse with water or saline (short term use)
Myoclonus
- Clonazepam 0.5-2mg PO QHS-TID PRN
- Midazolam 0.5-1mg SC q4h PRN or continuous SC
- Alternatives: other benzos, baclofen, anticonvulsants
Nausea
- Opioid induced
o Haloperidol 1-2mg PO/IV/SC BID-TID
o Prochlorperazine 5-10mg PO/IM/IV/PR q4-6h
- Gastroparesis, dysmotility
o Metoclopramide 10mg PO/IV/SC QID
o Domperidone 10-20mg PO QID
- Vestibular, motion-induced
o Diphenhydramine 25-50mg PO/IM/IV/PR q4h
o Meclizine 25-50mg PO QID
- Alternatives
o Dexa 2-4mg PO/SC/IV OD-BID
o Ondansetron 4-8mg PO/IV q8h
o Nabilone 1mg PO BID-TID
o Nozinan 5-25mg PO/SC q6h
Respiratory Secretions
- Scopolamine 0.4-0.6mg SC q4h PRN
- Glycopyrrolate 0.2-0.4mg SC q4h
- Atropine 1% ophthalmic: 3 drops SL/buccal q1-2h PRN
- Scopolamine patch (transderm V) q3 days PRN
- **scopolamine can cause confusion in the elderly
Sedation
- Methylphenidate 10mg at 8am, 5mg at 2pm
Seizure
- Acute seizure:
o Ativan 2mg SL/SC stat, 2mg q30min PRN
o Midazolam 5mg SC stat then 5mg q30min PRN or
continuous infusion
o Diazepam 10mg PR q15-30min until controlled or
max dose 30mg
- Maintenance: phenobarbital 120-240mg SC q8-12h or
midazolam 1-2mg/hr per continuous SC (max 60mg/d)
Skin Care
- Protection: 20% zinc oxide + barrier cream
- Pruritus:
o Topical camphor/menthol or antihistamine
o Topical steroids: 1% hydrocortisone
cream/ointment
o Hydroxyzine 10-25mg PO TID and 25-100mg QHS
o Antihistamine, oral steroid, gabapentin,
nalfurafine, ondansetron, cholestyramine
- Cholestatic jaundice
o Cholestyramine 4mg PO QID PRN (max 16g/d)
o Metronidazole 250mg PO TID x 7d
- Malodour
o Metronidazole topical gel or 250-500mg PO/IV q8h
Approach to Parkinsonism:
- Consider atypical Parkinsonism if:
o Early onset postural instability/falls
o Early onset dysautonomia (e.g. fecal/urinary
PARKINSONISM
incontinence), early cognitive impairment Condition Presentation Treatment
o Early onset <50y Idiopathic RF: age, male, head injury, pesticide exposure, family Hx (10%) Levodopa/carbidopa
o Recent diagnosis of psychiatric disease Parkinson’s TRAP- tremor (pill rolling 4-5Hz), rigidity (lead pipe + cogwheeling), Dopamine agonist (e.g.
o Symmetrical at onset Disease akinesia, postural instability, early unilateral → progresses to pramipexole)
o Abrupt onset of sx + rapid progression bilateral, reduced arm swing + en bloc turning, masked facies + MAOB inhibitors
o Lack of tremor shuffling gait, micrographia, hypophonia, fatiguing repetitions Anticholinergics (e.g.
o Poor response to levodopa Postural instability, falls, dementia, psychosis + depression benztropine)
- Multidisciplinary approach: SLP, OT, family, counsellor Sleep disturbance, cognitive impairment
- Inquire about functional limitations Autonomic dysfunction: constipation, orthostatic hypotension, Deep brain stimulation of
- Inquire about medication side effects excess sweating medications fail
- Look for comorbidities including dementia, Multiple Can be Parkinson’s predominant or cerebellar predominant Poor/absent response to
depression, falls, constipation system Gradual progressive onset, vertical supranuclear palsy or slowing of levodopa
- Clinical diagnosis, consider labs + MRI at onset atrophy vertical saccades → postural instability/falls within 1st year onset
- Abnormal neck posture
Treatment & Side Effects:
Early dysphagia/dysarthria, early cognitive impairment
- Levodopa/carbidopa
o On/off symptoms, dyskinesia, end-of-dose Corticobasal Asymmetric Parkinsonism, dystonia, limb apraxia, myoclonus Poor/absent response to
deterioration, orthostatic hypotension,
Ganglionic Progressive nonfluent aphasia levodopa
headache, nausea, constipation, sleep Degeneration
disorder + abnormal dreams Lewy Body Fluctuating cognitive function Levodopa/carbidopa
- Dopamine agonist e.g. pramipexole, ropinirole Dementia Visual hallucinations, Parkinsonism features Cholinesterase inhibitors
o May help reduce on/off Sx Early extrapyramidal features: tardive dyskinesia, akathisia, acute (donepezil, rivastigmine,
o SE: dyskinesia, visual hallucinations, edema, dystonia galantamine)
excess daytime somnolence, hypotension, Atypical antipsychotics
impulse control disorder Drug-induced Caused by: 1st gen antipsychotics (haloperidol) > 2nd gen Stop/switch medications
- Amantadine antipsychotics (risperidone, olanzapine), quetiapine & clozapine are Trial levodopa >
o Mechanism unknown, dopamine agonist + lower risk, antiemetics e.g. metoclopramide/prochorperazine amantadine,
noncompetitive NMDA receptor antagonist Others: lithium, SSRIs anticholinergics
o SE: orthostatic hypotension, peripheral
edema, delusions/hallucinations, paranoia, Approach to Tremors
sedation, compulsive behaviour, withdrawal - Young pt <45y must do TSH, ceruloplasmin, & CT/MRI (cerebellar disease) as indicated by type of tremor
reaction with abrupt discontinuation o Postural: physiologic, anxiety, sedative/alcohol withdrawal, drug toxicity, heavy metal poisoning, carbon
- COMT inhibitors e.g. entacapone, tolcapone monoxide poisoning, thyrotoxicosis, benign essential tremor
o Potentiates levodopa to reduce on/off Sx ▪ Benign essential tremor is a common autosomal dominant trait that presents as a bilateral postural
o SE: rare transaminitis, fulminant tremor of the vertical axis, especially in the upper extremities → >90% does not need treatment
hepatotoxicity, dyskinesia, visual • Classically affects arms/head/voice, lower limb tremor unusual
hallucinations, nausea, orthostatic • Worse with anxiety, excitement, adrenergic stimulation
hypotension, diarrhea, orange urine • Relieved with EtOH
- MAOB inhibitors e.g. selegiline, rasagiline, safinamide o Intention: brainstem lesion, cerebellar lesion, alcohol, anticonvulsants, sedatives, Wilson's disease
o Prolong half-life of dopamine, ↓ wearing off ▪ Alcohol dampens essential tremor & potentiates intention tremor (no change in resting tremor)
o Nausea, h/a, confusion, hallucinations, falls, o Resting: Parkinsonism, Wilson's disease, mercury poisoning
insomnia, dyskinesia
-
Abdominal Aortic Aneurysm
- Screen one time using US in men aged 65-80y
- Not recommended in men >80y of women
Asymptomatic Bacteriuria in Pregnancy
- Screen once in 1st trimester with urine culture
Asymptomatic Thyroid Dysfunction
- Do not screen in asymptomatic non-pregnant
adults aged 18+
Breast Cancer
- Women <50y: do not screen with
mammography if average risk
- Women 50-74y: screen q2y w/ mammography
- Do not screen with MRI, US, clinical breast
exams, or self-examination
Cervical Cancer
- Preventative care task force: screen women
25-70y q3y with pap smears
- SOGC guidelines: screen women 21-70y who
are sexually active, q3y using pap smears
- Women >70y do not require screening if 3
successive pap smears negative in last 10y
Cognitive Impairment
- Do not screen in asymptomatic adults >65y
Colorectal Cancer
- Adults 50-74y: screen with FIT q2y or flexible
sigmoidoscopy q10y
- Adults ≥75y: do not screen
- Do not use colonoscopy as a screening test
Depression
- Do not routinely screen for depression if at
average risk, or even if in a subgroup of
population who may be at increased risk
- PHQ-2 in chronic disease, screen in pregnancy
Obesity in Children:
- Growth monitoring at all appropriate primary
PERIODIC HEALTH care visits 0-17y
- Offer formal structured interventions if obese/
ASSESSMENT/SCREENING overweight but not if normal weight
- Do not routinely offer orlistat in ages 2-17y or
Developmental Delay surgical interventions
- Do not screen using standardized tools in children 1-4y
Pelvic Exam
old with no apparent signs/concerns
- Do not screen in asymptomatic women
DM Type 2
Prostate Cancer
- Stratify using CANRISK
- Men all ages average risk: do not screen with
- Low-moderate: do not screen
PSA- see prostate handout
- High risk: screen q3-5y with A1c
- Very high risk: screen q1y with A1c
Tobacco Smoking in Children/Adolescents
- Discuss smoking prevention/abstinence
Hepatitis C
- Do not screen for HCV in adults who are not at (including 2nd hand smoke) in children & youth
5-18y
elevated risk
Hypertension
Common Screening Tests
- Screen at all appropriate primary care visit, according
to CHEP recommendations for office/ambulatory
measurement
Impaired Vision
- Do not screen in average risk adults >65y
Lung Cancer
- Low-dose CT annually up to 3 consecutive times if aged
55-74y, with 30+ pack year smoking Hx
- Must be currently smoking or quit <15y ago
- Not recommended in any other population
Obesity in Adults
- Screen height, weight, BMI at appropriate primary care
visits- do not routinely offer pharmacologic
interventions e.g. orlistat, metformin
- Offer structured interventions if overweight/obese but
not if normal weight
Personality Disorder:
- An enduring pattern of inner experiences &
behaviour that deviated markedly from the
expectations of the individual’s culture,
PERSONALITY DISORDER
manifested in 2+ of: Classification:
o Cognition
o Affectivity Cluster A: ‘mad’ Familial association with psychotic disorders, patients seems odd/eccentric/withdrawn, common
o Interpersonal functioning defense mechanisms including intellectualization, projection, magical thinking
o Impulse control
- Pattern is inflexible and pervasive across Paranoid Pattern of distrust, suspiciousness that others’ motives are malevolent
broad range of personal & social situations
- Enduring pattern leads to clinically significant Schizoid Pattern of detachment from social relationships, restricted emotional expression
distress or impairment in functioning
- Pattern is stable and of long duration, onset Schizotypal Pattern of eccentric behaviours, peculiar thought patterns
can be traced back to adolescence or early
childhood
- Relationship building and establishing
boundaries are important, focus on
validating/empathy/speaking to pt strengths
Cluster B: ‘bad’ Familial association with mood disorders, patients seem dramatic, emotional, inconsistent,
Management: common defense mechanisms include denial, acting out, regression (histrionic PD), splitting
- Clearly establish and maintain limits e.g. (borderline PD), projective identification, idealization/devaluation
appointment length & frequency,
prescribing, accessibility
Antisocial Pattern of disregard for and violation of right of others
- Look for new medical & psychiatric diagnosis
when there are new symptoms/change in
symptoms, do not attribute all concerns to Borderline Pattern of instability in interpersonal relationships, self-image, and affect, and marked impulsivity
personality disorder
Narcissistic Pattern of grandiosity, need for admiration, and lack of empathy
- Limit the impact of your personal feelings
e.g. transference, countertransference Histrionic Pattern of excessive emotionality and attention seeking

- Limit use benzodiazepines

o Short term + lowest dose
o Treat comorbid psychiatric
disorders as needed
- Evaluate diagnosis yourself rather than Cluster C: ‘sad’ Familial association with anxiety disorders, patients seem anxious/fearful, common defense
accepting previously assigned label mechanisms including isolation, avoidance, hypochondriasis
- Therapies:
o Interpersonal psychotherapy
Avoidant Pattern of social inhibition, inadequacy, hypersensitivity to negative evaluation
o Dialectical behavioural therapy
(DBT)- evidence of effectiveness in Dependent Pattern of submissive and clinging behaviour related to an excessive need to be taken care of
borderline personality disorder
o Cognitive behavioural therapy (CBT) Obsessive Pattern of preoccupation with orderliness, perfectionism, and control
compulsive
Pneumonia: acute infection of pulmonary parenchyma
- CAP: no hospitalization within 14d of onset, or onset
-
when hospitalized <48h
HAP: occurs 48h+ after admission or <2w post-
discharge, ‘healthcare associated’ no longer used
Pathogens:
- CAP: S. pneumoniae
o COPD: H. influenza, M. catarrhalis
- HAP: gram neg e.g. pseudomonas, klebsiella, E. coli,
enterobacter
- Paeds: viral more common, S. pneumoniae
Risk Factors for Unusual Pathogens:
- Travel Hx (MERS)
- TB, HIV, prolonged high dose steroids (PCP)
- Living/working environment (e.g. legionella in
contaminated air conditioning, hot tubs, humidifier)
- Animals/birds: e.g. avian flu, Coxiella burnetii
- Dementia/swallowing difficulties: aspiration, gram
negative organisms
Clinical Presentation:
- Fever/chills
- Cough or change in chronic cough, purulent sputum
- Pleuritic chest pain, SOB
- Atypical sx: delirium, abdo pain, N/V, diarrhea
o Elderly & children more likely to have
atypical presentation, GI sx more common
in kids
- O/E:
o Febrile +/- low O2 saturations
o Localized crackles
o Bronchial breath sounds
o Examine for early signs of respiratory
distress & reassess periodically
Investigations:
- Labs: CBC, lyts, Cr, consider lactate if acutely unwell
- Consider ABG is respiratory distress
- ECG, troponin to r/o ACS
- CXR to confirm diagnosis: consolidation, infiltrate,
+/- cavitation → false neg possible in
immunocompromised patients/dehydration or
within 1st 24h
PNEUMONIA
Management:
CURB-65 Score: 0-1 outpatient treatment, 2 likely admission, 3-5 hospitalize & treat as severe
- Confusion, Urea >7, RR >30/min, BP <90/60, Age ≥65y
Antibiotics:
- No comorbidities: B-lactam or macrolide
o E.g. amoxicillin or erythromycin/clarithromycin/azithromycin
- Comorbidities: B-lactam + macrolide (or respiratory fluoroquinolone)
o E.g. amoxicillin/amoxiclav/cefuroxime + clarithromycin/azithromycin (or levo/moxi)
- Aspiration: amoxiclav or clindamycin
- MDR:
o Piptazo or antipseudomonal cephalosporin or antipseudomonal carbapenem
o AND respiratory fluoroquinolone
- MRSA: vancomycin or linezolid
- Pediatrics: 3 months- 5y B-lactam or macrolide, 5y+ macrolide
- RSV in immunocompromised patients: ribavirin (not for routine use)
o Prophylaxis in targets group infants e.g. Down syndrome with palivizumab
Management tips:
- Treat comorbidities concurrently e.g. asthma, COPD, CHF
- Monitor for interaction with Abx
o E.g. enhanced anticoagulant effect of warfarin, QTc prolongation in macrolides/fluoroquinolone,
interaction with estrogen-based contraceptives
- If not responsive to treatment:
o Insufficient time (may need >72h)
o Unusual/resistant organism e.g. MRSA, pseudomonas → sputum culture + gram stain, consider AFB +
bronchoscopy
o Complications: empyema, abscess, parapneumonic effusion → if CXR negative consider CT chest
o Wrong diagnosis: e.g. COPD, PE, CHF, ILD, malignancy, viral/fungal etiology → consider CT chest
ICU Indications: 1 major or ≥2 minor criteria
- Major: invasive mechanical ventilation, septic shock + pressors
- Minor: RR >30, temp <36, hypotension needing aggressing fluids, new confusion, multilobular pneumonia
Follow-Up:
- Ensure appropriate patient education on when to return e.g. no improvement in 48h, respiratory distress, confusion,
dizziness, vomiting
- Consider repeat CXR in some cases to ensure resolution
Pneumonia Vaccination: High Risk Patients Vaccination:
1. Determine previous doses of pneumococcal vaccines. Prevnar-13: routine in children <5y
2. Determine if eligible for Prevnar 13 based on high risk eligibility. → Administer if eligible. If Pneumovax-23 given first, - High risk adults >50y, 4th dose in high risk
wait 1 year. children 2-6m
3. Determine if eligible for Pneumovax 23 based on high risk eligibility. → Administer if eligible. If Prevnar-13 given first, - Recommended not funded: 65y+, 2-17y w/
wait 8 weeks. asthma, 18-49y immunocompromised
4. If eligible for Pneumovax 23, determine if eligible for booster dose in 5y.
5. If ≥65y, determine if it has been 5 years since previous dose Pneumovax 23. Pneumovax-23: routine in adults 65y+
- High risk individuals 2+
- Recommended not funded: alcoholism,
smoking, homeless patients, illicit drug use,
2y+ & asthma
Contact Tracing:
- All confirmed cases of the following
pathogens are reportable: (mandatory
reporting through Public Health)

o Tuberculosis
o Legionella
o Invasive GAS (strep pyogenes)
o Lab confirmed influenza
o Hantavirus pulmonary syndrome
o Severe acute respiratory
syndrome (SARS)

