Common presenting problems Flashcards
What must you rule out in patients 50+ years old presenting with abdominal pain?
AAA
What is allergic rhinitis
Inflammation of the nasal mucosa that is triggered by an allergic reaction
What are different classifications of allergic rhinitis
seasonal
◆ symptoms during a specific time of the year
◆ common allergens: trees, grass and weed pollens, airborne moulds
perennial
◆ symptoms throughout the year with variation in severity
◆ common allergens: dust mites, animal dander, moulds
• persistent allergic rhinitis may lead to chronic rhinosinusitis
Allergic rhinitis differential diagnosis
- Acute viral infection
- Vasomotor rhinitis
- Deviated septum
- Nasal polyps
- Acute/chronic sinusitis
- Drug-induced rhinitis
What is rhinitis medicamentosa
Rebound nasal congestion.
Occurs with prolonged use (>5-7 d) of vasoconstrictive
intranasal medications.
Patient may become dependent, requiring more frequent dosing to achieve the same decongestant effect
What is the pathophysiology of allergic rhinitis
increased IgE levels to certain allergens
→ excessive degranulation of mast cells
→ release of inflammatory mediators (e.g. histamine) and cytokines
→ local inflammatory reaction
What other conditions is allergic rhinitis associated with
asthma
eczema
sinusitis
otitis media
Allergic rhinitis management
- Conservative - minimize exposure, hygiene, saline nasal rinses
- Oral antihistamines (first line therapy for mild symptoms)
Cetirizine (Reactine)
Fexofenadine (Allegra)
Loratadine (Claritin) - Intranasal corticosteroids for moderate/severe or persistent symptoms (>1 mo of consistent use to
see results) - Intranasal decongestants (use must be limited to <5 d to avoid rhinitis medicamentosa)
- Allergy skin testing
■ for patients with chronic rhinitis
■ symptoms not controlled by allergen avoidance, pharmacological therapy
■ may identify allergens to include in immunotherapy treatment - Immunotherapy (allergy shots)
■ reserved for severe cases unresponsive to pharmacologic agents
■ consists of periodic (usually weekly) subcutaneous injections of custom prepared solutions of one or
more antigens to which the patient is allergic
Symptoms of generalized anxiety disorder
AND I C REST Anxious, nervous, or worried No control over the worry Duration >6 mo Irritability Concentration impairment Restlessness Energy decreased Sleep impairment Tension in muscles
What is the precursor to asthma
cannot be diagnosed at first presentation; called reactive airway disease until recurrent presentations
When can a child begin to do PFTs
pulmonary function tests (PFTs) can be done from age 6 or when child able to follow instructions to
do PFTs
What can be used to monitor asthma in the outpatient setting
Peak flow meter
When someone has a cough in asthma when is it typically exacerbated
Worse in cold, at night, and in early AM
COPD management ladder
Mild
Step 1: SABA prn (salbutamol)
Step 2: SABA prn + LAAC (i.e. tiotropium)
or + LABA (e.g. salmeterol)
Moderate
Step 3: SABA prn + LAAC + low-dose combined
ICS/LABA
consider inhaled vs. oral steroids
Severe
Step 4: ± theophylline
Pneumococcal vaccination, annual influenza
immunization
Asthma management ladder
Ongoing patient education, and environmental
control
SABA taken prn as rescue medication + maintenance meds
Maintenance medications
Step 1: Low-dose ICS
Step 2: Medium/high dose ICS
or low-dose ICS plus either LABA, LT modifier, or long-acting theophylline
Step 3: Medium/high-dose ICS plus either LABA, LT
modifier, or long-acting theophylline
Step 4: As above plus immunotherapy ± oral
glucocorticosteroids
+ pneumococcal vaccination, annual influenza immunization
What is the benefit of using aerosol puffers with spacers
Aerosols (puffers=MDI, MDI + spacer)
MDIs should be used with spacers to:
• Reduce side effects
• Improve amount inhaled
• Increase efficiency of use
In what population is dry powder inhalers often not used and why
Dry Powder Inhalers (discus, turbuhaler,
and diskhaler) require deep and fast
breathing (may not be ideal for children)
What is your differential diagnosis for wheezing
• Allergies, anaphylaxis • Asthma, reactive airway disease • GERD • Infections (bronchitis, pneumonia) • Obstructive Sleep Apnea • COPD • Less common: congestive heart disease, foreign body, malignancy, cystic fibrosis, vocal cord dysfunction
What electrolyte abnormality is associated with Salbutamol and how does it present
lethargy, irritability
paresthesias, myalgias, weakness
palpitations, N/V, polyuria
What is the pathophysiology of BPH
hyperplasia of the stroma and epithelium in the periurethral transition zone
What is the meaning of different PSA values
◆ <4.0 ng/mL: normal, but must take into account patient’s age and velocity of PSA increase
◆ 4-10 ng/mL: consider measuring free/total PSA
◆ >10 ng/mL: high likelihood of prostate pathology
When is PSA testing inappropriate
PSA testing is inappropriate in men with a life expectancy less than 10 yr or patients with prostatitis,
UTI
What investigations should be completed for BPH
■ Urinalysis - exclude UTI and for microscopic hematuria (common sign)
■ Cr, BUN
■ post-void residual volume by ultrasound
■ urodynamic studies, renal ultrasound
■ patient voiding diary
What are late complications of BPH
Hydronephrosis
Loss of renal concentrating ability
Systemic acidosis
Renal failure
Management for mild or non bothersome BPH
■ fluid restriction (avoid alcohol and caffeine)
■ avoidance/monitoring of certain medications (e.g. antihistamines, diuretics, antidepressants,
decongestants)
■ pelvic floor/Kegel exercises
■ bladder retraining (scheduled voiding)
Pharmacological therapy for moderate/severe BPH symptoms
■ α-receptor antagonists (e.g. terazosin [Hytrin®], doxazosin [Cardura®], tamsulosin [Flomax®],
alfuzosin [Xatral®])
◆ relaxation of smooth muscle around the prostate and bladder neck
■ 5-α reductase inhibitor (e.g finasteride [Proscar®])
◆ only for patients with demonstrated prostatic enlargement due to BPH
◆ inhibits enzyme responsible for conversion of testosterone into dihydrotestosterone (DHT