- Contacts of above cases may require close

monitoring or Abx prophylaxis, if exposure
to pt 1w prior to sx onset – 24h after Abx
AND:
o Co-residents of LTC
o Co-attendants of child care center
o IVDU w/ shared needles
o Sexual/sleeping partners
o Household contact avg >4h/day
o Direct mucous membrane/
secretion contact, contact with
open skin lesions
Approach to Poisoning: Poisoning in Children
- Prevention:
Immediate Management
- Airway: intubate if obstruction/absent gag reflex, seizures,
POISONING o Never leave any poisonous products unattended
o Keep household plants out of reach
o Use childproof latches on cupboards
GCS <8, resp failure/caustic exposure/salicylate poisoning, Decontamination in Poisoning o Keep products in original, labelled, containers-
suction secretions - Remove from source never in food containers!
- Breathing: oxygenation & ventilation, O2 saturations + ABG - Copious irrigation with pH monitoring o Keep poison control number readily available
- Circulation: rule out arrhythmia, IV fluid +/- pressors - Single-dose activated charcoal
- Disability: GCS, pupils, fundoscopy, EOM, glucose - Induced emesis with ipecac • Common household poisons:
- Gastric lavage o Cosmetics, nail care products, perfumes
- Drugs: D50W 1 amp, thiamine 100mg IV, naloxone 0.4-
- Whole bowel irrigation o Prescription & OTC medications
0.8mg IV q3-5min max 10mg o Arts & crafts products
Elimination
Sample Hx - Multi-dose activated charcoal o Cleaning agents (bleach, detergent, cleaners, polish)
o Alcohol-based hand sanitizer
- Signs & symptoms - Urinary alkalinisation
o Windshield washer fluid, anti-freeze
- Allergies - Hemodialysis or hemoperfusion
o Turpentine solvents, lighter fluid, paint thinners
- Medications Antidotes (see table)
o Garden products (e.g. insecticide, fertilizer)
- Past medical Hx Manage Complications o Batteries
- Last oral intake (& LMP) - Consider psych referral if intentional o Mothballs
- Events leading up to illness/injury overdose, Hx substance use or addictions o Cannabis & edibles
o Include time of ingestion Antidotes: (for toxidromes see Substance Abuse) Acetaminophen Overdose
o Method of ingestion - Most present early within 24h
o Consider multi-drug/substance ingestion Antidote Indication
- Treatment ideally given within 8h
N-acetylcysteine (mucomyst) Acetaminophen, hepatotoxins
Investigations Atropine sulfate Carbamate,
ingestion or as soon as possible
- CBC, GBCL, LFTs, bili, INR/PTT organophosphates - GI contamination with activate
- ECG Calcium chloride/gluconate CCB, hydrofluoric acid charcoal 1g/kg (max 50g) within 4h, CI
- Serum osmolality + anion gap Desferoxamine mesylate Iron if sedation + compromised airway
o Elevated anion gap >12 → MUDPILES CAT (desferal) - Plot serum acetaminophen levels on
Digoxin Gab (Digifab) Digoxin normogram, NAC indicated if above
▪ Methanol/metformin
Dimercaprol Arsenic, mercury, lead treatment line, or any signs of
▪ Uremia
Fomepizole (antizol) or Methanol, ethylene glycol hepatotoxicity with delayed
▪ DKA ethanol
▪ Propylene glycol presentation, single ingestion
Hydroxocobalamin (cyanokit) Cyanide
▪ Isoniazid >150mg/kg (7.5g total regardless of
Insulin/dextrose BB, CCB
▪ Lactic acidosis Intralipid 20% Lipid soluble toxin
weight) unknown time of ingestion &
▪ Ethylene glycol Methylene blue Methemoglobinemia serum level >10mcg/mL
▪ Salicylates/sepsis/starvation ketosis Naloxone Opioids
▪ Cyanide/CO Octreotide Repaglinide - NAC Dosing:
▪ Alcoholic ketoacidosis/acetaminophen Physostigmine salicylate Anticholinergics o Loading dose 150mg/kg IV
▪ Theophylline Potassium iodide Prophylaxis for radioactive over 60 mins (max 15g)
iodine o Then 50mg/kg over 4h (max
- ABG, lactate
Pralidoxime Organophosphates 5g)
- B-hCG
Pyridoxine Isoniazid, ethylene glycol o Then 100mg/kg over 16 hours
- Acetaminophen levels, salicylates, EtOH, tox screen Sodium bicarb TCAs, cocaine, salicylates
(max 10g)
Preconception Counselling
- Reproductive Hx: GTPAL, details of previous
pregnancy, deliveries, health of children, sexual Hx
PMH: chronic conditions including:
- Asthma (delay until good control)
- Cancer: adverse effects of treatment, consider fertility
preservation
- DM: optimize A1c <6 if possible w/o hypo, folate 5mg,
ACEI & statins CI, oral agents CI other than metformin
- HIV: vertical transmission 2% w/ ART- should be
continued, efavirenz CI, require C-section or
intrapartum zidovudine if viral load >1000, all infants
require PEP, breastfeed w/ ART/PEP in resource poor
area, formula in resource rich
- HTN: optimize control & monitor for target-organ
damage, ACE CI
- IBD: delay conception until remission
- PKU: maintenance low phenylalanine
- Renal disease: optimal control + BP
- Seizures: optimize meds, valproate/ lithium/
topiramate CI, folic acid 5mg, lamotrigine,
levetiracetam preferred, monitor level q4w
- SLE/RA: cyclophos/MTX/ leflunomide CI, consider
ASA/heparin in APLA
- Thromboembolic dx: ↑ risk in pregnancy, warfarin CI
- Thyroid: euthyroid prior to conception, ↑ dose
levothyroxine 30% as soon as pregnant, radioiodine CI
Meds:
- Check teratogenicity for all meds
- Folic acid 5mg PO daily until 12w if taking folate
antagonists e.g. sulfonamides, MTX
- Low dose ASA: 12-36w if Hx placental insufficiency, or
2+ RFs (pregestational HTN, obesity, maternal age
>40y, artificial reproductive technology, pregestational
DM, multiple gestation, Hx placental abruption)
Infectious Diseases
- Screen for HIV, hep B/C
- If high risk: TB, CMV, toxoplasmosis
Vaccinations: update varicella, HPV, MMR prior
- Influenza & Dtap (27-32w) during pregnancy
Preconception Counselling Continued
Nutrition
PREGNANCY - Folic acid 0.4-1mg through supplement, prior to
conception & throughout pregnancy
Preconception Counselling Continued - Calcium 1000mg daily through food/supplement
Family & Genetic Hx: *refer - Essential fatty acids, vitamin D, vitamin B12
- Congenital malformation, birth defects, genetic - Avoid raw/undercooked meat & fish
disorders, developmental delays, learning disabilities - Avoid fish high in mercury
- Consanguinity (1st cousins or closer) - Avoid unpasteurized milk & cheese
- Childhood deaths, sudden unexplained deaths - Screen for IDA if at risk, issues related to access
- Hx infertility, multiple miscarriage (>3) - Nausea/vomiting → 80% women, hyperemesis in 2%
- Ethnicity: hemoglobinopathies o Nonpharm: dietary changes, d/c iron,
o CBC/Hb electrophoresis: African, normal sleep cyle, ginger, B6, acupuncture
Mediterranean, Middle Eastern, Asian, SE o Pharmacological: diclectin, others: gravol,
Asian, Hispanic, South & Central American metoclopramide→ Zofran (risk birth defects)
o CF mutation in Caucasians if FHx Mental health:
o Tay-Sachs in French Canadians or FHx - Pre-conception wellness
o Hematopoietic stem cell screening for those - Screen for: depression, anxiety, substance use,
with Ashkenazi Jewish ancestry bipolar disorder, schizophrenia, family Hx mental
- 5mg folic acid daily prior to conception if +ve FHx NTD health issues- discuss benefits/risks of meds
or high risk ethnicity (Sikh, Celtic, Northern Chinese)
Environment
Tobacco: - Avoid travelling to countries with high risk of zika
- Encourage smoking cessation prior to conception when planning- mosquito prevention measures
- Screen to tobacco use & second-hand smoke - Avoid exposure to cat litter & feces
Alcohol/substance use:
Prenatal Screening:
- Encourage all individuals to be substance free prior to
Screening Modalities:
conception, no safe limit
eFTS NIPT MSS
- Screen: alcohol use, cannabis, other substances
Tests Blood test Blood test Blood test
+ NT US for cell-free
Physical Activity
DNA
- At least 150min mod-vigorous aerobic/w, muscle & GA 11-13+6w 9-10w + 15-20+6w
bone strengthening 2d/w Detection 85-90% 99% 80%
- Weight: health BMI 18.5-24.9, waist <88cm False +ve 3-6% <0.1% 5%
- 1st trimester: <2kg weight gain - All women should be offered NIPT & can pay privately
- Healthy weight gain: - OHIP covers NIPT for high-risk populations: women
o BMI < 18.5 → 12.5-18kg, 0.5kg/w 40y+ at EDD or at egg retrieval date if IVF, previous
o BMI 18.5-24.9 → 11.5-16kg, 0.4kg/q trisomy 21/18/13, positive IPS/eFTS/MMS in current
o BMI 25.0-29.9 → 7-11.5kg, 0.3kg/w pregnancy
o BMI >30 → 5-9kg , 0.2kg/w Invasive Prenatal Testing
- Amniocentesis: 15+ weeks, additional risk miscarriage
Stress 0.01-0.5% (baseline 2nd trimester risk 3%)
- Screen for access to care, social isolation & support, - Chorionic villus sampling: 10+ weeks, additional risk
workplace stress, housing, IPV, finances, relationship miscarriage 1%
Antenatal Complications: Premature Rupture of Membranes
Hypertension in pregnancy • PROM: rupture of membranes/amniotic sac prior to labour at any gestational age
- BP ≥140/90mmHg, severe HTN ≥160/110mmHg • Prolonged ROM: >18-24h between ROM & onset of labour
- Proteinuria: 0.3g/d on 24h urine protein (dipstick ≥1+) • Preterm ROM: <37w, associated with preterm labour
- Classification: • PPROM: rupture of membranes <37w GA & prior to onset of labour
o Pre-gestational (<20w) vs gestational (≥20w) Risk Factors
o Pre-eclampsia: HTN w/ proteinuria, or adverse conditions/severe • Maternal: multiparity, cervical incompetence, infection (cervicitis, vaginitis, STI,
complications UTI), FHx, low socioeconomic status/poor nutrition
o HELLP: hemolysis, ↑ liver enzymes, ↓ platelets • Fetal: congenital anomaly, multiple gestation
o Eclampsia: HTN with seizures Presentation: gush of fluid or continued leakage
Adverse Conditions Severe Complications Investigations:
CNS h/a, visual sx GCS <13, stroke, seizure, blindness • Sterile speculum: pooling of fluid posterior fornix, leaking out of cervix on valsalva
Cardio & Chest pain, dyspnea, O2 MI, O2 <90%, inotropes, pulm • Nitrazine paper turns blue, ferning under microscope
resp <97% edema, severe HTN >12h on 3 agents
• Consider US to r/o fetal anomalies, BPP- decreased amniotic fluid volume
Haem ↑WBC/INT/PTT, ↓ Platelets <50, transfusion any
Management:
platelets product
Renal ↑ Cr, uric acid AKI (Cr >150), dialysis • Admit for expectant management, vitals q4h, daily BPP
Hepatic N/V, RUQ or epigastric INR >2 (no DIC or warfarin), hepatic • Culture cervix + lower vagina
pain, elevate liver hematoma or rupture • Assess fetal lung maturity by L/S ratio
enzymes/bili/LDH, ↓ o Consider betamethasone if <34w +/- tocolysis (12mg IM q24h, x 2)
albumin o Consider Abx if not in labour
Feto- Abn FHR, IUGR, oligo, Abruption w/ compromise, stillbirth, • Delivery urgently if evidence of fetal distress and/or chorioamnionitis
placental absent/reversed end- reverse ductus venous A wave Complications: cord prolapse, infection, premature delivery, limb contracture
diastolic flow
Dermatoses:
- Treatment: delivery if term - Pemphigoid gestationis: biopsy + high potency topical steroids
HTN Labetalol 100-400mg PO BID-TID Max1200mg/d - Pustular psoriasis of pregnancy: biopsy + high potency oral steroid
Nifedipine XL 20-60mg PO OD Max 120mg/d - Polymorphic eruption of pregnancy: (PUPPS): low potency topical steroids +/- oral
Methyldopa 250-500mg PO BID-QID Max 2g/d antihistamines
Severe Labetalol 20mg IV bolus then 60- Max 300mg, risk - Atopic eruptions of pregnancy: treat at atopic dermatitis
HTN 120mg/h neonatal brady, - Intrahepatic cholestasis of pregnancy: generalized pruritus w/o skin change → ↑ risk
CI asthma/CHF intrauterine demise & neonatal RDS
Nifedipine 5-10mg PO q30min CI: pre-exist DM o Measure bile acids, LFTs, PTT
Hydralazine 5mg IV bolus then 0.5- Max 20mg, risk o Rx: ursodeoxycholic acid + delivery at 36w
10mg/h IV maternal ↓BP
Ectopic Pregnancy:
HELLP Platelet transfusion <20, or <50 for C-section/bleed
- Sx: 4Ts: temp, tenderness, (abdo & cervical), tissue/mass
Seizures Mg sulphate 4mg IV bolus then 1g/h, risk resp depression
- Site: ampullary > isthmus > fimbria
Mg tox Calcium gluconate 10% 10cc IV over 3min
- RFs: previous ectopic, PID, infertility, IVF, tubal surgery, IUD, DES exposure, age
Urinary Tract Infections: - Ix: B-hCG, assess hemodynamic stability (FAST US if unstable), group & screen, TVUS
- Rx:
- Treat UTIs & all asymptomatic bacteriuria in pregnancy: o Medical: MTX 50mg/m2 BSA given in single IM dose, follow B-hCG weekly until
o Risk pyelonephritis, preterm labour, low birth weight
undetectable → 25% will require 2nd dos, tubal patency post-Rx 80%
o Follow up urine culture 1w following treatment o Surgical: laparoscopy w/ salpingostomy if tube salvageable, salpingectomy if tub
- Abx selection: amoxicillin 100mg q8h x 5-7d, cephalexin 500mg PO q6h damage or ipsilateral recurrence, hCG q1w until undetectable
x 5-7d, fosfomycin 3g PO x 1, avoid Septra/Macrobid in 1st Δ & term ▪ Laparotomy if pt unstable
Bleeding in Early Pregnancy Antenatal Hemorrhage (>20w- term)
- 1st trimester bleeding <12w, 2nd trimester bleeding <20w
DDx: bloody show (most common etiology in T3), placenta previa, placental abruption, vasa previa, cervical
lesion, uterine rupture, placenta accrete, abn coagulation, other course e.g. bladder/bowel
- Ix: B-hCG- doubling time 48h in early pregnancy, US to
confirm intrauterine & viability, CBC, G&S (Rh) Placenta Previa: abnormal location of placenta, near/partially covering internal cervical os
- DDx: • RF: Hx previa, multiparity, maternal age, multiple gestation, uterine tumour/anomalies, uterine scar
o Physiologic e.g. implantation • Sx: painless vaginal bleeding
o Abortion: see table, *always r/o ectopic o O/E: uterus soft, non-tender, FHR usually N, presenting part high, possible shock- do not perform
o Abnormal pregnancy e.g. ectopic, molar vag exam until previa r/o on US
• Ix: diagnosed on transvaginal US, if <20mm from os after 26w repeat US regularly
o Trauma e.g. post-coital
• Rx: stabilize, IV hydration, consider O2
o Genital lesion (e.g. cervical polyp) o Monitor: vitals, urine output, blood loss, FHR, labs- CBC, INR/PTT, fibrinogen, G&
o Rhogam if Rh negative
- Management: + Rhogam if Rh negative o GA <37w & minimal bleeding: expectant management: admission, limited activity, no
intercourse, consider corticosteroids for lung maturity, delivery when mature or hemorrhage ↑
Type Hx Clinical Rx o GA >37y or profuse bleeding or L/S ratio >2:1 → delivery by cesaren
Threatened Vag bleed Cx closed & Watch & wait,
+/- cramp soft, US <5% abort Placental Abruption: premature separation of normally implanted placenta >20w
viable fetus • RF: previous abruption, maternal HTN, smoking, excessive alcohol, cocaine, multiparity, maternal age
>35y, PPROM, uterine anomaly, trauma
Inevitable ↑ bleed, Cx close Watch & wait
• Sx: painful vag bleed, concealed in 20%, uterine tenderness +/- contraction, shock out of proportion to loss
cramp, +/- until POC → miso 400- o +/- fetal distress/demise, bloody amniotic fluid
ROM expel- 800ug PO/PV
• Ix: clinical diagnosis, US (not sensitive)- retroplacental clot
open, US → D&C + /- • Rx: stabilize, IV hydration, consider O2
nonviable oxytocin o Monitor: vitals, urine output, blood loss, FHR, labs- CBC, INR/PTT, fibrinogen, G&
Incomplete Heavy Cx open, US Watch & wait o Rhogam if Rh negative
bleed, shows POC → miso 400- o Blood products on hand: red cells, platelets, cryoprecipitate (DIC risk 20%)
cramp, +/- 800ug PO/PV Mild:
tissue → D&C + /- • GA<37w: serial Hct to assess concealed bleeding, deliver when mature or hemorrhage ↑
oxytocin • GA>37w: stabilize & deliver
Complete Bleeding + Cx open/ Expectant o Moderate/severe
complete closed, US management • Hydrate, restore blood loss, correct coagulation defect if present
passage no POC • Vaginal delivery if no contraindication and no evidence of fetal/maternal distress
Missed No bleed, Cx close, US Watch & wait • C/S if live fetus or maternal distress develops, or labour fails to progress
fetal death nonviable, →
in utero no HR misoprostol Vasa Previa: unprotected fetal vessels pass over cervical os
400-800ug • Associated with velamentous insertion of cord into membranes of placenta or succenturiate lobe
PO/PV → • Sx: painless vaginal bleeding & fetal distress --> 50% perinatal mortality before ROM
D&C +/- oxy • Ix: alkali denaturation test (Apt test) to determine if bleeding is fetal
• Rx: emergency C/S
Recurrent ≥3 Evaluate mechanical,
consecutive genetic, environmental RFs,
SA consider APLA Placenta Accreta: abnormal placental implantation into uterine myometrium
Septic Contents D&C, IV broad spectrum Abx - RFs: previous cesarean, uterine surgery, D&C, endometrial ablation, age >35y, postpartum endometritis
infected - Does not separate spontaneously at delivery, often resulting in hemorrhage
- Can be identified on antenatal US
FHR Monitoring: Intrapartum Complications: also see Placental Abruption
- Auscultation for healthy women, no RF adverse outcomes Meconium Stained Amniotic Fluid:
o 1st stage latent (q1h) vs active (q15-30 mins), 2nd stage q5 mins - Usually not associated with poor outcomes, may be sign of fetal distress
- Continuous electronic FHR monitoring: any RF adverse outcomes or abn - Yellow/green/black stained, watery or thick
intermittent auscultation - Rx: call RT + paeds to delivery room, closely monitor HRT, +/- suctioning before stim
Interpretation: Dystocia:
- Baseline FHR 110-160bpm - Abnormal progression: >4h of 0.5cm/h during active 1st phase, >1h with no descent
- Variability: 6-25bpm (moderate) during 2nd phase active pushing
- Accelerations:↑ in FHR >15bpm x 15s, if <32w- ↑ in FHR >10 bpm lasting >10s - Etiology: 4Ps: power, passenger, passage, psyche
- Decelerations: - Rx: ensure adequate contractions, assess for cephalopelvic disproportion, IV oxytocin
o Early: ↓ in FHR >15bpm, occurs & resolves with contraction (head augmentation +/- amniotomy
compression) Shoulder Dystocia:
o Late: ↓ in FHR >15bpm that is persistent beyond contraction - Impaction of ant shoulder against symphysis pubic after head delivered → emergency!
(uteroplacental insufficiency) - RF: maternal obesity/DM, multiparity, prolonged gestation, macrosomia, prolonged 2nd
o Variable: ↓ in FHR >15bpm with no relationship to contraction, no return stage labour
to baseline (umbilical cord compression) - Presentations: turtle sign
- Interventions: improve uterine blood flow & umbilical blood flow, improve - Complications: fetal hypoxia, brachial plexus injury (Erb’s C5-7, Klumpke’s C8-T1), fetal #,
maternal/fetal oxygenation, ↓ uterine activity 1% LTD, maternal perineal injury, PPH
- Management: mnemonic POISON-ER - Rx: ALARMER- apply suprapubic pressure + ask for help, legs in full flexion (McRobert’s),
o Position (LLDP), O2, IV fluids, scalp stimulation/electrode- not w/ ant shoulder disimpaction, release post shoulder by rotation- hand in vagina (+
contraction, oxytocin cessation, notify MD/obstetrician, examine for cord anesthesia), manual corkscrew, episiotomy, rollover
prolapse, r/o fever/dehydration /drugs/prematurity Umbilical Cord Prolapse:
Classification: - Descent of cord to adjacent or below presenting part- cord compression
Normal Atypical Abnormal - RF: prematurity/PROM, malpresentation, low placenta, polyhydramnios, multiple gest
Baseline 110-160bpm Brady 100- Brady <100bpm or tachy - Sx: visible/palpable cord, FHR changes (bradycardia, variable decelerations)
110bpm or tachy >160bpm for >80min, erratic
- Rx: emergency c/S, O2, monitor FHR, alleviate pressure on presenting part, warm saline
>160 for >30min baseline
to <80min, rising soak, Trendelenburg or knee/chest position
baseline Uterine Rupture
Variability 6-25bpm, ≤5 ≤5bpm for 40- ≤5 bpm for >80min, ≥25 for >10 - Sx: often during labour, prolonged fetal brady + loss of station, acute onset abdo pain +
bpm for <40m 80min min, sinusoidal hyper/hypotonic uterine contraction, vag bleed, CTX cessation
Accelerations Spontaneous Absence of Usually absent - RF: VBAC, uterine scarring e.g. surgery, excessive stimulation, uterine trauma,
accelerations acceleration with multiparity, uterine abnormalities, dystocia, uterotonic drugs, age
present + with fetal scalp - Rx: r/o placental abruption, immediate C/S (50% mortality), maternal stabilization +/-
fetal scalp stim stimulation
hysterectomy, wait min 18m next pregnancy, always C/S
Decelerations None or Repetitive ≥3 Repetitive ≥3 complicated
Amniotic Fluid Embolus
occasional uncomplicated variables
uncomplicated variables, - Decels to <70bpm for >60s, - Amniotic debris in maternal circulation,anaphylactoid immunologic response
variables or occasional late loss of variability in trough - RF: abruption, short labour, multiparity, uterine rupture manipulation
early decels decels, single or baseline biphasic decels - Sx: sudden resp distress, CV collapse (↓BP/O2), coagulopathy, seizures 10%
prolonged decel - Overshoots - Rx: supportive-ICU admission, high flow O2, ventilation support + fluid resuscitation,
>2min but <3min - Slow return to baseline inotropic support +/-intubation, coagulopathy correction
- Baseline lower after decel, Chorioamnionitis
baseline tachy/brady • RF: prolonged ROM/labour, multiple vag exams in labour, internal monitoring, BV
- Late decels >50%
• Sx: fever, maternal/fetal tachy, uterine tenderness, foul & purulent cervical discharge
contractions
- Single prolonged >3min but
• Ix: CBC, amniotic fluid analysis
<10min • Rx: IV Abx (amp 2g IV q6h & gent 1.5mg/kg q8h), +/- anerobic (e.g. clinda if C/S)
Postpartum Complications: Potentially Life-Threatening
Postpartum Hemorrhage
- Loss of >500mL blood at time of delivery or >1000mL w/ C/S
• Early <24h vs late 24h-12w
- Etiology: 4Ts (early)
- Late usually retained products +/- endometritis
• Tone: uterine atony (prolonged/augmented labour, uterus
infection, placental abnormality, HTN)
• Tissue: retained placenta/clots, GTN
• Trauma: lacerations, episiotomy, hematoma, uterine
rupture/inversion
• Thrombin: coagulopathy (thrombocytopenia, DIC, ASA,
TTP, vWD, therapeutic)
- Rx:
• ABCs, 2 large bore IVs + crystalloids, labs (CBC, coag,
crossmatch 4 units pRBCs)
• Treatment of underlying cause
o Local: bimanual compression, packing, tamponade
o Med: oxytocin 20u/L, NS/RL (continuous IV),
ergotamine 0.25mg IM q5min max 1.25mg,
carboprost 0.25mg IM q15min max 2mg,
misoprostol 600ug, TXA 1g IV, recombinant VIIa
o Surgical: (intractable)- D&C, uterine artery
embolization, laparotomy with uterine artery
ligation, last resort hysterectomy
Delayed Onset Preeclampsia
- Often within 48h, Rx: antiHTNs, consider MgSO4 if candidate
PE
- CP/dyspnea, ↓ O2, tachy, r/o peripartum cardiomyopathy
Severe painful vulvar edema
- Related to obstetric manipulation, r/o GAS/necrotizing fasciitis
Uterine Inversion
- Inversion of uterus through cervix +/- introitus
- Etiology: excess traction, excess tocolytics
- Sx: profound vasovagal +/- hypovolemic shock (+/- concealed)
- Rx: immediate ABCs, anesthesia, crystalloids
• Tocolytic/nitro IV to aid replacement
• Replace then remove placenta
• IV oxytocin then re-explore
Retained Placenta
- Placenta undelivered after 30 mins postpartum
- RF: abn implantation, prior C/S or manual removal, infection
- Sx: incomplete removal, risk PPH/infection
- Rx:
o IV fluids, type & screen
o Brant maneuver
o Oxytocin 1IU in 20mL NS into umbilical vein
o Manual removal +/- D&C if required
Non-Life Threatening
Infection
- Endometritis: higher risk with section → clinda +
gentamicin
- Septic pelvic thrombophlebitis
o Persistent fever despite Abx
o CT vs MRI, empiric piptaz + anticoagulation
- Wound/surgical site infection vs pelvic abscess
Postpartum Pyrexia
- >38C on any 2 of first 10d postpartum
- Etiology: B5W- breast (engorgement, mastitis), wing
(atelectasis, pneumonia), water (UTI), wound
(episiotomy, C/S), walking (DVT), womb (endometritis)
- Ix: detailed exam, blood & genital cultures
- Rx: endometritis (clindamycin + gentamicin IV), mastitis
(cloxacillin or cephalexin), wound infection (cephalexin)
o Prophylaxis against post C-section endometritis:
begin Abx after cord clamping x 1-2 doses
(cefazolin)
Cervical Laceration
- Repair as needed, GI consult if 3rd or 4th degree tear
Mastitis
- Inflammation of mammary glands
- Differentiate from mammary duct ectasia (ductal
inflammation + nipple discharge)
- Lactation mastitis usually S. aureus, unilateral localized
pain + tenderness & erythema
- Rx: heat or ice packs, continue nursing or pumping, Abx
(diclox or Keflex, erythron if pen allergic)
- Abscess: fluctuant mass + purulent nipple discharge,
fever leukocytosis → d/c nursing, IV Abx, I&D
Breastfeeding Problems
- Inadequate milk: poor production, poor latch, stress,
consider domperidone
- Breast engorgement: cool compress, expression/pump
- Nipple pain: clean milk off nipple after feeds, moisture
cream, topical steroids if needed or APNO
- Mastitis: see above
- Inverted nipples: makes feeding difficult
- Maternal medications: may require paeds consultation
Mnemonic: BREAST (breastfeeding contraindicated drugs)
- B: bromocriptine/benzodiazepines
- R: radioactive isotopes/rizatriptan
- E: ergotamine/ethosuximide
- A: amiodarone/amphetamines
- S: stimulant laxatives/sex hormones
- T: Tetracycline/tretinoin
Postpartum Hx
- Baby: physical exam, feeding, growth,
weight, sleep, jaundice
- Breast: latch, production, blocked duct vs
mastitis, consider lactation consultant
- Bowel: constipation, fistula
- Bladder: kegels, pelvic floor physio
- Belly: incision if relevant, afterpains
- Bottom: hemorrhoids, laceration/tears
- Bleeding: lochia until 2-8 weeks, r/o
endometritis or retained products
- Blues: r/o postpartum depression
- Birth control: avoid/delay OCP re: decrease
production breast milk, discuss
contraception options & return of menses
- Bloodwork: TSH, CBC/ferritin, OGT if
relevant, lipids if HTN/DM in pregnancy
Postpartum Mood Disorders
Postpartum Blues
- 85% new mothers, day 3-10
- Related to physiological hormonal changes
+ routine with baby, self-limited & should
resolve within 2 weeks
- Emotional lability, increased sensitivity to
criticism, tearfulness, irritability, fatigue,
poor concentration
Postpartum Depression
- Major depression occurring within 6 months
of childbirth
- RF: personal/FHx depression (including
PPD), prenatal depression/anxiety, stressful
life situation, poor support, unwanted
pregnancy, colicky or sick infant
- Sx: as with 'the blues' but persisting >2w or
if early severe symptoms (extreme
disinterest in baby, SI/HI)
- Ix: Edinburgh Postnatal Depression Scale
- Rx: psychotherapy + supportive care,
antidepressants, ECT if refractory
Postpartum Psychosis
- Onset of psychotic symptoms over 24-72h
within 1m postpartum, +/- in context of
depression → referral to postpartum psych
as high risk SI/HI to baby
-
Prostate Cancer Screening
- No population based screening program
- Avoid PSA screen in >70y or w/ <10-15y life
expectancy, greatest benefit 55-69y
- Individual discussion between provider + pt
depending on risk factors, life expectancy,
pt understanding of risks/benefits of biopsy
& treatment, wishes for surveillance vs Rx
- Consider use of risk calculator (e.g. PCPT) to
interpret results
- If PSA done, do not continue if <1ng/mL at
60y or <3ng/mL at 70y
OHIP Coverage for PSA
o Receiving Rx for prostate ca
o Being followed after treatment
o Suspected prostate (FHx/
exam/Hx)- diagnosis not screen
Screening Method
- DRE: abnormal texture, nodularity, focal
lesion/induration, asymmetry
- PSA: < 4 considered normal, serum PSA =
free (15%) + bound (85%), velocity + ratio
↑ sensitivity & specificity
↑ PSA Etiology
- Benign prostate hypertrophy
- Prostate cancer
- Prostatitis
- Prostate biopsy/massage
- Pelvic radiation therapy
- Acute urinary retention
- Acute kidney injury
- Urethral catheterization, cystoscopy
- Strenuous exercise
- Perineal trauma
- Ejaculation
Risk Factors for Prostate Cancer
- Family history
- Increasing age
- Race (black)
PROSTATE
Prostate Cancer
- Usually asymptomatic, commonly detected on
DRE/elevated PSA/incidental finding on TURP
- DRE: hard irregular nodule, dense induration or
asymmetry, uni or bilateral
Investigations: DRE/PSA initial, TRUS vs US guided needle
biopsy, bone scan to assess for mets
- Complications of biopsy: bleeding, exacerbation of urinary
Sx, infection, transient urinary incontinence
- TNM staging, Gleason score
Prostate Cancer Treatment
Benign Prostatic Hypertrophy
- Peripheral hyperplasia of stroma & epithelium in transition zone,
etiology ?DHT + age related (50% at 50y, 80% at 80y)
- Presentation: LUTS (‘FUNWISE’)
o Frequency, urgency, nocturia, weak stream,
intermittency, straining, emptying incompletely, *QoL
o O/E: smooth rubbery, symmetrically ↑
- Complications: retention, hydronephrosis, overflow
incontinence, infection, bladder stones
- Ix: urinalysis, Cr + renal US (r/o hydronephrosis/ AKI), PSA, biopsy
if exam suspicious, consider cystoscopy if persistent after
treatment, optional- urine flow study/PVR
- Rx: lifestyle modification (evening fluid ↓, planned voiding)
o Med: a-antagonists + 5a reductase inhibitors, combo
synergistic, anticholinergics if no ↑PVR
o Surg: TURP, laser ablation, TUIP, prostatectomy, if not
able to tolerate open- stent/ TUNA
Prostate Cancer Recurrence/Spread
- Method:
o Local invasion
o Lymphatic spread to regional nodes: obturator
> iliac > pre-sarcral/aortic
o Hematogenous dissemination early
- Locally advanced disease: storage/voiding symptoms,
erectile dysfunction
- Metastatic disease:
o Bony mets to axial skeleton ? visceral mets
(liver, lung, adrenal)
o Leg pain & edema with nodal mets obstruction
lymphatic & venous drainage
Prostatitis
- Acute bacterial prostatitis: ascending urethral
infections with KEEP organisms
- Associated with outlet obstruction, recent
cystoscopy, prostate biopsy
- Sx: acute onset malaise, perineal pain/lower back,
LUTS, post-ejaculatory pain
o O/E: tender boggy prostate + perineum
- Ix: U/A + C&S, CBC, transrectal US if not resolving
(r/o pelvic abscess)
- Rx: supportive + PO/IV Abx, consider catheter if
severe LUTS/retention
o Ciprofloxacin 500mg BID x 4-6 weeks,
alternative 3rd gen cephalosporin IV x 4w
o Urology for I&D if abscess present
Chronic Bacterial Prostatitis: recurrent exacerbations
same organism → Ix & Rx as above, + uro & 4 glass test
Approach to Managing Sexual Assault:
-
-
ABCs, emergent medical conditions first
Reassure victim they are safe, provide quiet
place to wait, ensure patient not left alone and
provide a nurse or support person if possible
- Provide explanation about legal & medical
procedure, informed consent is essential
- Obtain consent for physical exam, collection of
evidence, and treatment
- Offer sexual assault kit/forensic evidence
collection
- Do not report to police unless victim requests
or consents to this
o If victim is unsure, offer to collect
forensic evidence for future use
- If victim is <16y, you are legally required to
report to CAS
- Offer community crisis resources
- Documentation of history, physical, exam and
specimen collection is important
History:
- Sexual assault history: date, time, place,
perpetrator if known, type of sexual contact,
mechanism of injuries
- Medical Hx: ob/gyn, LMP, contraception use
- Medications
- Immunizations (including hep B)
- Social Hx: available support systems,
relationships, occupation
Physical Examination:
- ABCs, vitals, injuries requiring immediate
attention take precedence
- Examine for: bruising, laceration, vaginal/ oral/
anal trauma, petechial hemorrhages of palate
(if forced penetration)
- All injuries should be documented on body map
diagram accurately
- Sexual assault kit to collect all clothing worn
Investigations: **B-hCG, cervical swabs for G/C &
trichomonas, rectal + oral G/C, HBV/HCV serology,
RAPE/SEXUAL ASSAULT syphilis 0/3/6m, HIV 0/6w/3m/6m
Management:
1. Medical Management
- ABCs, assess injuries & image as required
- Suture lacerations
o Consider gyne consult if FB or complex lacerations
- Tetanus prophylaxis
2. Pregnancy Prevention
- Emergency contraception: Plan B (levonogestrel 1.5mg PO x 1)
- Follow up urine B-hCG in 21 days if no menstruation +/- referral for termination if desired
3. STI Prophylaxis
- Chlamydia & gonorrhea
o Azithromycin 1g PO x 1
o Ceftriaxone 250mg IM x 1
- HIV
o Risk in most sexual assault is low, higher if known HIV +, IVDU, multiple perpetrators,
significant injuries
o PEP (contact HIV/ID specialist)
o Initiate ASAP, within 72h to be maximally effective) and continue x 28d
- Hep B
o If not immune: HBIG x 1 dose IM, ASAP after exposure
o Hep B vaccine at 0, 1, and 6 months
4. Counselling
- Refer to counselling/social work, revisit need for support if patient declines initially
- Inquire about mood, anxiety, somatic sx
- Inquire about substance use
- Book regular follow up
- Encourage seeking support in family/friend if patient comfortable
- Refer as necessary (with patient consent)
o Sexual assault treatment centres (for follow up STI testing, HIV testing, HIV pep, vaccinations)
o Psychological supports
o Local victim organizations
Ocular History
- Sx: change in vision, FB sensation, photophobia, Hx
trauma, contact lens wear, discharge
- Associated Sx: rhinorrhea/URTI, systemic disease
Red Flags
- Ocular pain
- ↓ visual acuity
- Ciliary flush
- Photophobia
- Severe FB sensation (unable to open eye)
- Corneal opacity
- Fixed pupil/pupil abnormality
- Copious discharge
Physical Examination
- Visual acuity (Snellen → CF, HM, LP, NLP)
- Pupil (mid-dilation: AACG, pinpoint: keratitis)
- Pattern (diffuse, ciliary flush, hemorrhagic)
- Purulent discharge
- White spot (keratitis), opacity
- FB → evert eyelid
- Hypopyon/hyphema
- Fluorescein + slit lamp if relevant
‘Red Eye’ Differential
- Red eye: conjunctivitis (bacterial, gonococcal, viral,
allergic), scleritis/erpiscleritis, subconjunctival
hemorrhage, corneal abrasion/ulcer, FB, keratitis
o Ant chamber: iritis, hyphema, hypopyon,
globe rupture, endophthalmitis
- Lids/lashes: stye/hordeolum, chalazion, blepharitis,
preseptal cellulitis, orbital cellulitis, dacrocystitis
- Trauma: orbital #, eyelid lac, corneal abrasion,
hyphema, globe rupture (DO NOT put pressure on
globe/measure IOP), lens dislocation, retrobulbar
hemorrhage, retinal detachment
- Painful vision loss: AACG, iritis, corneal abrasion,
globe rupture, lens dislocation, optic neuritis,
temporal arteritis, endophthalmitis, keratitis
- Painless vision loss: retinal detachment, CRVO/CRAO,
amaurosis fugax, occipital stroke
RED EYE
Conjunctivitis
- Allergic: bilateral watery d/c, pruritus++, atopy- Rx:
supportive, artificial tears, cold compresses, topical
antihistamines +/- systemic
- Viral: adenovirus, URTI prodrome, unilateral →
bilateral, gritty irritation + watery d/c- Rx: NO abx,
supportive as above, hand hygiene
- Bacterial: Staph, strep pneumo, H. influenzae,
purulent d/c throughout day, uni/bilateral- Rx:
erythromycin/polytrim, cipro if contact lens wearer
(pseudomonas coverage), NO steroids
- Gonococcal: *sight threatening, hyper acute onset,
copious green/yellow d/c, lid edema-
Rx: ophtho referral, cultures, empiric
ceftriaxone + azithromycin, treat
partner + public health reportable
- Neonatal: G <5d (prophylactic erythromycin, Rx IV
ceftriaxone + r/o systemic), C 5d-2w (prophylactic Rx
mother), requires PO erythromycin x 14d
Subconjunctival Hemorrhage
- ASx, no vision change/pain, Hx cough/strain
- Rx: reassure, check BP, r/o coag disorder if recurrent
Keratitis
- Cornea inflammation, UV, viral (HSV, HZV), bacterial
- Pain worse w/ blinking, profuse tearing, photophobia,
FB sensation, dendrite on slit lamp
- Refer to ophtho for IV acyclovir +
topical antiviral
Corneal Ulcer & Perforation
- Ocular emergency, white spot on cornea stains with
fluorescein +/- reduced vision +/- hypopyon, diffuse
injection
- Flat anterior chamber, pupil asymmetry, extrusion
- ↑ risk in contact lens wearers
- Emergent referral to ophtho,
frequent topical Abx (q1h)
with monitoring
Foreign Body
- Mechanism: *metal striking metal, risk of penetration
injury, ask about eye protection
- FB sensation, mild pain/irritation, tearing
- Tetanus status
- Evert lids, +/- rust ring, ↑ fluorescein uptake
- X-ray/CT if possible, penetration injury
- RX: remove under magnification w/ topical anesthetic
(sterile needle/swab), topical Abx +
NSAIDs/cycloplegic, resolve in 48h
Iritis
- Pain, photophobia, pupil constriction, ↓ visual acuity,
ciliary flush
- Rheum HLA-B27, post-traumatic, systemic-
Crohn’s/lupus/ank spondylitis/vasculitis, HSV/HZV
- Complications: acute angle closure glaucoma
- Rx: refer to ophto, steroids + cycloplegics, consider
rheumatological/GI workup if systemic Sx
Acute Angle Closure Glaucoma
- Severe painful red eye, sudden onset, N/V, ↓ visual
acuity, mid-dilated unreactive pupil +/- corneal haze,
NO FB sensation or d/c
- ↑ IOP on exam (N 10-20mmHg, disease 60-80mmHg)
- Rx: (immediate) lower intraocular pressure- topical
pilocarpine, topical timolol, IV acetazolamide, IV
mannitol)
- Rx: (definitive) laser peripheral iridotomy
Temporal Arteritis
- Headache, jaw claudication, fever, anorexia, temporal
artery tenderness, afferent pupillary defect
- Rapid ↓ vision (usually unilateral)
- Associated with PMR, myalgias
- Investigations: ESR, refer for temporal artery biopsy
- Rx: PO prednisone high dose (1mg/kg max 60mg/d x
2-4 weeks) slow taper over months once clinical +
labs resolving, requires pulse IV methylprednisone if
visual loss
When to Refer
- AACG, penetrating trauma, hyphema/hypopyon, iritis,
infectious keratitis, temporal arteritis, retinal damage,
abnormal pupil
Schizophrenia Diagnostic Criteria (DSM-V)
1. Criteria A: characteristic symptoms ≥2 of the following,
each present for significant portion of time during 1m
period (or less if treated), mnemonic- negative ABCs
- Auditory or visual hallucinations
- Beliefs: delusions
- Catatonic or grossly disorganized behaviour
- Disorganized speech
- Negative symptoms
2. Social/occupation dysfunction in 1+ areas of
functioning (work, interpersonal relations, self-care)
markedly below previous level achieved
3. Continuous signs of disturbance ≥6 months, including
≥1 month active phase sx, may include
prodromal/residual sx
4. Schizoaffective and mood disorders excluded
5. Not due to direct physiological effects of a substance
or general medical condition
Subtypes: paranoid, catatonic, disorganized,
undifferentiated, residual
Schizophreniform Disorder:
1. Characteristic symptoms: ≥2 sx, each present for
significant portion of time during 1m period (or less if
successfully treated)
- Delusions, hallucinations, catatonic or
disorganized behaviour, disorganized speech,
negative symptoms
2. Schizoaffective and mood disorders excluded
3. Not due to direct physiological effects of a substance
or general medication condition
4. Duration 1-6 months
Schizoaffective Disorder:
- Uninterrupted period of illness during which there is a
MDE, manic episode, or a mixed episode with
symptoms meeting criterion A for schizophrenia
- In same period- delusions of hallucinations ≥2w in
absence of prominent mood sx
- Sx that meet criteria for mood episode present for
substantial portion of acute/residual periods of illness
- Not due to direct physiological effects of a substance
or general medical condition
SCHIZOPHRENIA
Schizophrenia Follow-Up Visits:
History
- Sx: positive & negative, disorganization, mood, safety
- Hospitalizations & precipitating factors
- Function: collateral Hx, social Hx (housing finances,
social supports, ADLs, relationships), occupation/school
- Asses for suicidal/homicidal thinking & behaviour
- **Assess for substance use → at risk population
- Regular monitoring for medication compliance
- Regular monitoring for side effects of treatment:
movement disorders, obesity, diabetes, hyperlipidemia,
sexual dysfunction
Examination
- Vitals, MSE
- Neurological exam: extra-pyramidal Sx: (TAPA) tardive
dyskinesia, akathisia, Parkinsonism, akinesia
- BMI & waist circumference
Investigations:
- CBC, electrolytes, renal function, liver function, TSH
- Fasting glucose, A1c, lipid panel
- Consider VDRL, hepatitis, HIV, tox screen if indicated
- ECG for QTC prolongation
Brief Psychotic Disorder: acute psychosis (presence of 1 or
more positive symptoms in criterion A of schizophrenia)
lasting from 1 day to 1 month, with eventual full return to
premorbid level of functioning
Delusional Disorder:
- Non-bizarre delusions for ≥1 month
- Criterion A for schizophrenia has never been met
- Functioning not markedly impaired, behaviour not
obviously odd or bizarre
- If mood episodes occur concurrently with delusions,
total duration brief relative to duration of delusional sx
- Disturbance not due to direct physiological effects of a
substance or general medical condition
Shared Psychotic Disorder (Folie a Deux)
- Develops in an individual who is in a close relationship
with another person with a psychotic disorder (with
prominent delusions)
- Delusion is similar in content to that of other person
Treatment:
- Antipsychotics should continue for min 1y following
-
record, risk of relapse greatest in first 5y
Consider long acting injectable medication if poor
adherence
- Treatment nonresponse to adequate trial 2
antipsychotics from 2 classes → trial clozapine
Psychosocial
- Psychotherapy (individual, family, group), CBT
- Assertive community treatment (ACT) assist with
medication adherence, basic living skills, social
support, job placements, community resources
- Social skills training, employment programs,
disability benefits, housing (group, transitional)
Pharmacological
- Acute treatment + maintenance with antipsychotics
- Typical (1st gen), high EPSE, low metabolic effects
- Atypical (2nd gen), low EPSE, high metabolic effects
- +/- anticonvulsants +/- anxiolytics
Side Effects
- Extra-Pyramidal Side Effects: acute dystonia
(benztropine or Benadryl), akathisia (lorazepam,
propranolol), Parkinsonism (benztropine), tardive
dyskinesia (discontinue rx)
- Neuroleptic dysphoria: subtle change in arousal,
mood, thinking, motivation → noncompliance
- Neuroleptic Malignant Syndrome: FARM (fever,
autonomic, rigidity, mental status change), any
antipsychotic/dose/time → stop med, supportive:
dantrolene/bromocriptine, benzo
o Differentiate Serotonin Syndrome: restless,
↑tone, myoclonus, hyperreflexia, N/V/D,
seizures)
- Metabolic: weight ↑, obesity, DM/IFG, dyslipidemia
- QT prolongation → arrhythmia, syncope, torsades
- Sexual SE: ↓libido, galactorrhea, ED, ↓ gonadal
hormones may increase risk osteoporosis
- Cognitive effects & sedation/dulling
- Clozapine-specific:
o Agranulocytosis (weekly CBC in 1st 6 months
to ensure WBC & neutrophils normal)
o Seizures
o Rare myocarditis & cardiomyopathy
o Anticholinergic effects: constipation, dry
mouth, gastroparesis
o Does not elevate prolactin or induce extra-
pyramidal side effects
Seizure: transient neurological dysfunction cased by
excessive activity of cortical neurons, resulting in
paroxysmal alteration of behaviour &/or EEG changes
Classification
- Provoked (fever, hypoxia, metabolic, trauma,
structural) vs unprovoked
- Partial: simple (motor, sensory, autonomic) vs complex
(altered LOC)
- Generalized: non-convulsive (absence) vs convulsive
(clonic, tonic, tonic-clonic, myoclonic, atonic)
Epilepsy: condition characterized by 2+ unprovoked seizures
Status Epilepticus: unremitting seizure > 5 mins or
successive seizures without return to baseline state
Acute Management
1. ABCs: secure airway when safe (NP, OP, LMA) lateral
decubitus position to avoid aspiration, O2
2. Rectal diazepam if no IV (0.2mg/kg x 1)
3. Secure IV access
4. Lorazepam 0.1mg/kg (2-4mg IV) OR diazepam 0.2mg/kg
5. R/o & treat acute reversible causes: hypoglycemia,
hypoxia, electrolytes abnormalities, EtOH
withdrawal/tox screen, fever/infection
Status Epilepticus Management
- As above, consult neurology
- Phenytoin 20mg/kg (1-1.5g IV over 30 mins)
- Intubate + ICU
- Phenobarbital 10mg/kg (1-1.5g IV over 30 mins) or
other longer acting antiepileptic e.g. Keppra
- General anesthesia with midazolam/propofol
- Thiamine 100mg IV, dextrose 50g IV push
Investigations
- Labs: CBC, lytes + extended lytes, Cr + BUN, glucose,
LFTs, tox screen, medication levels
- Lactic acid to help differentiate from non-seizure LOC
- EEG: abnormal spikes, spike-wave complexes, sleep-
deprived EEG
- Video monitoring
- Neuroimaging if focal neuro sx, consider if 1st episode
- LP to r/o space occupying lesion, meningitis/
encephalitis, all HIV +ve patients
Antiepileptics
- Indications: 2+ unprovoked seizures, known organic brain
SEIZURES disease, EEG with epileptiform activity, 1st episode status
epilepticus, abnormal neuro exam, findings on
neuroimaging, pt or family considers further seizure risk
History (+ collateral) & Examination
unacceptable
- Differentiate pseudoseizure, syncope
- Monotherapy where possible, titrate to symptoms not
- Behaviour prior to seizure, aura
lab values/levels
- Type & pattern of movements including head +
- Consider taper if >1y seizure free and normal EEG
eye deviation, LOC
- HPI: recent illness, head trauma, sleep Side Effects
deprivation, meds + recent dose changes - Carbamazepine: drowsiness, h/a, unsteadiness, N/V, SJS,
- PMH: prior seizure, fam Hx,stroke/head trauma agranulocytosis, aplastic anemia, osteoporosis
- Known epilepsy: compliance, alcohol, meds - Phenytoin: ↓BP, SJS/TEN, gingival hypetrophy, h/a,
- Social: drugs, EtOH blood dyscrasias, osteoporosis, sedation, GI, teratogenic
- Exam: full neuro exam including skin for - Valproic acid: liver failure, h/a, N/V, ↓plt, pancreatitis,
neuroectodermal syndromes encephalopathy, tremor, diplopia, teratogenic
- Ethosuximide: CNS depression, blood dyscrasias, SJS, GI
Etiology - Lamotrigine: GI, insomnia, mood changes, visual changes
A: alcohol & illicit drugs, meds
- Levetiracetam: HTN, behavioural/mood changes,
B: brain (tumour, trauma, infection) aggression, h/a, GI, weakness, agranulocytois
C: cerebrovascular disease* (stroke most common
cause >50y) Counselling:
D: degenerative - Psychosocial issues: stigma, patient and family education,
E: electrolytes & metabolic (uremia, hepatic failure, pregnancy, driver's license
- Safety: driving, heavy machinery, bathing, swimming
hypoglycemia)
Pregnancy:
F: febrile & sleep deprivation in childhood
- Teratogenicity of antiepileptics (neural tube defects, cleft
palate, urogenital malformations, heart defects
Differential - Should take 5mg/d folic acid
- Syncope - Optimize AED on lowest dose associated with good
- Pseudoseizures seizure control- preferably monotherapy if possible
- Panic disorder - Monthly serum levels during pregnancy + titrating
- TIA - Refer to high risk OB for intrapartum fetal screening
- Hypoglycemia Contraception:
- Movement disorder - Hepatic enzymes affected, no POP & require ta least 50ug
- Migraine estrogen, long-acting methods e.g. IUD recommended
- Narcolepsy/cataplexy - Double dose of EPC (1.5mg levonorgestrel)
Driving (Ontario Regulations)
- Report all new seizures to MoT or changes from baseline in pts with epilepsy. Driving permitted if:
1. Medication preventing seizures AND seizure free 6 month, no impairing side effects, compliant, agree to report
2. Single spontaneous seizure unrelated to toxic illness and full neuro exam normal/no epileptic activity
3. Seizures only during sleep AND seizure free >6 months OR consistent pattern >1 year
4. Partial seizures AND seizure free >6 months OR pattern consistent >1 year, AND favourable physician assessment
5. Seizure free >6 months but occurs after ↓ meds under physician supervision- may resume once on previous dosing
Sexual History: 5Ps
- Partners: # in past 12 months, gender/sex, relationship
-
status (monogamous vs polygamous vs anonymous)
Practices: digital, oral, anal, vaginal, toys, drug use
during/prior to intercourse, transactional
- Protection: condoms/barrier methods, contraception
- Pregnancy: history, possibility, contraception, family
planning, GTPAL, LMP
- Prior Hx of STIs: self, partners, treatments
- Other factors:
o Age of first intercourse
o Perceived gender of self, sexual orientation
o Pain or bleeding with intercourse
o Sexual satisfaction (desire, arousal, orgasm)
o History of assault/abuse
o Resources: sexualityandu.ca
Investigations:
- Fasting glucose, A1c, CBC, lipid panel, ECG,
LFTs/enzymes, Cr, TSH
- Men: morning free testosterone x 2 (to workup
hypogonadism, if low → TSH/LH)
- Gonorrhea/chlamydia NAAT
- Nocturnal penile tumescence testing
- TVUS
- Duplex doppler US
Management of Sexual Dysfunction:
- Lifestyle (diet, exercise, decreasing EtOH & nicotine)
- Menopause: replens/lubricant, testosterone (if
surgically induced) but not common due to SE
- Vaginismus: vaginal dilators, pelvic floor physio
- Female anorgasmia: counselling, PDE5-I, different stim
- Dyspareunia: treat underlying condition
- Male libido: counselling
- Erectile dysfunction:
• PDE5 inhibitors:
o Silendafil (30-60min prior)
o Tadalafil (active for up to 36)
o SE: h/a, flushing, dyspepsia, visual
disturbance, rare vision loss/hearing loss
• Intrauretral alprostadil, intracavernosal injection,
vacuum assisted device, penile prosthesis, switch
to/add bupropion if taking antidepressants
• Ejaculatory disorder: counselling, SSRI
Age of Consent:
- 12-13y, partner up to 2y older
SEX -
-
14-15y, partner up to 5y older
16y+, anyone as long as not exploitative
- 18+, anyone
High Risk Populations for Sexual Dysfunction:
- Medications:
o Antihypertensives, anticonvulsants, opioids, benzos, ranitidine, antineoplastics, antipsychotics,
antidepressants, anticholinergics, antiemetics, chemotherapy, ketoconazole
- Cancer: multifactorial re: disfigurement or physical factors, mood, fatigue, ADRs or medication
- Neuro: MS, CVA, spinal cord injury
- Endocrine: thyroid, DM, menopause/andropause, hypogonadism, hyperprolactinemia
- Vascular: HTN, post-MI, CAD, PVD
- Uro/gyne: anatomy, vestibulitis, STIs
- Psychiatric: depression, anxiety, PTSD, psychosis, gender dysphoria intellectual/developmental disability
- Psychosocial: EtOH, cigarettes, illicit substances, relationships, losses, stress, sexual orientation
Sexual Dysfunction
Desire
- Hypo/hyperactive sexual desire
o Hypogonadism (gynecomastia, decreased hair, small testes/penis, increased time to ejaculation, decreased
amount of ejaculate)
- Sexual aversion disorder
Arousal
- Female sexual arousal disorder (inability to attain/maintain adequate lubrication/swelling)
- Vaginismus: involuntary contraction of perineal muscles with vaginal penetration
- Dyspareunia: genital pain with intercourse → DDx: vulvitis, vestibulitis, infection, vaginismus, endometriosis, ovary in
cul-de-sac, adhesions, UTI, constipation, proctitis, STI/PID
- Erectile dysfunction
Orgasm
- Female orgasmic disorder: delay or absence of orgasm in context of normal arousal
- Premature ejaculation
- Delayed ejaculation
Approach to Sexual Dysfunction:
- Ask about sexuality in all patients, especially pregnant women/menopausal/adolescents
o Include normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction
- Hx including history of partner and relationship between partners
o Clues for non-organic cause:
▪ Abrupt onset
▪ No Hx of trauma
▪ No new meds
▪ Ongoing nocturnal erections
▪ Dysfunction specific to certain situation/partner
- Psychiatric screen: MDD, anxiety, PTSD, psychosis
- Physical exam: endo, vascular, uro/gyne
- Address offending medications
STI Risk Factors:
- Sexual contact with person with known STI
-
-
Sexually active <25y
New sexual partner or >2 partners in the last year
- No contraception or non-barrier method
- IVDU or substance use
- Sex workers, homelessness
- Victims of sexual abuse
- Previous STI
Prevention:
- Abstinence, mutual masturbation, toys, *oral sex-
however G/C, warts, HSV can still be transmitted
- Buying condoms in advance
- Limiting alcohol/drugs
- Harm reduction (publicly available condoms)
- Testing at regular intervals and with new partners
- HIV risk
o Discuss window for prevention, 95%
develop antibodies within 3 months, 99%
within 6 months
o Nominal vs anonymous testing, duty to
report to PH, assess supports in case of
positive result, obtain consent to test
o Make plan for obtaining results, usually 7d
Approach to STIs
- High risk pts: screen & discuss prevention, treat
before laboratory confirmation
- Legal reporting obligations: risk of harm to
self/others, reportable conditions(G&C, syphilis,
Hep B/C, HIV) & suspected child abuse
- Age of consent for intercourse (Canada): 16y
o 12-13y if partner within 2y, 14-15y if
partner within 5y
- Sexual Hx: orientation, number of partners in last
12m, type of sex, previous STI testing, protection &
contraception, family planning, sexual function,
meds, ob & gyn Hx
- Specimen collection: urethral swab (no void 2h
prior, introduce 3-4cm & rotate), cervical swab
(remove secretions, 1-2cm into canal & rotate),
pharyngeal swab, anorectal, vesicular lesion (viral
swab, deroof first)
SEXUALLY TRANSMITTED
INFECTIONS
Pelvic Inflammatory Disease:
- Sx: lower abdo pain, dyspareunia, vag bleed, fever, CMT
- Etiology: G/C, HSV, trichomoniasis, often polymicrobial
- Ix: endocervical wab G&C, viral swab HSV, vag culture, B-
hCG to r/o ectopic
o TVUS: thickened fluid filled tubes, pelvic fluid,
tubo-ovarian complex
o Laparoscopy: gold standard
- Rx: initial broad spectrum Abx, inpatient cefoxitin IV + doxy
IV/PO x 14d, can stepdown to PO if improvement x 24h
o Outpatient: ceftriaxone 250-500mg IM x 1,
doxycycline PO x 14d
o Adnexal mass/abscess/peritonitis/BV: add flagyl
- Hospitalization: surgical emergency, pregnancy, not
responding to PO Abx or cannot tolerate, severe illness
- Follow-up: if IUD in situ can remove after at least 2 doses
Abx, should begin to resolve within 72h
Chlamydia & Gonorrhea
- Most common STI (C. trachomatis) gonorrhea 2nd most
common , often co-infection, both reportable
- Sx: often asymptomatic, cervicitis, discharge, dysuria,
lower abdo pain, abnormal vag bleeding, dyspareunia,
conjunctivitis, pruritus, testicular pain
- Complications: PID, infertility, ectopic, chronic pelvic pain,
epididymo-orchitis
- Ix: urine NAAT (1st catch) if pelvic exam not warranted or
asymptomatic, cervical/vaginal/urethral swab,
conjunctival/oropharyngeal/rectal PRN
- Rx:
o Always treat both due to risk co-infection, no
intercourse x 7d post-treatment
o Chlamydia: azithromycin 1g PO x 1 or doxycycline
100mg PO BID x 7d (amox 500mg PO TID if
pregnant)
o Gonorrhea: cefixime 800mg PO x 1 or ceftriaxone
250mg IM x 1
Genital Herpes
- HSV 1&2- most by asymptomatic shedding (not
reportable), cluster vesicles on erythematous base,
painful +/- fever, LNs → less severe recurrences
- Ix: viral PCR swab
- Rx: 1st episode valacyclovir 1000mg PO BID x 10d,
recurrences valacyclovir 500mg PO BID x 3d
- Suppressive Rx: if 6+/y valacyclovir 500mg PO OD
Genital HPV
- Types 6 & 11 (90% warts), 16 & 18 (pre-cancerous),
not reportable, mostly asx, warts on cervix/vag,
external genitalia, flesh coloured cauliflower lesion
- Ix: pap smear q3y as per Ontario screening, +/-
colpo if abnormal, +/- biopsy PRN
- Rx: imiquimod 3x/w, podofilox q12h x 3d, cryo
- Prevention: vaccination grade 7-8, 2 dose (0/6m) if
<15y, recommended 9-45y if not previously
vaccinated, 3 doses if starting >15y (0/2/6m)
Trichomoniasis
- Increased risk HIC transmission, reportable
- Sx: vaginal d/c, pruritus, dysuria, yellow frothy
discharge, erythema of vulva/cervix, can be asx
- Ix: vag culture- motile trichomonads on wet mount
- Rx: metronidazole 2g PO x 1, treat partner
Syphilis
- Increased transmission of HIV, reportable
- Presentation:
o 1⁰: chancre + lymphadenopathy
o 2⁰: rash, fever, malaise, LNs, h/a, uveitis,
meningitis, skin lesions
o Latent: asymptomatic
o 3⁰: CV (aortic aneurysm/regurgitation),
neurosyphilis(dementia, personality
change, AR pupil, h/a, vertigo)
- Ix: VDRL, treponemal specific enzyme immunoassay
+ dark field microscopy
- Rx:
o 1⁰/2⁰/early latent: benzathine penicillin G
2.4million unit IM x 1 (repeat in 1w if preg)
o Late latent/unknown/CV: weekly x 3 doses
o Neurosyphilis: penicillin G 3-4 million units
IV q4h x 10-14d
Hepatitis B
- Reportable, transmission through IV, sexual, horizontal
household contact, vertical
- RF: IVDU, multiple partners, MSM, HBV partner, carrier in family
- Sx: 50% asx, fatigue, N/V, anorexia, rash, arthralgia, jaundice
- Ix: serology markers HbsAg (acute), anti-HBs (previous vaccine)
- Rx: refer to hepatology, requires monitoring for cirrhosis/HCC
o 1⁰ prev: vaccination grade 7 + high risk groups
o 2⁰ prev: HBIG & hep B vaccine for needlestick injuries
<7d, sexual contact <14d, infants of HBV mothers
(HBIG at birth, vaccine within 12h)
Chancroid
- Painful, necrotizing, purulent ulcers in inguinal region, LNs
- Ix: gram stain, H. ducreyi PCR/culture
- Rx: single dose azithromycin 1g PO or cipro 500mg PO or
ceftriaxone 250mg IM
Lymphogranuloma Venereum
- Painless genital/rectal papule/ulcer + inguinal/femoral
lymphadenopathy, urethritis or prostatitis
- Ix: NAAT/culture for C. trachomatis, if +ve perform serotype
- Rx: doxy 100mg PO BID x 21d, treat sexual contacts x 7d
Granuloma Inguinale
- Painless anogenital papules/ulcers, highly vascular + bleed
easily on contact, K. granulomatis
- Ix: difficult to culture, consult microbiology
- Rx: azithromycin 1g PO q1w for at least 3w or until lesions
clear, treatment halts progression but often relapse in 6-18m
Pubic Lice
- Small insects on pubic hair, pruritic, nits on hair shaft
- Ix: visualization of lice/eggs
- Rx: permethrin 1% cream rinse applied for 10 mins, then
rinse, repeat in 3-7d
- Wash all clothes & bedding in hot water or place in plastic bag
for 7d, treat household contacts & recent partners
Scabies
- Mites that dig under skin, head & neck sparing, itchy at night,
red papules/crusts, curvy red burrow lines, persistent pruritus
- Rx: permethrin 5% cream applied from neck down (including
fingernails) overnight, rinse in AM, repeat in 7d
- Wash all clothes & bedding in hot water or place in plastic bag
for 7d, treat household contacts & recent partners
Human Immunodeficiency Virus
- Recommended testing for certain groups:
o Pregnant women, immigrants
o High risk pts: (yearly) IVDU + partners, partners of HIV-infects pts, sex trade workers, MSM, new
partner since last screen
o Pts with sx of disease: pneumocystis jirovecii pneumonia, toxoplasmosis, Kaposi’s sarcoma,
persistent vaginal candidiasis, multi-dermatomal HZV
- Testing:
o HIV ag/Ab combo (p24 antigen + HIV Ab) 99% sensitive, confirmed w/ Western Blot, window <2w
o If initial (baseline) testing negative: repeat after 3w new exposure & at 3 months
o Offer to all sexually active patients or other high-risk groups
o Can use pt name, non-identifying test, or anonymous
- Investigations:
o Initial investigations: HIV viral load, genotype, CD4 count, hepatitis A/B/C serology, syphilis,
toxoplasmosis, varicella, CBC, lytes, Cr, FBG, LFTs, urinalysis, cholesterol profile, TB skin test
▪ CXR, ECG, G6PD, HLAB5071 (relevant for ARV choice)
o Every 3 months: Cr, BUN, lytes, CBC, LFTs, HIB viral load, CD4
o Ophthalmologic exam: refer if CD4 <50
o Neuropsychiatric: screen for HIV-associated neurocognitive disorders & dementia
- Screening for concurrent infections:
o TB- skin test at baseline then q2y, CXR at baseline then q2y if TST positive or previously treated,
prophylactic treatment if induration >5mm
o STI- GC/chlamydia at baseline then yearly, syphilis at baseline then q3m if high-risk
o Hep B/C- at baseline then yearly if high risk
o Pap- baseline, in 6 months, then yearly if results normal, consider anal pap in MSM
- Disease prophylaxis:
o Influenza vaccine annually, pneumococcal vaccine at baseline & repeat in 5y
o Hep A if HAV-IgG neg, Hep B if HBsAb neg (double dose at 0, 1, 2, 6m + boost if titres <10 IU/mL)
o Live vaccines: MMR, varicella safe if CD4 >350 x 6m and viral load suppressed
o Opportunistic infections:
▪ Pneumocystis jirovecii pneumonia: Rx septra 1 DS tablet PO M/W/F for CD4 <200
▪ Toxoplasma encephalitis: Rx septra 1 DS tablet PO daily for CD4 <100
▪ Mycobacterium avium complex: Rx azithromycin 1200mg weekly/clarithro 500mg PO BID
for CD4 <50
- Management: highly active anti-retroviral therapy (HAART)
o Start at CD4 <350, strongly consider for CD$ 350-500 or if pt desires
o ID consultation recommended for initiation/alteration of therapy
o Mandatory reporting
o Shared care model with primary care/specialized HIV clinic
Eczema
- Atopic dermatitis, common relapsing remitting
inflammatory skin disease
- Typically develops <5y, can persist to adulthood
- Atopic triad (asthma, eczema, allergic rhinitis)
- Sx: erythematous poorly demarcated plaques- risk
secondary infection, flexural distribution
o Infants: cheeks, scalp, extensors
- Rx:
o Non-pharm: lukewarm baths, mild cleansers,
pat dry after bathing, avoid harsh soaps,
regular moisturizing
o Topical steroids: face/folds (low potency e.g.
hydrocortisone 1% BID), body (mid-potency
e.g. betaderm 0.1% ointment BID)
o Pruritis: antihistamines e.g. reactine 10mg PO
o Abx if co-existing staph infection (impetigo)
o Consider fungal infection if not improving
Psoriasis
- Hyperproliferative state mediated by immunity,
chronic multisystem disorder, 1/3 genetic Hx
o Distribution: extensor, scalp/ears, elbow/knee
o Nails: oil drop stains, pitting, onycholysis
o Auspitx sign, Koebner phenomenon
- Classification: plaque (well demarcated erythema +
silvery scale), flexural, guttate, erythrodermic, pustular
- Systemic sx: psoriatic arthritis (30%), metabolic
syndrome, IBS, uveitis, depression
- Rx:
o Topical steroids/calcipotriene: scalp
(betaderm lotion + tar shampoo, clobetasol),
body (dovobet, dovonex)
o Topical calcineurin inhibitors (tacrolimus,
proptopic 0.03% ointment for face/folds)
o Systemic: NO STEROIDS (cause flare),
immunosuppressants (cyclosporine,
methotrexate), phototherapy, biologics
SKIN DISORDER
Acne
- Disorder of pilosebaceous follicles, debris & bacteria
collect (propionibacterium acne)
- Androgens + increase sebaceous gland activity →
plugging + keratinization
- Sx: located on face, neck, trunk, upper arms
o Open (black) vs closed (white) comedones
o Nodulocystic acne if rupture into dermis
o Inflamed red papules + pustules, post-
inflammatory hyper/hypopigmentation
Grades: I (comedones + papules), II (as I + few pustules),
III (as II + few nodules), IV (as III + nodules, cysts)
Rx:
- Comedones: BPO or topical retinoids or both,
combination BPO/clinda or BPO/adaplene →
clinda/tretinoin → COCP
- Papulopustular: as above → systemic Abx
- Severe papulopustular/nodular: systemic Abx +
topical BPO +/- topical retinoid OR OCP → oral
isotretinoin (Accutane)
- Referral to derm if 1st/2nd/3rd line ineffective
Rosacea:
- Chronic inflammatory skin condition
- Sx: erythema + telangiectasia on mid-face, +/-
papules & pustules, +/- rhinophyma, NO comedones
- Triggers: alcohol sunlight, heat, spicy food, emotion,
stress, exercise
- Rx: avoid triggers, topical metronidazole +/- BPO →
tetracycline PO daily → electrodessication
Skin Malignancies
Premalignant Lesions
- Actinic keratosis
- Bowen’s disease (SCC in situ)
Basal Cell Carcinoma
- Most common skin cancer
- RF: immune ↓, sun exposure, 2+ 1⁰ relatives melanoma
- Classification: nodular, superficial/sclerosing, pigmented
- Dx: shave/punch/excisional biopsy
- Rx: imiquimod cream (superficial), excision,
electrodessication, radiation, Mohs (>2cm,↑ risk area)
Squamous Cell Carcinoma
- Can develop from AK or marjolin ulcer (non healing or
growth on edge of wound, sun exposed areas
- Slow growing- indurated erythematous nodule with
surface scale/crust, +/- ulceration
- Dx: punch/excisional biopsy
- Rx: excision +/- radiotherapy
Malignant Melanoma
A: asymmetry, B: border irregular, C: color variation, D:
diameter >6mm, E: evolution
Rx: biopsy, remove full depth dermis + margins only after
histology, node dissection if >1mm OR ulcerated
- Referral to oncology for staging + chemotherapy +/-
radiotherapy as adjunct
- Stage: T1 (<1mm), T2 (1-2mm), T3 (2-4mm), T4 (>4mm)
Superficial Spreading
- Commonly back/leg/head & neck, ABCDEs
- RF: sun exposure, blue eyes, red hair, freckling, family
Hx, multiple nevi (>50)
Lentigo Maligna
- Occur on sun exposed areas, face- flat brown stain like
lesion, gradually enlarged + darkens
Nodular
- Rapid vertical growth, ulceration blue/black, firm
Acral Lentiginous
- Palmar, plantar, mucosal, subungal
Serious Pathology: Systemic Disease Dermatologic Emergencies
Melanoma (see above) Necrotizing Fasciitis
Granulomatosis with Polyangiitis
- RF: DM, chronic dz, immunosuppression,
- Systemic small vessel vasculitis
Cutaneous T-Cell Lymphoma - malnutrition, age >60y, IVDU, PVD, renal failure,
- Sx: chronic rhinosinusitis, nasal ulcerations, cough,
- Uncommon type of non-Hodgkins obesity, underlying malignancy
hemoptysis, CP, CXR nodules, renal failure, skin
- Mycosis fungoides most common - Precipitant: surgery, IVDU, penetrating injury, bite,
lesions (irregular ulcers + erythematous plaques with
o Starts in areas not exposed to sun, pruritic burns, skin/soft tissue infection
subcutaneous nodules)
plaques → progress to tumours, spread to LN, - Sx: erythema ill-define, tense edema w/ grey discharge,
- Dx: necrotizing vasculitis of resp tract,
liver, spleen, lungs vesicles/bullae → necrosis, systemic sx (fever, tachy),
glomerulonephritis, c-ANCA +
- Sezary syndrome *pain out of proportion*
- Rx: steroids + cyclophosphamide,
o Fast growing, redness all over (appears like - Rx: surgical emergency- widespread debridement +
+/- dialysis
sunburn), high risk for infection broad spectrum Abx
- Primary cutaneous anaplastic large cell lymphoma Drug Reaction:
Stevens Johnson Syndrome
o Slow growing, many different size tumours, 1. Immediate <1h (urticaria, angioedema, anaphylaxis)
- Acute life-threatening
rupture & become open sores 2. Delayed usually >6h (exanthematous eruption)
mucocutaneous reaction, 2⁰ to medications/infection
- Rx: UV light therapy, radiation + chemo, - Lasts 8-11 days, persisting several days after stopping
- High risk meds: (SATAN) sulfa, allopurinol,
immunotherapy & biologics - Limited to skin, erythematous papules, trunk →
tetracyclines, anticonvulsants, NSAIDs
extremities, pruritus +/- fever
- Sx: within 8q exposure, fever, headache, myalgia,
Pemphigus - Rx: d/c med, reassure, PO antihistamines +/- steroid
eruption of symmetrical macules face/upper
- Rare but serious autoimmune mucocutaneous blistering
trunk/proximal extremities, erythematous irregular
- RF: meds (ACE, penicillamine), stress/trauma, sun,
shaped, dusky red + purpuric, painful, Nikolsky +ve,
ethnicity (Mediterranean, Ashkenazi, North Indian)
SLE (see joint disorders) mucous membrane involvement
- Sx: non-healing erosion, flaccid blisters easily ruptured-
- 4/11: MD SOAP BRAIN - Rx: admit, withdrawal offending med, supportive care
crusts + erosions, Nikolsky sign
- Derm: malar rash, discoid, oral ulcers, photosensitive + fluids, infection prophylaxis, derm consult, consider
- Rx: derm consult, PO prednisone +/- biologics
optho, burn unit if >25% BSA, consider IVIg
Ulcers Pressure Ulcers Toxic Epidermal Necrolysis
Venous Arterial Diabetic - Severe spectrum SJS, diffuse erythema then necrosis &
-Classification: I (nonblanchable
Cause Valvular incompetence, Atherosclerotic Peripheral neuropathy- sheet-like epidermal detachment
venous HTN disease injury, atherosclerosis erythema >1h), II (partial
thickness skin loss), III (full - Systemic Sx: electrolyte imbalance, dehydration, AKI,
Hx Medial malleolus- Distal- claudication, Pressure point
thickness skin loss into SC tracheal erosions, fever→ 30% mortality
edema, rapid onset +/- slow progress, + distribution- DM,
tissue), IV (through fascia into - Rx: burn unit, debride necrotic area, IVIg /cyclosporine
thrombophlebitis, pain pain-rest peripheral neuropathy,
painless +/- paresthesia muscle/bone/tendon) Burns
O/E Yellow exudate, Pale white, punched Necrotic base, variable -Rx: treat medical issues, - Wound care + prevent infection
granulation, irregular out, necrotic base +/- border + hyperkeratotic, nutrition, debridement + - Consider admission to burn unit/ICU if severe
edge, brown pigment eschar, cool ↓ hair, deep, +/- hypersensitive, moisture retentive dressing, - Parkland Formula: initial fluid resus
surrounding , N pulses, ABI <0.9, ↓ pulses, likely ↓ pulses, ABI topical Abx or systemic if o Initial 24h: 4ml/kg x BSA RL IV, ½ in 8h & ½ in
ABI >0.9, *doppler dependent rubor inaccurately ↑ infection, consider next 16h
Rx Elevation, rest, Rest, no Control DM, wound + reconstruction Chemical Burns
compression 30mmHg, compression, moist foot care, orthotics, early -Prev: nursing care (clean/dry, - Tissue damage dependent on potency, concentration &
moist dressing +/- dressing +/- intervention for
repositioning), appropriate duration- extent often underestimated
topical/systemic Abx, topical/systemic Abx, infection, vasc consult to
mattress, nutrition, encourage - Rx: ABCs, stabilization, remove exposure/clothing,
consider graft, vasc-refer modify RFs, refer- consider debridement
vasc (angio/bypass) mobilization & regular turning irrigation x 15-20 mins then check pH, poison control
- Tetanus, consider topical Abx, pain control
States of Change
Precontemplation
- Not considering the possibility of change
- Raise doubt: help patient understand benefits
& costs of the unhealthy behaviour
Contemplation
- Seriously thinking about change, not ready to
take action, considers change & rejects it
- Tip the balance in favour of change, strengthen
patient self-efficacy to change
Preparation
- Getting ready to change
- Help the patient identify small, realistic
behavioural steps towards change
Action
- Actively engaged in a new healthier behaviour
- Support new behaviours, empathize difficulty
Maintenance
- Maintain new behaviour for several months
- Help use new skills to prevent relapse
SMOKING CESSATION
Management: nonpharmacologic
• Every smoker should be offered treatment
• Combination counselling & pharm most effective
• Make aware of withdrawal symptoms: low mood,
insomnia, irritability, anxiety, difficulty concentrating,
restlessness , increased appetite + weight gain in 4/5
patients (5-10lb)
• Withdrawal 2-3h after last cigarette, peak at 2-
3d, improvement 2-3w, highest relapse 2-3m
• 4+ counselling sessions >10 mins each with 6-12 month
follow-up yields better results
• Develop quit plan: STAR (set quit date, tell
family/friends, anticipate challenges, remove tobacco-
related products)
Pharmacologic Therapy
Nicotine Replacement Therapy
Motivational Interviewing
- 5Rs: relevance to patient, risks of smoking,
rewards of quitting, roadblocks to quitting,
repetition at each visit
Reduce to Quit
Step 1: (0-6w) target date for # cigarettes per day to cut down
(at least 50% recommended) and date to achieve this, use gum
to manage cravings
Step 2: (6-up to 6m) continue to cut down using gum, goal to
completely stop by 6m
Step 3: (within 9m) stops all cigarettes & continue using gum
for cravings
Step 4: (within 12m) cut down amount of gum used then stop
gum completed within 3m of stopping smoking

Relapse
- Return to old pattern of unhealthy behaviour
- Help avoid discouragement and demoralization

Specific Populations
Pregnancy: counselling is 1st line Rx in pregnancy &
breastfeeding, intermittent dosing NRT preferable
to continuous, encourage smoke-free home
Native Population: offer cessation with emphasis on
culturally appropriate methods

Hospital Inpatients: make aware of smoke-free Bupropion

policies, identify smokers on admission & provide
NRT, provide f/u support post- hospitalization
Comorbid Mental Health Conditions: screen all
patients for tobacco use, monitor mental health
while quitting & counsel on side effects, adjust
medications as necessary
Youth: screen at all visits, enquire about peer
pressure, cigarettes + vaping
- Inhibits re-uptake of dopamine and/or norepinephrine
- Side effects: insomnia, dry mouth
- Dosage: 150mg qAM x 3d, then 150mg BID x 7-12 weeks, consider maintenance up to 6 months, can use with NRT
- Prescribing: decide on a quit date, continue to smoke for first 1-2 weeks then completely stop (therapeutic within 1w)
Varenicline
- Partial nicotinic receptor agonist (↓cravings) & antagonist (↓response to smoked nicotine)
- Side effects: N/V, constipation, h/a, insomnia, vivid dreams, insomnia, increased risk psychosis/depression/suicidal ideation
- Dosage: 0.5mg qAM x 3d, then 0.5mg BID x 4d, continue 1mg BID x 12weeks +/- additional 12 w maintenance
- Prescribing: decide on quit date, continue to smoke for 1st week of treatment then stop completely, do not use with NRT
Approach to Somatic Complaints
- Consultation (psychiatry or CBT as appropriate)
- Assessment (evaluate for medical/psychiatric diseases
for all new sx)
- Regular visits (short-interval follow-up to avoid
overuse of medical care e.g. ED visits, urgent appts)
- Empathy (listen, acknowledge illness experience &
what they are feeling is real)
- Medical-psychiatric interface (emphasize the mind-
body connection)
- Do no harm (limit investigations, referrals, reassure)
Tips for Managing Somatization
• Avoid debating about whether the symptoms are
due to psychiatric or nonpsychiatric illness
• Avoid telling patients that they are blowing their
symptoms out of proportion
• Periodically reassess ongoing symptoms and
consider investigation of new symptoms as
appropriate
• Consider and discuss the possibility of somatoform
disorders early in the work-up if suspected
• Counsel that not all symptoms indicate evidence of a
pathological disease
• Encourage maintenance of interpersonal function
despite symptoms
• Identify key life stressors and sources of anxiety
• Consider co-morbid substance use/withdrawal as
well as primary mood/anxiety disorders
• Focus treatment on function, not symptoms, and
management- not cure
• e.g. symptoms are like a radio channel that is
fixed and cannot be changed, what you can do
is gain control over the volume knob and the
sensitivity of the antenna
• Communicate with specialists and patient re: need
for consistency and single cook in kitchen to avoid
'doctor shopping'
• Do not use diagnostic tests and specialty
consultations for the purpose of reassuring the
patient- negative findings rarely provide lasting
reassurance and there is risk of incidental findings
SOMATIZATION
Differential Diagnosis:
• General medical disorders (e.g. IBS, fibromyalgia), excessive thoughts/feelings/behaviours around
medical condition
• Adjustment disorder- symptoms related to distinct event or change in life situation
• Body dysmorphic disorder- perceived defect vs physical symptom
• Conversion disorder- neurologic sx incompatible with anatomy/physiology + la belle indifference
• Delusional disorder, somatic type- overvalued vs fixed false beliefs +/- bizarre features
• Depressive disorder- fatigue/anergy vs somatic sx, if sx occur exclusively during unipolar depression
then does not meet criteria for somatic symptom disorder
• Generalized anxiety disorder- generalized worries about multiple aspects of life vs health and
physical symptoms, vs specific phobias
• Illness anxiety disorder- minimal symptoms but excessive preoccupation
• Obsessive compulsive disorder- intrusive/unwanted thoughts with compensatory compulsions
• Panic disorder- intensive acute episodes (vs chronic course w/ somatic sx disorder)
DSM-V Diagnostic Criteria for Somatic Symptom Disorder
1. One or more somatic symptoms that cause distress or psychosocial impairment
2. Excessive thoughts, feelings, or behaviours associated with the somatic symptoms, as
demonstrated by one or more of the following:
• Persistent thoughts about the seriousness of the symptoms
• Persistent severe anxiety about the symptoms or one's general health
• The time and energy devoted to the symptoms or health concerns is excessive
3. Persistent (6+ months) although the specific somatic symptom may change
*Qualifiers with predominant pain, severity, and persistence
Treatment:
• Taper and discontinue unnecessary medications
• Cognitive behavioural therapy
• Mindfulness-based therapy
• Pharmacotherapy (amitriptyline, fluoxetine); avoid MAOI, bupropion, antiepileptics, antipsychotics
• St. John's wort (more effective than placebo, safe, well tolerated)
• Relaxation techniques, graded exercise
• Self-help guides and groups
• Complementary medicine:
• Allow measures from complementary medicine according to patient's wishes, explaining that
these measures may be temporarily helpful (e.g. placebo) but are less effective than self
management (e.g. acupuncture, naturopathy, biofeedback)
 Stress Reduction Strategies
Approach to Stress
STRESS
- Exercise, massage, meditation (mindfulness, guided imagery)
- Consider stress as a cause or contributing factor in patients with
- Control manageable issues, counselling/CBT
relevant sx (e.g. headache, fatigue, pain) - Encourage peer & social supports
- Assess impact of stress of functioning (e.g. coping vs not coping, - Breathing exercises, progressive muscle relaxation
stress vs distress)
- In those not coping with stress, r/o mood disorder Acute Stress
o Clarify & acknowledge contributing factors Physical Response
o Explore resources and possible solutions - Increased ACTH, epi + norepinephrine, glucocorticoids, & endorphins
o Assess supports & resources available to patient - Decreased insulin + reproductive hormones
- Increased cognition & memory
- Look for inappropriate coping mechanisms (e.g. drugs, alcohol,
- Decreased pain sensation
eating, violence)
- Increased mobilization of energy stores, tachycardiac, HTN, tachypnea
- R/o acute stress disorder (symptoms of PTSD with onset <4 weeks Emotional Response
from stressor and duration <4 weeks) - Denial (defense mechanism) & disbelief
- Shock
Stress: any demand on the body, mind, and spirit to perform, - Ander & fear
function is maintained & coping is adaptive - Anxiety, restlessness
- Confusion, forgetfulness
Distress: coping & adaptation processes fail to return patients to - Self-doubt
physiological/psychological baseline
Chronic Stress
Coping: behavioural response to reduce stress in non-detrimental Physical Response
way to maintain functioning - GI upset, sleep disturbance, headaches, lethargy, muscle + back pain
- Poor coping evident in social functioning, work, economic, - Decreased libido
family functioning, and/or maladaptive coping - Decreased immune response
- Maladaptive coping: EtOH, substance use, smoking, social - Increased risk of developing mood disorder (GAD, MDD)
withdrawal, violence - Increased serum cholesterol, hypertension
- Increased platelet aggregation, risk of cardiovascular events
- Coping strategies:
- Increased risk of DM related complications, metabolic syndrome
o Task oriented
Emotional Response
o Emotion oriented - Mental blocks, chronic fatigue
o Distraction oriented - Hopelessness, frustration, boredom, depression guilt
- Reduced feeling of empathy, anger, cynicism, pessimism
Comorbidities:
Behavioural Response
- Depression
- Mistakes or judgement error
- Psychoses - Impulsiveness, apathy
- Generalized anxiety disorder, panic disorder, phobias - Inappropriate or aggressive communication
- Substance use: EtOH, smoking, recreational drugs - Increased drug or alcohol use
- Eating disorders - Withdrawal, isolation
- Ander/violence - Difficulty maintaining healthy lifestyle (diet, exercise, sleep)
- PTSD - Disordered eating patterns
Stroke: sudden onset neuro deficits caused by infarction of brain
tissue (confirmed with neuroimaging)
TIA: sudden onset transient neuro deficits without infarction (no
evidence on neuroimaging)
Pathophysiology:
- Ischemic (80%)
o Thrombus: stenosis of artery causing insufficient
blood flow beyond lesion, usually due to
atherosclerosis
o Cardioembolic: blockage of blood flow due to clot
from cardiac source, usually due to AF
o Systemic hypoperfusion: due to cardiac arrest,
arrhythmia, MI
- Hemorrhagic (20%)
o Rupture of small microaneurysms (usually from HTN)
Risk Factors:
- Modifiable: HTN, DM, smoking, dyslipidemia, physical
inactivity & obesity, alcohol excess
- Non-modifiable: age >80y, ethnicity (black > white), male,
FHx, OSA, hypercoaguable state (e.g. antiphospholipid,
inherited thrombophilias- factor V leiden, protein C/S ↓)
Differential Diagnoses: (Stroke Mimics)
- Seizure: aura, convulsions, tongue biting, incontinence, post-
ictal state
- Migraine: gradual onset, h/a prominent, Hx migraines
- Transient global ischemia: pure amnesia, no focal deficits
- Syncope: sudden LOC with rapid recovery, +/- prodrome
- Hypoglycemia: generalized weakness, nausea, tremor,
confusion, Hx insulin use/DM
- Tumour: gradual onset of neurological sx
- Meningitis/encephalitis: fever, neck stiffness, altered LOC, h/a
- Subdural hematoma: head trauma, elderly, chronic EtOH use
Investigations:
- *Do not delay neuroimaging
- CBC, Cr, lytes, INR/PTT, ECG: r/o AF
- Non-urgent CXR + echo
- Imaging:
o <4.5h: potentially tPA → urgent noncontrast CT head
o <6h: potentially EVT → urgent non-contrast CT head
& CT angio
o 6-24h: potentially EVT in selected pts: urgent CT
head & CT angio, CT perfusion study
STROKE
Presentation:
- Sudden onset, maximal at onset
- Fitting distribution of vascular territory
- Severe headache
- Visual/speech disturbance
- Vertigo or loss of balance
- TIME = BRAIN (time of onset/last normal)
Exam:
- Vital signs
- Cardioresp exam, r/o AF
- Standardized neuro exam: e.g. NIHSS
o LOC questions/commands, best
gaze, visual fields, facial paresis,
motor upper limbs, motor lower
limbs, limb ataxia, sensory, best
language, dysarthria, extinction
& inattention
Stroke Syndrome by Vascular Territory
- ACA: contralateral leg paresis & sense loss
- MCA: contralateral weakness & sensory
loss of face/arm, cortical sensory loss, +/-
contralateral homonymous hemaniopia,
aphasia (L hemisphere), neglect (R
hemisphere), eye deviation towards side
of lesion/away from weak side
- PCA: contralateral hemionopia, midbrain
findings (CN III/IV palsy) sensory loss,
amnesia, ↓LOC, +/I hemiparesis
- Basilar: locked in syndrome, quadriparesis
+ dysarthria, impaired eye movements
- PICA: ipsilateral ataxia, Horner’s, facial
sensory loss, contralateral abn pain/temp,
vertigo, nystagmus, dysphagia/dysarthria
- Anterior spinal: contralateral impaired
vibration/proprioception, ipsilateral
tongue weakness
- Lacunar: pure motor hemiparesis
contralateral arm/leg/face, pure
hemisensory loss, ataxic hemiparesis,
dysarthria- clumsy hand syndrome
Management: (acute)
- ABCs: assess vitals, give O2 if necessary, IV fluids, cardiac monitor
-
→ manage glucose, electrolyte disturbances
Elevate head of bed
- Keep NPO until swallowing assessed
Antihypertensives:
- tPA: target BP <185/110 prior to tPA & <180/105 for at least 24h
after
- no tPA: only lower BP is >220/120, decrease by 15% in first 24h
(permissive hypertension)
Thrombolytics: IV tPA (alteplase)
- Inclusion criteria: ischemic stroke, age 18y+, <4.5h
- Exclusion criteria: CT shows hemorrhage, recent stroke or severe
head trauma within 3m, prior ICH, recent GI/GU hemorrhage
within 3w, recent LP, BP >185/110, elevated INR/PTT,
thrombocytopenia, acute bleeding diathesis, sx minor/improving,
seizure at onset, anticoagulation (unless on warfarin + INR <1.7)
Endovascular Therapy
- Ischemic stroke due to large artery occlusion in anterior
circulation, within 24h from onset, may also receive tPA
Antiplatelet:
- (if no tPA/ICH) ASA loading dose then dual antiplatelet initiated
within 24h onset x 3w → monotherapy indefinitely, if tPA delay
24h until no ICH on repeat CT
Hemorrhagic Stroke
- BP, control ICP, urgent neurosurg, poor prognosis (risk herniation)
Other Considerations:
- DVT prophylaxis, stroke rehab (MDT), prevent complications e.g.
aspiration pneumonia/pressure ulcers, SLP within 24h, home OT +
mobility aids
- Cognition (MoCA, MMSE) & mood (PHQ-9)
- Advanced care planning
Driver’s License:
- Report, no driving x 1m, may resume if no neuro deficit, no
obvious risk recurrence, underlying cause treated, no seizure,
driving eval, visual field study
TIA Management: ABCD2 score
- Age >60y, BP >140/90, clinic features (2 unilateral weakness, 1
speech) duration (2 >60min, 1 10-59m), DM
- ASA loading dose then 81mg daily, dual therapy if high risk x 21d
Secondary Prevention:
- Ix: BP, A1c, lipid, carotid dopplers, CT angio, echo, 48h holter
- Nonpharm: ↓Na, diet, healthy BMI, exercise, ↓smoking/EtOH
- Pharm: dual antiplatelet, high intensity statin, NOAC if AF or
CHADS ≥1, control DM → carotid endarterectomy if ipsilateral
stenosis 50% (urgent if 70% +) vs angioplasty & stenting
Substance Use
- Intoxication: reversible physiologic/behavioural
changes due to recent exposure to psychoactive
substance
- Withdrawal: substance-specific syndrome that
develops following cessation/reduction of regular
used substance
- Addiction: 4Cs- loss of Control, use despite
Consequences, Compulsion to use, Craving
Approach to Substance Use
- Screen high risk groups: mental health conditions,
chronic disability, high EtOH intake, THC use, any illicit
drug use, age <40y, PHM/FHx substance use disorder,
Hx crime/low SES/poverty
- Screening tools: AUDIT & AUDIT-C, CAGE, DAST-10,
ORT (opioids), screening to brief intervention (S2BI)
- IVDU: screen for hep B/C & HIV, vaccinations
- Adolescents: discuss with pts & caregivers routinely
and when warning signs present (e.g. school failure,
behaviour change)
- Family members: offer support
- Consider in patients not improving from medical
conditions e.g. alcohol-hyperlipidemia, inhalational
drug use- asthma
- Social implications: CAS involvement, driving
implications, crime + financial concerns, increased STI
Substance Use Disorder: DSM-V Criteria
- Maladaptive pattern of use leading to
impairment/distress
- ≥ 1 of the following over 12m, mild (2-3), moderate (4-
5), severe (6+)
o Mnemonic: COPED WITH IT
▪ Cravings for substance
▪ Obligations not fulfilled
▪ Physically hazardous
▪ Effect on interpersonal relationships
▪ Desire/unsuccessful quit attempts
▪ Withdrawal, use to avoid withdrawal
▪ Interests/activities given up
▪ Tolerance (↑ amount for effect)
▪ Harm (continues despite sx)
▪ Increase amount/duration
▪ Time (to procure, use, recover)
SUBSTANCE ABUSE
Alcoholism
- Intoxication: euphoria, psychomotor deficit, ataxia,
judgement ↓, slurred speech, N/V, confusion, resp ↓
o Rx: fluids +/- dextrose, thiamine 100mg IV x 1
then 100mg PO TID x 2 weeks, then once daily
- Withdrawal:
o <24h: tremors, anxiety, tachycardia, N/V,
hallucination (tactile, visual, auditory)
o 24-48h: seizures, >48h: delirium, tremor,
sympathetic ↑, hallucinations, ↑ESR/leuk/enz
- Rx: (acute) CIWA protocol, PRN diazepam 5-10mg
IV/10-20mg PO q1-2h or lorazepam 1-2mg PO TID-QID
- Rx: naltrexone, acamprosate, disulfram
Opiates
- E.g. Heroin, methadone, morphine, oxycodone
- Complications: risk of contaminated needles, acute
(pulmonary edema, respiratory failure), chronic (skin
infection, endocarditis, HIV, hepatitis)
- Intoxication: ↓ RR, ↓HR, ↓LOC/temp, pinpoint pupils
o Rx: naloxone 0.4-2mg IV/IM q2min, max 10mg
- Withdrawal:
o Hours after last use, peak 48-72h, subsides 1w
o Yawning, tears, diarrhea, cramping,rhinitis, N/V
o Treatment:
• Methadone (1mg/4mg of morphine or
start at 10-15mg methadone/day), CI if
pregnant/adolescent/poor compliance,
requires monitoring of QTc
• Suboxone- buprenorphine & naloxone (if
methadone CI or no access)
• Naltrexone: prevents intoxication once
abstinent through opioid receptor
blockade, 25-50mg qAM
• Clonidine (0.1-0.2 initially can be repeat
q1h up to 4x until sx resolve if BP/HR
stable, then maintenance q6-8h, taper)
Hallucinogens (PCP, LCD)
- PCP: muscle rigidity, seizures, rhabdomyolysis, coma
- Anticholinergics (Benadryl, dimenhydrinate)
o 'mad as a hatter, red as a beet, dry as a bone'
o Delirium, SVT, HTN, seizure, dysuria, dysphagia,
constipation, diplopia
Cannabis
- Screen: screen all patients for cannabis use (especially
patients with psychiatric disorder or substance abuse
disorder) and those with problems that could be
caused by cannabis (mood, psychosis, respiratory)
- Frequency, amount, tolerance, withdrawal, attempts
to decrease use, harm, school/work dysfunction
- Indicators for problematic use: daily use, anxiety,
unsuccessful attempts at quitting, hardships (medical,
financial, social), friends/family concerned
- Complications: anxiety, impaired executive function,
withdrawal (hypersomnia/insomnia, fatigue, anxiety,
depression, cravings), addiction (9%), schizophrenia
(OR 2.09), respiratory dz (2x risk lung ca), driving risk
- Management: counselling, goal of abstinence or
reduced use
o Strategies: record on calendar, purchase
smaller amounts, prepare smaller joints,
certain # of days without, avoid high risk
situation, other coping mechanism for stress
Cocaine (Sympathomimetic)
- Use: smoke, inhale, topically, injected
- Intoxication: ↑RR/HR, HTN, agitation, paranoia,
diaphoresis, elation, euphoria, psychosis
- Complications: MI, stroke, pulmonary edema,
rhabdomyolysis, seizure, ventricular arrhythmia
- Withdrawal: more psychologically addictive than
physically, increased sleep, fatigue, irritability
Amphetamines (Sympathomimetic)
- Intoxication: increase sympathetic nervous system
stimulation, ↑HR, HTN, anorexia, insomnia, seizure,
euphoria, improved concentration
- Complications: coma
- Withdrawal: mild- depression, increased appetite,
diarrhea, headache, abdo pain
Benzodiazepines
- Alprazolam has highest risk for misuse
- Measure use: Severity Dependence Scale
- Intoxication: no tx required
- Withdrawal: grand mal seizures, agitation,
restlessness, insomnia, tremors, hyperthermia
o delayed d-w if long acting (e.g. Diazepam)
o withdrawal with abrupt cessation if use ≥3w
o Treatment: benzo- taper rate depends on
starting dose, risk of relapse, and patient's
tolerance of tapers
Symptom Management Toxidromes
• Brief intervention --> teachable moment
• Pain: OTC analgesia, NSAIDs Intoxication HR BP RR Temp Pupils BS Diaphoresis Other Rx
• Diarrhea: imodium, lomotil
• Sneezing/tearing/rhinorrhea: H1 blocking antihistamine Sympathomimetics ↑ ↑ ↑ ↑ Dilated ↑ ↑ N/V, IV fluids, benzos
• Nausea/vomiting: ondansetron, promethazine • Epinephrine, hallucinations, Clonidine
• Tachycardia/HTN: clonidine cocaine, hyperreflexia,
• Anxiety/insomnia: H1 blocking antihistamine, benzo amphetamines, agitation, tremor,
MAOIs delirium
Toxidromes by Vital Signs

Bradycardia P Propranolol (B-blockers), poppies (opiates) Anticholinergic ↑ ↑ N ↑ Dilated ↓ ↓ Mad as a hatter, IV fluids, benzos
(paced) A Antiarrhythmics, anticholinesterase • Antipsychotics, red as a beet, Clonidine
C Calcium channel blocker, clonidine
TCAs, oxybutinin, blind as a bat, hot
E Ethanol
D Digoxin, digitalis
muscle relaxants, as a hare, dry as a
GI antispasmodics, bone
Tachycardia F Free base (or other cocaine) ipratropium
(fast) A Antipsychotics, amphetamines,
S anticholinergics, alcohol withdrawal Cholinergics ↓ N N N Pinpoint I I Diarrhea, emesis, Atropine
T Sympathomimetics • Ach receptor lacrimation, Airway
TCA, thyroid hormone, theophylline antagonist, salivation management
organophosphates
Hypothermia C Carbon monoxide
, nicotine
(cools) O Opioids
O Oral hypoglycemics and insulin
L Liquor (alcohol)
S Sedative (hypnotics)
Sedatives N N N N N ↓ N Nystagmus, ataxia, Elevate head of
• Benzo, decreased LOC bed, nasal/oral
Hyperthermia N Neuroleptic malignant syndrome, nicotine antihistamines, airway,
(NASA) A Alcohol withdrawal barbiturates, supplement O2,
S Salicylates, sympathomimetics, serotonin EtOH, GHB flumazenil if
A syndrome accidental
Anticholinergics, antidepressants,
antipsychotics Opioids ↓ ↓ ↓ ↓ Pinpoint ↓ ↓ Decreased LOC Naloxone,
Hypotension C Clonidine, calcium channel blocker
• Heroin, supplemental O2
(crash) R Rodenticides methadone
A Antidepressants, antihypertensives
S Sedative (hypnotics)
H Heroin (opiates) Cannabis ↑ ↑ N N Dilated N N Conjunctival Lorazepam,
engorgement, dry ondansetron
Hypertension C Cocaine mouth, altered
(CT scan) T Thyroid supplements sensorium,
S Sympathomimetics ↑appetite,
C Caffeine
euphoria,
A Anticholinergics, amphetamines
psychomotor
N Nicotine
impairment
Bradypnea S Sedative (hypnotics)
(slow) L Liquor (alcohol)
O Opioids
W Weed (marijuana)
Epidemiology: SAD PERSONS: 0-2 (low risk), 3-4 (monitor), 5-6 (consider
- 10th leading cause of death in North America hospitalization), ≥7 (hospitalize)
- Highest risk in males >65y SUICIDE -
-
S: sex (male)
A: age (35-44, 65+)
- 10-40 attempts per completion
- D: depression
Risk Factors - P: previous attempts
Medical Cancer, head injury, AIDS, dialysis, COPD, MS, quadriplegia, burns, CHF, chronic pain - E: ethanol abuse
Psychiatric Depression, anxiety, insomnia, cluster B personality disorders, psychotic Sx, PTSD, - R: rational thinking loss
comorbid substance use, higher risk in early psych diagnoses except alcoholism (late) - S: social support lacking
Meds SSRIs, gabapentin, lamotrigine, oxycarbamazepine, tramadol - O: organized plan
Social Living alone, recent loss/stressful life event, older men, Hx legal problems, Hx abuse, - N: no spouse (divorced/widowed/separated male or female,
Factors access to firearms, sexual minority single male)
Occupation Police/public safety workers, physicians, dentists, prisoners, unemployed - S: sickness (chronic/debilitating illness)
Warning Previous attempts, Hx self harm, family Hx suicide, suicidal ideation, substance use, Pediatric/Adolescent Suicidality
signs anger, recklessness, withdrawn, mood change, hopelessness, feeling trapped, - Completed 1/20, 2nd highest cause of death in Canadian adolescent
purposelessness - Hx: depression, substance use, conduct disorder, prior self-harm or
suicide attempts
Assessment
- Assess for impulsivity (physical aggression, risk taking behaviour)
- Screen: Columbia suicide severity rating scale and lack of social support
o 1. Have you wished you were dead or wished you could go to sleep and not wake up? - Precipitants: stressors + reactions, peers, bullying, relationships,
o 2. Have you actually had any thoughts of killing yourself? abuse, family conflict
o 3. Have you been thinking about how you might kill yourself?* - Assess as in adults (ideation, plan, intent/behaviour)
o 4. Have you had these thoughts and had some intention of acting on them?*
Forms:
o 5. Have you started to work out or worked out the details of how to kill yourself? Do you - 1: detention 72h to allow assessment by psych, if at risk of harm to
intend to carry out this plan?* self/other/self-neglect
o 6. Have you ever done anything, started to do anything, or prepared to do anything to end - 42: notice to pt of Form 1
your life? How long ago did you do any of these? - 2: order for examination based on info from member for the public
- Ideation: content, frequency, duration, change, intensity, passive vs active, protective factors if at risk to self/other/self-neglect, valid for 7d & allow police to
- Plan: specific, accessibility, lethality, likelihood of completion, preparing, final arrangements bring to appropriate assessment
- Intent/behaviour: past attempts (trigger, lethality, intoxication, feelings about survival), rehearsal, - 3: certification of involuntary admission (by psych), valid 14d, form
impulsivity, social support, explore ambivalence (e.g. reasons to die vs live) 4 is renewal 1-3m, form 30 is notification to pt
Mental Status Examination: Management Non-Suicidal Self Injury
- Appearance: signs of prev attempts - Moderate/low risk: contract for safety - ↑ risk suicide, associated with depression, borderline PD, substance use,
- Affect: flat (poor evidence), aggressively treat developmental disorder, eating disorders, GAD, PTSD
- Speech: withdrawn, impulsive underlying pscyh illness, avoid drugs with - Usually begins age 13-15y, 14-21% adolescents once
overdose potential (e.g. TCA, lithium), - DSM for NSSI:
- Thoughts: command safety plan & organize close f/u o ≥5/y, expects to solve problem/provide relief, experiences negative
hallucinations/delusions, obsession thoughts before NSSI + preoccupied, NOT socially sanctioned, clinically
significant distress across different domains, not with
with death, homicidal ideation - High risk: hospitalize + form if necessary,
delirium/psychosis/substance use
do not leave alone, remove dangerous
- Assess functional state + suicide risk
- Cognition: disoriented objects, ensure safety of minors, collateral
- Rx: treat underlying psych disorder (depression, personality disorder, etc.), coping
- Judgement: impaired, poor insight Hx, crisis team + social worker involvement
skills, DBT
Thyroid Hormone Production Risk Factors of Thyroid Cancer
- Male gender, extremes of age, <20y or >60y
THYROID - Rapid growth of thyroid nodule
- Sx of local invasion: dysphagia, anterior neck
Etiology pain, hoarseness
- 1⁰ hypo: chronic autoimmune thyroiditis (Hashimoto’s), - Hx radiation to the neck
transient causes (postpartum thyroiditis, subtotal - Family Hx thyroid ca or polyposis (Gardner’s)
thyroidectomy, post-treatment for Graves, subacute Additional Investigations:
thyroiditis), medications, iatrogenic Antithyroid Antibodies: not in routine assessment
Thyroid Testing
- 2⁰ hypo (pituitary/hypothalamic) - Anti-TPO: used to predict likelihood of
- No routine screening for asymptomatic adults
- 1⁰ hyper: autoimmune (Graves, rarely Hashimoto’s), toxic progression to permanent hypothyroidism in
- Consider testing in those with risk factors or
multinodular goitre, toxic adenoma, exogenous, subclinical/pregnant patients
suggestive signs & symptoms
postpartum, neoplastic, drug induced - TRAb: confirm Graves disease, alternative to
- Normal TSH 0.3-5.5mU/L
- 2⁰ pituitary, gestational (w/ hyperemesis), trophoblastic radioiodine uptake, assess for remission
Risk Factors for Thyroid Disease - Anti-Tg Ab: used to detect residual cancers
- Hx autoimmune disease e.g. T1DM, endo disorders Initial Investigations: Thyroid US: if physical exam suggests nodularity
- Hx neck radiation -TSH initial screen, free T4 to determine degree of hypo, free Thyroid uptake scan: differentiate causes of hyper
- Drug therapies (lithium, amiodarone), Hx AF T3& T4 to determine degree of hyper
Management:
- Family Hx thyroid disease - Normal HPA function:
Hypothyroidism:
- Women >50y, elderly patients Serum Serum Serum Assessment - Levothyroxine (T4), start at 50mcg & increase
- Postpartum women up to 6 months TSH free T4 free T3 incrementally based on TSH (q6-8 weeks),
N N N Euthyroid 25mcg in children/elderly
Clinical Presentation
Hyperthyroidism:
Hypothyroidism (↓) Hyperthyroidism (↑) N N/↑ N/↑ Euthyroid hyperthyroixinemia - PTU: start at 100mg TID, ↑ for thyrotoxicosis
- Methimazole: start at 15-60mg divided TID for
Weight gain Weight loss N N/↓ N/↓ Euthyroid hypothyroxinemia
4-6w, reduce once T3/4 N, avoid in T1 preg
Constipation Diarrhea N ↓ N/↑ Euthyroid: triiodothyronine - RAI: 1x pill, radioactive precautions x 1w, hypo
therapy in long-term, avoid pregnancy 6-12 m after
Hair loss Hair loss - Thyroidectomy: curative, life-long T4
N N/↓ N/↑ Euthyroid: thyroid extract replacement, rarely hypoparathyroidism &
Dry skin Diaphoresis, clammy skin therapy recurrent laryngeal nerve damage
Cold intolerance Heat intolerance ↑ ↓ N/↓ Primary hypothyroidism - B-blocker: symptomatic, atenolol 25-50mg OD
or propranolol 20-40mg BID
Bradycardia, diastolic Palpitations, tachycardia, AF, ↑ N N Subclinical hypothyroidism Monitoring
HTN HTN, widened pulse pressure
- Q6-8w after dose changes, change in Sx
↓ N/↑ ↑ Hyperthyroidism
Lethargy Proximal muscle weakness - Annually once stable or in subclinical
↓ N N Subclinical hyperthyroidism
Depression Nervousness, tremor, anxiety Pregnancy:
-Abnormal HPA function: - Maternal hypothyroidism- altered neonatal
Goiter Goiter neuro development, lower IQ
N/↑ ↑ ↑ TSH-mediated - TSH: T1 0.5-2.5mU/L, T2/3 0.5-3.0mU/L
Menstrual Menstrual irregularities hyperthyroidism
irregularities (amenorrhea, oligomenorrhea) - Levothyroxine requirements ↑
(menorrhagia) N/↓ ↓/N ↓/N Central hypothyroidism - Screen for postpartum thyroiditis at 3 & 6
months in women with +ve anti-TPO
Approach To Trauma Patients
Pre-arrival preparation: universal precautions + team
1. Primary Survey
- Airway
o Maintain patency & cervical spine protection
o Obstruction: noisy breathing, hoarseness
o Management: jaw thrust/chin lift, suction, OP/NP
airway or LMA, definitive airway with ETT/surgical
o Pre-intubation assessment: LEMON (look at injuries,
evaluate 3-3-2, mallampati, obesity, neck mobility)
- Breathing
o Ventilation + maintain adequate oxygenation,
look/listen/feel → bag valve mask
o Portable x-ray
- Circulation
o Control hemorrhage + maintain adequate end-
organ perfusion
o Fluid resus IV crystalloids + transfuse
o FAST/E-FAST, delay until 2⁰ if stable
o ECG: tamponade, MI, arrhythmias
- Disability
o Basic neuro: GCS, pupils, temp, glucose
- Exposure
o Undress + search for possible injury,*frequently
missed axilla/perineum/abdo folds, gluteal
fold/posterior scalp
o Identify + treat hypothermia
o Do not move unstable pts for Rx/investigations
2. Secondary Survey
- Detailed Hx + head-to-toe exam once stable
- Hx: mechanism, meds, medical/surgical Hx, including risk
for domestic abuse, suicide
- Exam:
o Head + face: basilar skull #, pupils + EOM,
Canadian CT head rules
o Neck: Canadian c-spine rules + imaging
o Chest: inspect/palpate/auscultate, NEXUS
o Abdo: *flanks, peritonitic signs, FAST
o Rectum/GU: *perineum, DRE/pelvic exam
o MSK: 4 limbs, compartment syndrome
o Pelvis: instability, ring disruption on x-ray
o Neuro: serial exams, GCS, sensorimotor
o Skin: lacerations, ecchymosis, hematoma,
tetanus prophylaxis
TRAUMA
Life-Threatening Complications
Flail Chest
- >2-3 rib # in 2 place, free floating segment
- Rx: analgesia, O2, +/- PPV or intubation + vent
Hemothorax
- Blood in pleural space, usually identified on
CXR/US
- Rx: chest tube insertion, thoracotomy if
>1500mL or initial drainage >250mL/h x 4h
Pneumothorax
- Air between visceral/parietal pleura, tension-
mediastinal shift to opposite side & ↓BP
- Rx: Decompression (2nd IC space midclavicular)
→ chest tube (5th IC space midaxillary line)
Cardiac Tamponade
- Blood in pericardial space restricting filling, ↓
venous return leads to hypotension
- Beck’s triad: ↓BP, muffled HS, ↑JVP
- Pulses paradoxus- accentuated drop in sBP on
inspiration
- Identified on bedside US
- Rx: pericardiocentesis, emergent thoracotomy
or sternotomy in ER if low BP
Spinal Cord Injuries
- Complete (no motor/sensory function below
level of injury + hyperactive reflexes) vs
incomplete (some motor function, may
improve over time)
- Avoid hyperglycemia/hyperthermia
- Complications:
o Resp if C3/4/5 affected
o Hypotension or autonomic
dysreflexia
o DVT & decubitus ulcers from
immobilization
o Gastric atony + ileus
Shock
Classification: SSHOCK (spinal, septic, hypovolemic,
obstructive, cardiogenic, anaphylaktic)
Initial management: BUFALO (blood cultures, urine output,
fluids, antibiotics, lactate, oxygen)
Septic:
- SIRS: 2+ of: T >38/<36, HR >90, RR >20, WBC >12 or <4
- Sepsis: SIRS + source of infection
- Severe sepsis: sepsis with one of: lactic acidosis, sBP
<90 or drop >40 from normal
- Septic shock: severe sepsis w/ ↓BP despite fluid resus
Hemorrhagic:
- Check chest, retroperitoneum, pelvic, long bones
- Hypovolemic: GI, skin losses, 3rd spacing
- Rx: control blood loss, fluids resus 20mL/kg/h, consider
transfusion if active bleeding
Obstructive:
- PE, pulm HTN, pneumo, cardiac tamponade
Cardiogenic: treat underlying cause
Anaphylaktic:
- Epinephrine 0.3-0.5mg IM (1:1000) → steroids,
antihistamines
PECARN: Pediatric Head Trauma CT Decision Guide
Child 2y+
- Any of: GCS <15, signs of basilar skull #, altered mental
status (agitation, somnolence, slow response,
repetitive questions) → CT
- Any of: vomiting, LOC, severe headache, severe
mechanism (fall <5ft, MVA w/ ejection/rollover/
fatality, bike or pedestrian accident w/ vehicle w/o
helmet, struck by high impact object → observation vs
CT using shared decision-making
- None of above → CT not indicated, observe
Child <2y
- Any of: GCS <15, palpable skull #, altered mental
status (agitation, somnolence, slow response,
repetitive questions) → CT
- Any of: scalp hematoma (excluding frontal), LOC >5s,
not acting normally per parent, severe mechanism (fall
>3ft, MVA w/ ejection/rollover/ fataligy, bike or
pedestrian accident w/ vehicle w/o helmet, struck by
high impact object → observation vs CT using shared
decision-making
- None of above → CT not indicated, observe
Canadian CT Head Rules: Patient Transfer
• Limited resource hospitals should contact trauma center if pt beyond
CT head is only required for patients with minor head injury with one of the following: their capacity
- High risk (for neurological intervention) • Should be stabilized as well as possible without delaying transfer
1. GCS <15 at 2h after injury • Complete workup not required
2. Suspected open or depressed skull # • CT should only be obtained if possible to treat at initial facility, if
3. Any sign of basal skull # transfer required regardless of imaging result- transfer should not be
4. Vomiting ≥2 episodes delayed
• Communication between transferring and receiving physicians:
5. Age ≥65y
identifying info, relevant medical Hx, prehospital course, ED evaluation
- Medium risk (for brain injury on CT) and treatment
6. Amnesia before impact ≥30min • Use transfer checklist
7. Dangerous mechanism (pedestrian, occupant ejected, fall from elevation)
Hypothermia
*Signs of basal skull # - Body temp <35⁰C
- hemotympanum, ‘racoon eyes’, CXF otorrhea/rhinorrhea, Battle’s sign - Sx: ↑HR/RR, ataxia → ↓HR/RR & CO, CNS depression, loss of shivering →
*Dangerous mechanism pulm edema, areflexia, ↓BP/HR, arrhythmias VF, asystole)
- pedestrian struck by vehicle - Investigations: glucose, ECG, CBC, lytes + extended lytes, Cr, lactate,
- occupant ejected from motor vehicle fibrinogen (DIC), CK, ABG, consider tox screen, CXR
- fall from elevation ≥3 feet or 5 stairs
Management:
Rule not applicable if: - ABCs
- Warmed crystalloids
- Non-trauma cases
- Rewarming (remove wet clothing, warmed blanked)
- GCS <13
- Warmed O2/fluids/bladder irrigation)
- Age <16y
- Manage arrhythmias as per ACLS- defibrillation rarely successful <30C (not
- Coumadin or bleeding disorder
dead until warm & dead)
- Obvious open skull #
Pediatric Non-Accidental Injury
Always consider, esp pediatric # or ecchymosis if:
• Mechanism does not fit injury
• Delayed presentation in seeking medical attention, multiple presentations for trauma/fractures
• History is vague or lacking details, history changes in repeated versions/conflicting histories are given by different family members
• Hx inconsistent with developmental stage of child
- O/E: appearance/hygiene, interaction w/ parent e.g. inappropriate lack of concern, skin lesions, retinal hemorrhages, trauma to genitals/mouth, signs of neglect
*Suspicious findings
- Pattern injuries: slap/belt shaped bruise, burns- cigarette, iron, spatula, immersion
- Multiple fractures in various stages of healing or different types of injuries
- Bruises of trunk/ear/neck or bruises in infants not crawling, # if can’t walk
- Rib # < 1y
- Subdural hematoma < 1y
- Injury to the genitalia
Ix: document all injuries +/- medical photography, r/o thrombocytopenia/coagulopathy, screen for abdo trauma with AST/ALT+ amylase → CT, skeletal survey, neuroimaging,
consider r/o STI + pregnancy
Rx: mandatory reporting (CAS), +/- admission, close f/u
Travel Medicine Info: CDC Traveler’s health website Travelling with Chronic Disease
- Advise patients to seek medical care at least 4-6w prior - Pacl extra supply meds- in carry on luggage
- Look up specific destinations for vaccines & advice
TRAVEL MEDICINE -
-
Keep meds in original bottles w/ copies of prescriptions
Keep a list of your PMHx/medications and doses
Vaccinations: Common Traveler’s Vaccines: Travel Hx: - Bring PRN meds (puffers, nitro, steroids, Abx, NSAIDs)
- If on warfarin, consider switch to DOAC/LMWH or portable
- Hepatitis A: (fecal-oral transmission) - Who (PMH, companions)
INR machine and phone HCP to adjust
o Fever, N/V, abdo pain, jaundice, dark urine, acholic stools - Where (destination, environment)
- Notify airline in advance if O2/other equipment required
o IM vaccine (0, 6, 12m) → 95% immunity with 1 dose st
- When (departure date, duration) - Set an alarm on phone re: dosing schedule and time zone
- Hepatitis B: (sex, blood, vertical transmission) - Why (purpose) difference for meds (e.g. warfarin, OCP, insulin)
o Risk of chronic infection, fulminant hepatitis, cirrhosis, HCC - What (water, food, bites, sexual activity) - Make sure you have travel insurance (cancellation vs health
o IM vaccines (0, 1, 6m) vs (0, 7, 21d + 1y booster) - How (nature & style of travel) vs medical evacuation)
st
60% immunity with 1 dose - Bring a buddy!
Pertinent Routine Vaccines -
- Yellow fever: (mosquito, South America, Sub-Saharan Africa) Fever in the Returning Traveller
- Td q10y
o Viral hemorrhagic fever, N/V, joint pain → hepatic/renal - <10d: dengue, chikungunya, zika, ticks, traveller's diarrhea
- MMR booster if only 1 in childhood
failure, coagulopathy, shock - >21d: malaria, HIV, TB, viral hepatitis
- Hep B if not received
o IM dose x 1 (>10d before travel +/- booster after 10y) Malaria
- Pertussis booster • Mosquito borne, fever/chills, cough, h/a, abdo pain
- Meningococcus: (meningitis belt of Africa)
- Polio if note received • Ix: malaria thick & thin films, CBC, LDH, LFTs
o Headache, photophobia, fever, nuchal rigidity, LOC
• Rx: chloroquine, malarone, IV artesunate
o Men-ACYW w/ routine schedule +/- booster q3-5y if high risk
Dengue
- Typhoid: (fecal-oral transmission, ‘enteric fever’)
• Mosquito borne, short onset & duration, fever, headache,
o Fever, abdo pain, rose spots, hepatosplenomegaly, GI bleed +/- perforation/bacteremia myalgia, maculopapular rash
o Oral vaccines (live) d1, 3, 5, 7- abstain from Abx within 72h, repeat q5y • Ix: PCR vs IgM and IgG depending on time course
o Polysaccharide IM vaccine: single dose +/- booster in 3y • Rx: supportive, no NSAIDs- capillary fragility
- Japanese encephalitis: (mosquito transmission, Asia) Chikungunya
o Acute encephalitis • Mosquito, fever, h/a, myalgia, arthralgia, conjunctivitis
o IM vaccine (-, 7-28d) at least 1 week prior to travel +/- 1 year booster with ongoing risk • Ix: PCR vs IgM and IgG depending on time course
- Rabies: (transmission through animal bites) • Rx: NSAIDs, arthralgia may persist for years
Zika
o Encephalopathy & death
• Mosquito borne, fever, arthralgia, conjunctivitis, pruritus,
▪ IM vaccine (0, 7, 21-28d) for pre-exposure, 2 boosters/3 days for post-exposure rash --> microcephaly +/- developmental problems in
▪ Otherwise requires Ig serum which may not be available infants born to affected mothers
- Malaria prophylaxis: (mosquito transmission) • Ix: PCR vs IgM depending on time course
o Fever, fatigue, myalgias, headache • Rx: supportive, prev: avoid travel if pregnant, avoid
o Malarone (atovaquone & proguanil) 1 tab 250/100mg PO daily, start 2d before until 7d after return conception 3m (M) vs 2m (W) post exposure
o Doxycycline 100mg PO daily, start 2d before travel & continue 4 weeks after return from endemic area Salmonella typhi (typhoid)
• Fever, headache, cough, constipation/diarrhea
Pre-Travel Counselling: Non-Infectious Concerns • Ix: CBC, LFTs, blood/stool culture, +/- marrow biopsy
- Boil it, cook it, peel it, or forget it! • Rx: fluoroquinolone, azithromycin
- MVCs: high rate of tourist death than all infectious disease combined, driving at night Traveller's Diarrhea
- Safe sex, higher rates of HIV, hep B, hep C, penicillin-resistant gonorrhea • SECS (salmonella, E. coli, campylobacter, Shigella),
- Insect bites: 30% DEET vs lemon/picardin/lemon eucalyptus, protective clothing, mosquito nets rotavirus, norovirus
- Sun exposure: SPF 30+, apply 15mins before exposure and q2h, protective clothing, shade • Dukoral not recommended (only covers cholera)
- Motion: scopolamine 1mg patch q72h, apply 4-12h before exposure • Ix: stool C&S, O&P if severe sx >2, colonoscopy if persistent
- Altitude sickness: prophylaxis indicated if Hx intolerance or rapid ascent above 2500m- acetazolamide 250mg PO BID, IBS >6w
start 2-3d prior to strenuous activity • Rx: initiate oral rehydration therapy, mild- loperamide 4mg
o High altitude cerebral edema: often over 3-3.5km, descent ASAP, supplemental O2 + dexamethasone x 1 then 2mg PRN (max 16mg/d), prophylactic bismuth →
mod loperamide + Abx → no loperamide, Abx immediately
o Others: alcohol, dehydration, safe travel for women, jet lag, DVT, register travel at http://travel.gc.ca

Pharyngitis
- Viral 80-90% adults & 50-70% children, more likely
if multiple systems involved
- Bacterial: group A strep most common
Modified Centor Score
Criteria: absence of cough, swollen tender anterior
cervical nodes, temperature > 38⁰C, tonsillar exudate or
swelling
- Age: 3-14y (1), 15-44y (0), 45y + (-1)
Interpretation
- 0: risk of GABHS 1-2.5%, no further Ix/Abx
- 1: risk of GABHS 5-10%, optional RADT/C&S
- 2: risk of GABHS 11-17%, RADT/C&S
- 3: risk of GABHS 28-35%, RADT/C&S
- 4+: risk of GABHS 51-53%, RADT/C&S, empiric Abx
Treatment:
- Analgesia + antipyretics
- Reasonable to delay Abx until culture results as self
limited (8-10d), may prevent relapse, Abx <9d
prevents rheumatic fever
- Abx (GABHS): penicillin, cephalexin, clinda if allergic
- No improvement in 72h: Abx noncompliance,
concurrent viral infection, suppurative
complications (sinusitis, retropharyngeal/
peritonsillar abscess)
Sinusitis
- Purulent nasal drainage + obstruction, facial
pain/pressure/fullness
- Viral (98%), bacterial likely if: >10d, worsening Sx
within 5-7d after initial improvement, paeds: fever
>39 x 3d & purulent nasal discharge/facial pain
- O/E: assess for mucopurulent discharge, co-existing
allergic sinusitis (edema, polyps), FB in children
- Red flags: black necrotic tissue (mucormycosis),
altered mental status/meningeal signs, ↓ visual
acuity/orbital edema/painful EOM (orbital cellulitis)
- Rx: supportive (analgesia, antipyretic, nasal
irrigation, ↓allergens, ↓tobacco exposure)
o See PODS criteria for Abx indications
o Acute (<4w & <3x/year)- amoxicillin 7d or
doxy/clinda if pen allergic
o Chronic (>12w or 4+/year)- amoxicillin 3w
or doxy/clinda if pen allergic, ENT referral
Upper Respiratory
Otitis Media
- Majority <6y, spont resolution 80-90%
- RF: viral URTI, environmental smoke
Tract Infection exposure, daycare, pacifier/bottle in supine
position, orofacial abnormalities
o Breastfeeding to 6m ?protective
Red Flags for Pharyngitis
Red Flag Diagnoses to Rule Out - Presentation: otalgia, ↓ hearing, irritability,
fever, poor feeding, URTI Sx
Drooling Epiglottitis, retropharyngeal or
peritonsillar abscess - O/E: loss of landmarks on otoscopy, bulging
TM + poor mobility, purulent canal (rupture)
Hx suspicious of FB Foreign body
- Rx: antipyretics + analgesia
Acutely unwell/toxic Epiglottitis, retropharyngeal abscess,
o Consider Abx if mod/severe pain
diphtheria, sublingual abscess
with fever >39/ bilateral/ systemic
Pain out of proportion to Epiglottitis, peritonsillar abscess
findings features, severe inf (e.g. perf), no
Unilaterally enlarged Peritonsillar abscess resolution in 2-3 days, Sx worsen
tonsil or uvular deviation o Amoxicillin/amoxiclav +/- ciprodex
Unvaccinated, thick Diphtheria (if TM perf or ventilation tubes)
gray/white pharyngeal
OME: fluid in middle ear w/o Sx of AOM- no ABX,
membrane
f/u in 1 month, ENT if hearing ↓
Oral lesion Coxsackie, herpes, SJS, Bechet’s,
Kawasaki’s, periodic fever w/ aphthous Complications: meningitis, mastoiditis, vertigo,
stomatitis hearing ↓- speech abnormalities, facial paralysis
Adenopathy & EBV (infectious mononucleosis)
splenomegaly Otitis Externa
- Presentation: otalgia, otorrhea*, aural
PODS Criteria
fullness +/- hearing loss, pruritus, pain with
stretching of pinna
o r/o otomycosis (5-10%), psoriasis
- Avoid flushing/curette, hydrogen peroxide to
soften debris or low suction
- Rx: (prev) remove moisture after swimming,
avoid q-tips, (pharm) buro-sol, cortisporin,
ciprodex- especially if TM defect
o Clotrimazole/ ketoderm if fungal
o Consider systemic Rx if
immunocompromised, immediate
ENT if suspicious of necrotizing
Influenza
- Seasonal epidemic influenza Dec-March
- Sx: fever, myalgias, arthralgia, h/a, fatigue ,
cough, SOB → clinical diagnosis + NP swab
- Rx: supportive esp severe/elderly, Tamiflu
within 48h, later if ↓ immunity/critically ill
*NP cultures not recommended, imaging only if chronic/ complications - Prev: vaccine q1y, start at 6m (x 2 q4w 1sty)
Acute Uncomplication Cystitis: women with classic
symptoms, no anatomic abnormalities, not
immunocompromised
Acute Complication Cystitis
- Upper tract symptoms
- Systemic symptoms
- All men
- Any anatomic abnormality
- Chronic indwelling catheter
- Immunocompromised
High Risk Patients: pregnancy, neonates, young males,
elderly males (e.g. BPH), immunocompromised
Asymptomatic Bacteriuria: bacteriuria with or without
pyuria in absence of symptoms, does not warrant
treatment unless pregnancy or undergoing urologic
procedure
Recurrent UTI: 2 uncomplicated UTIs within 6 months, or
3+ positive urine culture in 12 months
- Causes: post-coital UTI, atrophic vaginitis, urinary
retention
Reinfection: occurs after 2 weeks of completing
antimicrobial therapy, caused by a different organism
Relapse: occurs within 2 weeks of completing
antimicrobial therapy, caused by original organism
Micro: most commonly ‘KEEPPSS’ organisms: klebsiella, e.
coli, enterococcus, pseudomonas, proteus, staph
saprophyticus, serratia
Complications: sepsis, pyelonephritis, urinary retention,
impacted infected stones
Clinical Presentation:
- Dysuria, frequency, urgency, hematuria
- Abdo pain, suprapubic pain, flank pain
- Nausea/vomiting
- Fever/chills
- In women- vaginal symptoms: pruritus, change in
vaginal discharge
- Nonspecific sx: abdo pain, fever, delirium/ confusion-
more common in elderly & children
Treatment
Acute Simple Cystitis
URINARY TRACT - McIssac Criteria: 2+ of dysuria, leukocytes, nitrites=
empiric Abx prior to culture results
- TMP/SMX 1DS tab BID x 3d
INFECTION -
-
Macrobid 100mg BID x 5d
Fosfomycin 1 dose 3g dissolved in 1/2 cup of water
Differential:
Acute Complicated Cystitis & Pyelonephritis
- STI: e.g. chlamydia/gonorrhea, vaginal discharge,
- TMP/SMX 1 DS tab BID
pruritus, odour, high risk sexual Hx or multiple
- Ciprofloxacin 500mg BID
partners, dysuria +/- frequency and urgency
- Levofloxacin 500g OD
- PID: lower abdominal/pelvic pain and fever,
- 2nd line: amoxiclav 875mg BID
mucopurulent endocervical discharge, dyspareunia
- If lower tract sx only: treat 7-10d
- Vaginitis: vaginal discharge, odour, pruritus,
- If upper tract sx or systemic sx: treat 10-14d
dyspareunia, absence of frequency/urgency
- Urethritis: sexually active women with dysuria and NO
Considerations:
bacteriuria, should investigate for STIs/vaginitis &
- Macrobid NOT to be used in upper tract symptoms
noninfectious irritants
- Ciprofloxacin is active against pseudomonas
- Stones: severe flank pain occurring in waves, dysuria,
hematuria, vomiting, +/- fever if septic stones
Admission to Hospital:
- Prostatitis: recurrent or accompanied by
- Sepsis, severe illness
pelvic/perineal pain or fever, obstructive symptoms
- Hemodynamically unstable persistently high fever or
(dribbling, hesitancy), edematous tender prostate
pain despite treatment
- Inability to maintain oral hydration/medications
Investigations:
- No routine urinalysis in elderly/debilitated pts with
IV Antibiotics
nonspecific mental/function change only (colonized)
- IV ampicilllin 1-2g q6h PLUS IV gentamicin 4mg/kg q24h
- U/A: atypical sx in women, all men
o Dipstick: + leks (>trace) or nitrites (any), Asymptomatic Bacteriuria:
- Treat only during pregnancy & pre-op GU procedures
hematuria suggestive
o Microscopy: pyuria, bacteriuria - Amoxicillin 500mg TID
- TMP/SMX 1 DS tab BID
- Urine culture
- Macrobid 100mg BID
o Predictable pathogens- not necessary in F
Pediatric UTI
o Obtain if: male, RF for antimicrobial
- Suspect in infants <36 months with fever w/o source
resistance, at risk for serious infection
- Collect U/A clean catch, if unable- catheter/suprapubic
▪ RF for Abx resistance: MDR gram
- Mid-stream urine sample if toilet-trained
neg, inpatient stay (hospital, LTC),
- Urine with low colony counts, mixed growth, and no
recent fluoroquinolone, TMP/SMX,
pyuria are usually contaminated
broad spectrum B-lactam, travel to
- Febrile UTIs should be treated for 7-10d
high MDR area
- Children <2y should be investigated after 1st febrile UTI
• RF for serious infections: anatomic with renal & bladder US to identify significant renal
abn, immunocompromised, poorly
abnormalities and grade IV/V vesicoureteric reflux
controlled DM o Also US all males & recurrent UTI in females
- Abdo/pelvic ultrasound: men with recurrent cystitis
- Children w/ grade IV/V VUR or significantly abnormal
(BPH), all boys & young recurrent girl (PUV)
US should be discussed with a paeds uro/nephro
- CT abdomen, blood cultures → severe illness, sepsis
(to r/o obstruction, calculus, perinephric abscess)
Approach to Vaginal Bleeding:
- In any woman with vaginal bleeding r/o pregnancy
- Assess & treat for hemodynamic instability
o Once stable, consider medical vs surgical
treatment for significant bleeding
- Consider worrisome causes relevant in pregnancy:
ectopic, abruption, abortion
o Include assessment of Rh status and give Rh
immunoglobulin if required
- Consider worrisome causes in non-pregnant
patients: e.g. cancer, especially in postmenopausal
women with vaginal bleeding
Abnormal Uterine Bleeding: any variation from normal
menstrual cycle: regularity, frequency, duration of flow,
amount of blood loss
- Normal parameters: duration of bleeding 3-8d,
frequency q24-35d
Menorrhagia: >80mL, changing soaked pad >1/h,
changing overnight, leaking through, postural ↓BP
Amenorrhea: →
Oligomenorrhea: menses at intervals >35d
History:
- Bleeding Hx: normal cycles, post-coital bleeding,
intermenstrual bleeding, dysmenorrhea,
premenstrual sx, anemia sx
- Associated sx: vag discharge, odour, pelvic pain
- Sexual/reproductive Hx: STIs, GTPAL, paps, activity
- Systemic sx: to assess for coagulation disorders,
hypothyroidism, hyperprolactinemia, PCOS
- FHx (cancers, coag disease, menstrual dz)
- PMH (VTE, CVD, hormone dependent tumours)
- Meds: anticoagulation, OCP, tamoxifen
Exam: vitals (hemodynamic instability) **B-hCG
- Weight, BMI
- Skin (pallor, bruising, hirsutism, striae, petechiae)
- Thyroid exam
- Abdo exam (mass, hepatosplenomegaly)
- Gyne: inspection, bimanual exam, consider rectal
exam, pap if indicated, consider cervical culture +
vaginal cultures if indicated or STI risk factors
VAGINAL BLEEDING
Amenorrhea
1⁰- no menses by age 13y in absence of sexual characteristics, or by age 15y if secondary sexual characteristics present (2y
after thelarche)
- With normal 2⁰ sexual development:
o Normal: hypothyroidism, hyperprolactinemia, PCOS, hypothalamic dysfunction
o Normal breast, abnormal uterine development: androgen insensitivity, anatomic (Mullerian agenesis,
uterovaginal septum, imperforate hymen)
- Without 2⁰ sexual development:
o ↑FSH: gonadal dysgenesis (Turner’s- XO, vs normal sex chromosome)
o ↓FSH: constitutional delay (most common), congenital abnormalities (isolated GnRH ↓, pituitary
failure/adenoma), acquired (endocrine disorders e.g. T1DM, pituitary tumours, systemic disorders)
2⁰- no menses for >6m (irregular cycles) or >3m (regular cycles) at least 3 cycles after documented menarche
- Pregnancy until proven otherwise, functional hypothalamic amenorrhea 2 nd most common cause
- With hyperandrogenism:
o PCOS, autonomous hyperandrogenism (independent of HPO axis), ovarian (tumour, hyperthecosis), adrenal-
androgen secreting tumour, late onset/mild congenital adrenal hyperplasia (rare)
- Without hyperandrogenism:
o Hypergonadotrophic: (e.g. premature ovarian failure), idiopathic, autoimmune (T1DM, autoimmune thyroid
disease, Addison’s), iatrogenic, endocrinopathies (e.g. hyper/hypothyroidism)
o Hypogonadotrophic: pituitary compression/destruction (adenoma, craniopharyngioma, lymphocytic
hypophysitis, infiltration, head injury, Sheehan’s), functional hypothalamic amenorrhea (stress, excessive
exercise, anorexia)
Investigations:
- Initial work-up: B-hCG, hormonal workup (TSH, prolactin, FSH, LH, androgens, estradiol)
- Progesterone challenge to assess estrogen status
o Medroxyprosterone acetate 10mg PO OD x 10-14d → uterine (withdrawal) bleed 2-7d after completion
suggests presence of adequate estrogen, if no bleed- may be ↓estrogen or ↑ androgens/progesterone
- Consider karyotype if premature ovarian failure or absent puberty
- US to confirm normal anatomy, identify PCOS
Treatment:
- 1⁰: AIS (gonadal resection, psychological counselling, reconstruction), anatomical (surgical), Mullerian dysgenesis
(surgical reconstruction + psychological counselling)
- 2⁰: Uterine defect, Asherman’s (hysteroscopy), HP-axis dysfunction (treat underlying cause, consider COCP), premature
ovarian failure (screen for endocrinopathies, consider HRT to ↓ risk OP), hyperprolactinemia (MRI/CT head to rule out
lesion w/ surgical management- consider bromocriptine if fertility desired & COCP if not), PCOS (lifestyle modification,
OCP, oral hypoglycemia, consider ovulation induction for fertility)
Vaginal Bleeding in Pregnancy: Spontaneous Abortion
First Trimester Bleeding: Type Hx Clinical Rx
- Implantation bleeding, ectopic, molar pregnancy Threatened Vag bleed +/- cramp Cx closed & soft, US viable fetus Watch & wait, <5% abort
- Miscarriage: threatened, inevitable, incomplete, Inevitable ↑ bleed, cramp, +/- ROM Cx close until POC expel- open, Watch & wait → miso 400-800ug PO/PV → D&C + /-oxytocin
US nonviable
complete, missed
Incomplete Heavy bleed, cramp, +/- tissue Cx open, US shows POC Watch & wait → miso 400-800ug PO/PV → D&C + /-oxytocin
- Uterine, cervical, vaginal lesion/pathology
Complete Bleeding + complete passage Cx open/ closed, US no POC Expectant management
Second/Third Trimester: see antenatal hemorrhage below
Missed No bleed, fetal death in utero Cx close, US nonviable, no HR Watch & wait → misoprostol 400-800ug PO/PV → D&C +/- oxy

Approach Recurrent ≥3 consecutive SA Evaluate mechanical, genetic, environmental RFs, consider APLA
- History: pregnancy (GTPAL, GA, LMP, US findings, blood Septic Contents infected D&C, IV broad spectrum Abx
type & partner’s blood type)
Ectopic Pregnancy
o Bleeding Hx: onset, duration, quantity (# pads),
tissue or clot, RFs (trauma, intercourse, bleeding - Sx: 4Ts: temp, tenderness, (abdo & cervical), tissue
- Site: ampullary > isthmus > fimbria
disorder, fibroids, pelvic surgery, PID, STIs)
- RFs: previous ectopic, PID, infertility, IVF, tubal surgery, IUD, DES exposure, age
- Exam: ABCs, orthostatic vitals
- Ix: B-hCG, assess hemodynamic stability (FAST US if unstable), group & screen, TVUS
o Abdo exam, pelvic exam, cervix, POC, FHR
o 2nd/3rd trimester: NST, Leopald’s, sterile Management:
speculum, delay bimanual until previa r/o - Medical: MTX 50mg/m2 BSA given in single IM dose, follow B-hCG weekly until undetectable → 25% will require 2nd dose,
- Investigations: tubal patency post-Rx 80%
o Labs: CBC, hCG, Rh status, G&S +/- cross match, o MTX if: <3.5cm, unruptured, absent FHR, B-hCG <5000, no liver/renal/heme disease, willing & able to f/u
coag if unstable (PTT, fibrinogen), LFTs, Cr - Surgical: laparoscopy w/ salpingostomy if tube salvageable, salpingectomy if tub damage or ipsilateral recurrence, hCG q1w
o Transvaginal US until undetectable → laparotomy if unstable
Antenatal Hemorrhage (>20w- term) Vasa Previa: unprotected fetal vessels over os
DDx: bloody show (most common cause in T3), placenta previa, placental abruption, vasa previa, cervical lesion, uterine rupture, placenta - Associated with velamentous insertion of
accrete, abn coagulation, others e.g. bowel/bladder → *Postpartum hemorrhage- see pregnancy one pager cord into membranes of placenta or
succenturiate lobe
Placenta Previa: abnormal location of placenta, near/partially covering internal cervical os - Sx: painless vaginal bleeding & fetal
- RF: Hx previa, multiparity, maternal age, multiple gestation, uterine tumour/anomalies, uterine scar distress --> 50% perinatal mortality
- Sx: painless vaginal bleeding → O/E: uterus soft, non-tender, FHR usually N, presenting part high, +/- shock- NO bimanual exam until US - Ix: alkali denaturation test (Apt test) to
- Ix: diagnosed on transvaginal US, if <20mm from os after 26w repeat US regularly determine if bleeding is fetal
- Rx: stabilize, IV hydration, consider O2 - Rx: stabilization + emergency C/S
o Monitor: vitals, urine output, blood loss, FHR, labs- CBC, INR/PTT, fibrinogen, G&
o Rhogam if Rh negative (300mcg IM) Placenta Accreta: abnormal placental
o GA <37w & minimal bleeding: expectant: admission, limited activity/no intercourse, consider corticosteroids for fetal lungs, implantation into uterine myometrium
deliver when mature/hemorrhage ↑ - RFs: previous cesarean, uterine surgery,
o GA >37y or profuse bleeding or L/S ratio >2:1 → delivery by cesaren D&C, endometrial ablation, age >35y,
postpartum endometritis
Placental Abruption: premature separation of normally implanted placenta >20w
- Does not separate spontaneously at
- RF: previous abruption, maternal HTN, smoking, excessive alcohol, cocaine, multiparity, >35y, PPROM, uterine anomaly, trauma
delivery, often resulting in hemorrhage
- Sx: painful vag bleed, concealed in 20%, uterine tenderness +/- contraction, shock out of proportion to loss +/- fetal distress/demise
- Ix: clinical diagnosis, US (not sensitive)
- Rx: stabilize, IV hydration, consider O2 → monitor: vitals, urine output, blood loss, FHR, labs- CBC, INR/PTT, fibrinogen, G&S Uterine Rupture:
o Rhogam if Rh negative - Abdo pain + bleeding during labour or as
o Blood products on hand: red cells, platelets, cryoprecipitate (DIC risk 20%) a result of abdo trauma +/- fetal distress
o Mild: GA<37w: serial Hct to assess concealed bleeding & deliver when mature or hemorrhage ↑, GA>37w: stabilize & deliver - Maternal hemodynamic instability,
o Moderate/severe: hydrate, restore blood loss, correct coagulation defect if present → vaginal delivery if no contraindication bleeding may be concealed
and no evidence of fetal/maternal distress - RF: previous C/S, myomectomy, trauma
• C/S if live fetus or maternal distress develops, or labour fails to progress - Rx: stabilization + emergency C/S
Non-Pregnant Patients: Acute Management of Vaginal Bleeding:
Differential: PALM COEIN - ABCs: hemodynamic stabilization, IVF or blood products as needed
- Polyps, adenomyosis, fibroids, malignancy/hyperplasia - Examination/Investigation
- Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, NYD o R/O pregnancy → TVUS
o Ovulatory dysfunction: hypothalamic (PCOS, thyroid o BW to assess for anemia and if very significant then for DIC
dysfunction, liver/renal disorder, elevated prolactin or - Medications:
cortisol, stress, weight loss, excess exercise), rare estrogen o UNSTABLE:
producing tumour, perimenopause/puberty, OCP- ▪ Tranexamic Acid (TXA): 1000mg q6h IV over 20 mins (or PO)
inadequate estrogen or poor adherence ▪ IV estrogen 25mg q6h IV
▪ Alternatives: progestins
Investigations: o STABLE:
- CBC if heavy bleeding, **B-hCG**, TSH if sx suggestive of thyroid ▪ Hormonal contraceptive 2-4 pills per day for 7 days then 1 pill/day for 2 weeks
disorder, coagulation, no evidence that gonadotrophins/ - Surgical Intervention:
estradiol/progesterone is helpful o D&C, endometrial ablation → hysterectomy as last resort
- Imaging: TVUS → sonohysterogram, if lesion found- refer for
hysteroscopy Polycystic Ovarian Syndrome:
- Endometrial biopsy: indicated if >40y, risk factors for endometrial Diagnosis: Rotterdam Criteria, 2 of 3:
o Oligomenorrhea (for 6 months)
cancer, failure of medical treatment significant IMB
o Hyperandrogenism (hirsutism, acne, male pattern hair loss, or biochemical evidence)
o Polycystic ovaries on US
Risk Factors for Endometrial Cancer: OLD AUNT
- O: obesity - In adolescents, oligomenorrhea and hyperandrogenism must be present & persistent >2y
- L: late menopause or early menarche Differential:
- D: diabetes - Hypothyroidism, non-classical CAH (21 hydroxylase deficiency), hyperprolactinemia, androgen-
- A: cAncer PMH or FHx: endometrial, ovarian, breast, colon (Lynch) secreting tumour, Cushing’s syndrome
- U: unopposed estrogen (HRT, anovulation- PCOS) Clinical Features
- N: nulliparity - Abnormal, irregular uterine bleeding
- T: tamoxifen - Hirsutism
- Virilization (deepening of voice, clitoromegaly) *rare, must r/o androgen secreting tumor
Post-Menopausal Bleeding: endometrial cancer until proven otherwise → - Infertility
requires endometrial biopsy - Obesity
- Acanthosis Nigricans
- Impaired glucose tolerance/DM
Management of AUB: Investigations
- Hormonal: - BHCG*, Labs: FSH, 17- hydroxyprogesterone (r/o CAH), total testosterone) DHEAS
o OCP (andostenedione may be useful in some populations), TSH, prolactin, FBG/lipids
o IUD - Mirena - Pelvic & TVUS: polycystic appearing ovaries ‘string of pearls’ 12+ small follicles, ↑ ovary volume
o Depo-Provera Treatment
- NSAIDs: reduce prostaglandins in endometrium → vasoconstriction - Lifestyle modification: decrease BMI, exercise
o Most effective if started 2 days before onset of menses - OCP (endometrial protection, contraception, hyperandrogenism benefits)
and continued until bleeding stops - Progestins: provera (does not provide contraception/Rx of hirsutism), mini-pill, IUD
o Contraindications: platelet disorder, coagulation disorder, - Metformin if T2DM or trying to get pregnant (2nd line)
o Monitor ovulatory cycles with TVUS or serum progesterone measurement
peptic ulcer disease, pre-existing gastritis
- Tranexamic Acid: antifibrinolytic Infertility Treatment: lifestyle change, consider ovulation induction if >37y or diminished reserve
o Take at onset of heavy bleeding - letrozole, clomiphene citrate, metformin (limited evidence), bromocriptine (if ↑ prolactin)
o Dose: 500mg tab 2-3 tab TID PRN during menstruation Hirsutism Treatment: OCP (diane 35, Yasmin), spironolactone, finasteride
o Contraindications: history of VTE - Mechanical removal of hair (shaving, waxing, depilatory, electrolysis, laser removal)
- Danazol: androgen - Vaniqa (eflornithine hydrochloride) cream (prevents hair growth)
Complications (long term): hyperlipidemia, T2DM, obesity, OSA, endometrial hyperplasia, infertility
Vaginitis: general term for disorders of vagina, Sx include
vaginal discharge, odor, pruritus, discomfort
*Does not cover STIs which do not present as vaginitis
Condition Clinical Features
Candidiasis Pruritus, dysuria,
dyspareunia, white lumpy
d/c, erythema + edema, Hx
Abx use, 20% Asx
Bacterial 50-75% asymptomatic,
vaginosis white/grey thin diffuse
discharge, fishy odour
10-30% pregnancies
Trichomoniasis 25% ASx, pruritus, yellow
frothy d/c, malodourous,
strawberry cervix
Chlamydia Usually asymptomatic,
discharge, bleeding, dysuria,
abdo/pelvic pain, cervicitis
Gonorrhea Discharge, dysuria,
abdo/pelvic pain, cervicitis,
disseminated infection
Pubic Lice Pruritus, morbilliform rash,
2⁰ bacterial inf, LN
Scabies Nocturnal pruritus, burrows
+ tracking,
hands/flexor/groin/axilla
Atrophic Postmenopausal,
vaginitis dyspareunia, postcoital
spotting, mild pruritus
Lichen Lichenified/hypopigmented
sclerosis figure of 8, pruritus, loss of
labial architecture
Vulvar Hyperkeratotic, pruritus,
malignancy rarely ulcer/bleeding/LNs
Contact Erythema, pruritus,
dermatitis lichenification, Hx atopy
Colovaginal Stool/flatus from vagina,
fistula malodorous d/c + pruritus
Foreign body Discharge +/- foul odour,
visualization of FB (toilet
paper, condom, tampon)
Physiologic Clear/white, odourless, pH
discharge 3.8-4.2, ↑ w/ estrogen
VAGINITIS
Investigations
pH <4.5, (KOH wetmount-
hyphae + spores)
?Immunosuppression if
pediatric or recurrent
Clue cells- squamous
epithelial + Gardneralla
coccobacilli, pH >4.5
Motile flagellated
organisms + WBCs, pH >4.5
Cervical culture or NAAT,
vag self-swab, urine
Cervical culture or vag self
swab, urine, rectal/throat if
indicated
Clinical, visualize lice
Clinical + microscopic
examination, skin biopsy
may show mite
Visual diagnosis- thinning,
erythema, dry, petechiae
Visual diagnosis, biopsy to
r/o malignancy
Biopsy (most common
malignancy SCC), +/- colpo
Consider patch testing if
allergic
Clinical exam, colonscopy
Clinical exam +/- sedation in
paeds, consider US
Smear contains epithelial
cells + lactobacilli
Pediatric Vaginitis
- 50% nonspecific
(undeveloped labia, ↓
estrogen, poor hygiene)
Treatment
Hygiene: sitz baths, avoid bubble
Clotrimazole 2% 5g vaginally x 1, fluconazole 150mg PO x 1
baths, white cotton underwear,
Recurrent: fluconazole PO q3d x 3, topical Rx 14d,
no tight clothes/nylon, mild
fluconazole q1w x 3-6months
Pregnancy: topical only detergent, wiping front to back,
If non-pregnant + asymptomatic: no Rx avoid prolonged wet bathing suits
Metronidazole 500mg PO BID x 7 days, alternative: clinda Infectious: pinworms (tape test,
Pregnancy: topical metronidazole in 1st/2nd trimester, mebendazole), resp/enteric flora,
*important to treat as increased risk PROM, endometritis candida (investigate for
Metronidazole 2g PO x 1 or 500mg BID x 7 days, treat even immunocompromise if no
if asymptomatic diapers/recent Abx), STIs-
Treat partners investigate for child abuse
Doxy 100mg BID x 7d or azithromycin 1g PO x1 (pregnancy) FB: toilet paper*, remove with
Abstain from sex 7d, treat gonorrhea, treat partner swab/irrigation, xylocaine gel
Test of cure 3w pre-pubertal/pregnant, repeat screen in 6m Polyps: r/o sarcoma botryoides
Ceftriaxone 250mg IM x 1 or cefixime 400mg PO x 1 (2-5y), if benign Rx only if Sx
Abstain from sex 7d, treat partner, treat chlamydia
Systemic illness: Crohn’s, viral
Test of cure i3w pre-pubertal/pregnant, repeat screen 6m
Vulvar: lichen sclerosis, ulcer (STI
Wash clothes/bedding x 2, vacuum mattress, treat
or viral), labial adhesions (Rx
partners, shave, permethrin 1%, repeat in 7d, wet combing
Wash clothes/bedding x 2, vacuum mattress, treat topical estrogen/steroids)
household, permethrin 5% neck down x 8-12h + repeat in Uro: UTI, ectopic ureter, prolapse
7d, OR lindane Trauma: straddle- anterior
Local estrogen replacement, oral/transdermal HRT if injuries, sexual abuse
treating systemic Sx, hygiene measures, lubricants
Sexual Abuse in Pediatrics
Assessment: identify injuries,
Antihistamines for pruritus, topical steroids (0.05%
clobetasol x 2-4w then taper)- refer to gyne for regular treat STIs, reduce pregnancy risk,
monitoring +/- biopsy document findings
Benign: 1% fluorinated corticosteroids BID x 6w, malignant: Hx: child + caregiver, confidential
local excision vs ablative vs local immunotherapy, HPV vac in adolescents but involve CPS
Avoid irritants, substitution of soaps/detergents with Exam: mouth, breasts, genitals,
emollients, topical steroids inner thighs, perineal region,
Non-surgical: control diarrhea, hygiene measures buttocks, anus
Definitive Rx surgical repair -UV light/Wood’s lamp, STI screen
Removal with calcium alginate swab or vaginal irrigation, - Psychological assessment
w/ xylocaine gel in paeds, emergency removal under Management: STI prophylaxis (+/-
general if suspicious for battery, antibiotics rarely indicated EPC), psychological support,
Educate pt, if ↑ in peri/postmenopausal, consider other mandatory reporting, disposition
effects of ↑ estrogen (e.g. endometrial cancer) + safety planning
Common Causes of Violent Behaviour
- Toxicology: EtOH, stimulants,
withdrawal of sedatives/steroids/pain
meds or opioids
- Metabolic: hypoglycemia, hypoxia
- Neuro: stroke, intracranial lesions,
CNS infection, seizure, dementia +/-
behavioural sx, delirium
- Other medical conditions: shock,
hypo/hyperthermia, hyperthyroidism
- Psychiatric: psychosis, schizophrenia,
paranoid delusions, personality
disorders, PTSD
- Antisocial behaviour
- Autism spectrum disorder or other
developmental disabilities
Warning Signs
Impending Violent Behaviour
- Provocative behaviour
- Angry demeanor
- Loud or aggressive speech
- Tense posturing: gripping, clenching
- Restlessness: pacing, shifting
- Aggressive acts: pounding walls,
throwing objects, hitting oneself
Approach to Challenging Behaviour
HELP
- H: health- medical condition?
- E: environmental- problems with
supports or expectations?
- L: lived experience- life events,
trauma, emotional issues?
- P: psychiatric- mental health
condition or disorder?
VIOLENT/AGGRESSIVE PATIENT
Plan of Action
- Vital signs including pulse oximetry, glucose
- Assume armed until proved otherwise- disarm when safe/cooperative
- Interview in a private but not isolated area with a clear exit path
- Have security present and leave door open if necessary
- Remove all objects that can be dangerous from room & person (e.g. glasses, earrings, neckties, necklaces)
- Have an easily accessible panic button
- Have a code word/phrase to alert others to danger
- Manage practice environment appropriately & create a plan to deal with physical/verbally aggressive patients
Restraints
- Use the least invasive restraints for as little time as possible
- Physical:
o E.g. bed rails mitts, belt, 4 point restraints
o Complications: redness, bruising, swelling, edema, nerve & skin injury, pressure ulcers, strangulation, risk
of asphyxia, PTSD
- Chemical:
o Haloperidol 0.5-10mg IV q15-20mins, then 25% of total bolus q6h as needed- monitor ECG for QTc,
alternatively 2.5-10mg IM
▪ Preferred in psychiatric disorder
o Lorazepam 1-3mg PO/IV or 0.5-3mg IM q30-60mins
▪ Preferred in drug intoxication/withdrawal
Interview Strategies
- Ensure safety of patient and staff before assessment
- Be honest and straightforward
- Perform friendly gestures (e.g. offer food, blankets) where possible
- Avoid direct eye contact
- Do not approach patient from behind or move suddenly
- Stand at least one arm’s length away
- Address the violence directly (e.g. do you feel like hurting yourself or others?)
- Avoid arguing, machismo, condescension, or commands (e.g. calm down)
- Never lie to the patient
Growth & Output Sleep
- Weight at routine visits: naked + corrected GA to 2y, up - Back to sleep, own bed in same room until 6m
to 10% drop in 1st week which should be regained by
2w, 20-30g/day initially → plot in growth chart/Rourke
WELL-BABY CARE - No sleep positioners/soft objects/loose bedding/
smoking re: SIDS risk
- Height, supine until 2y - Alternate head position, tummy time-plaiocephaly
Well-Baby Physical Exam
- BMI, starting at age 2y - No swaddling- SIDS, hip dysplasia, hyperthermia
- Jaundice (bili if >2w)
- Pacifier after good latch, ?decrease SIDS risk, stop if
- HC, until 2y - Anterior fontanelle (<18m)
recurrent OM, wean gradually
- Wet diapers q4-6h - Posterior fontanelle (<2m)
- Encourage falling asleep alone, avoid reinforcing night
- Stools: 1-2 dark meconium stools on day 1-2, then - Red flex (<5y)
waking, consistent AM wake time
transitioning to yellow seedy stool, breastfed babies - Corneal light reflex (1m)
may go days between BMs - Cover test (6 months) Breastfeeding
- Normal parameters - Visual acuity (3-5y) - Recommend exclusively BF + vit D x 6m re GI/resp
- Ankyloglossia (birth, feeding difficulty) infection, SIDS protection, $$, nutritionally complete
Normal Growth
- Hearing (birth, as required) - May continue until 2y and beyond unless CI
Birth weight Avg Gain 20-30g/d in term - Teeth (6m) - Introduce iron-fortified foods as first to avoid IDA
3.25kg neonate, 2x BW by 4- - Tonsils (1y) - May consider frenotomy if ankyloglossia +
(7lb) 5m, 3x by 1y, 4x by 2y - Torticollis breastfeeding difficulty
Length/height Avg 50cm 25cm in 1st year, 12cm - BP at 2-5y, if premature, CHD, renal concern - See lactmed/toxnet re: breastfeeding- maternal meds
(20 in 2nd year, 8cm in 3rd - Hips - Slow, progressive weaning if possible (infant vs
inches) year then 4-7cm/y
mother led) CPS resources, La Leche League Canada
until puberty, ½ adult Nutrition
height at 2y - Vitamin D 400IU/day if breastfed or <1L/formula/day Toilet Training
Head 35cm (14 2cm/m for first 3m, - Liquid formula if preterm/LBW or <2m (sterility) - Requires dry diaper x 2+, able to follow instructions,
circumference inches) then cm/m from 3-6m, - Refrigerate prepared formula, >24h ↑ risk bacteria ambulate to toilet + remove diaper/pants, motivation
then 0.5cm/m 6-12m - Lactose-free, extensively hydrolyzed casein (CMPA), - Sit fully dressed on potty --> sit on potty after
soy (galactosemia or CMPA >6m) wet/soiled diaper is removed (and placed in) --> sit on
Failure to Thrive: <3rd percentile, crossing 2+ curves - Homogenized cow milk at 1y, <500-750mL/day until 2y potty multiple times daily without diaper --> timed
- DDx: - Using cup at 6-12m, no bottle at 18m routine on potty + reward system
• Low intake (behaviour, oromotor) - <125mL fruit juice/day; no energy/fruit juice/soda Male Circumcision & Foreskin Care
• High loss (GERD, emesis, malabsoprtion) - No honey <1y (botulism) - CPS does not recommend routine circumcision
• High energy needs (chronic disease) - <2 servings fish/week (low mercury only) - Discuss re: benefits (cultural, reduction in UTI (NNT
• Endocrine (hypothyroidism, GH deficiency) - Introduce pureed foods at 4-6m, when able to sit up 125), STI, HIV, vs risks infection, cosmesis, stenosis)
• Abuse/neglect with good head control → different textures, iron rich - Indications: phimosis
- O/E (small kid) foods, 2-3 foods/week → early exposure to allergenic - Contraindications: hypospadias, bleeding diathesis
o Subcutaneous fat loss foods, e.g. eggs, nuts, no evidence to delay - Ongoing ethical/legal debate re: consent
o Muscle atrophy - Avoid hard, small, round, smooth, sticky foods <3y - Foreskin: 50% retract by 6y, may take until puberty
o Alopecia - Inquire about nutritional intake regularly (type, quality,
o Lethargy Parenting Tips
and quantity of foods)
o Lagging behind - ' The Period of Purple Crying': peak of crying month 2,
- Consider anemia and tooth decay in at-risk populations unexpected, resists soothing, pain-like face, long-lasting,
o Kwashikor e.g. low SES, restricted diets/cultural variations evening & late afternoon
o Infection
Colic - Warm, responsive, flexible, and consistent discipline
o Dermatitis
- Crying 3h/day for 3d/w for 3w - Discourage physical punishment
- Ix: - Consider structured parenting program (incredible years,
o Labs: CBC, GBCL, extended lytes, albumin, iron - Provide reassurance, resolution usually by 3-4 months
right from the start, COPE program, triple P)
profile (TIBC, saturation, ferritin), AST/ALT/ALP - Trial soothing, car rides, music, vacuum, checking
- Encourage floor-based play, social interaction, reading to
o TSH, TTG, ESR/CRP, immunoglobulins, VBG diaper, elimination of cow's milk from mom's diet or
kids, limit screens (none <2y, max 1h/d)
o Urinalysis hydrolyzed formula - Ask about adjustment: sibling interaction, changing roles
o +/- sweat chloride, fecal elastase, bone age - No evidence for probiotics, avoid gripe water or both parents, involvement of extended family
Injury Prevention: Developmental Milestones:
- Rear seat away from airbag <12y
- Rear facing child seat until >2y
- Forward facing booster seat until 80lb
or 4'9'', 8y
- Bike helmets mandatory, replace if
damaged or as per manufacturer

- No unattended baths, rings/seats

- Install smoke detector on every level,
keep hot water <49C

- Keep medicines/cleaners locked; have

poison control centre number handy,
avoid IPECAC

- No unattended change table, window

guards, stair gates, bolt bookcases/TV
- Removal of firearms/safe storage
- Smoking cessation/reduction of second
hand smoke exposure
- Sun protection, SPF >30 if >6m, no
DEET <5y

- Screen serum lead if house build

before 1978, peeling or chipped paint,
screen refugee children

- Avoid OTC cough/cold medication

- Acetaminophen 10-15mg/kg/dose q4-
6h preferred if <6 months, may
consider ibuprofen 4-10mg/kg/dose
q6-8h thereafter

- Toothpaste: water vs rice grain size if

high risk (<3y), pea (3-6y), assistance
better than supervision
- Dentist by 6 months after first eruption
or by 1 year of age

Developmental Red Flags

- Gross motor: not walking at 18m
- Fine motor: handedness < 10m
- Speech: <3 words at 18 months
- Social: not smiling at 3 months; not
pointing at 15-18 months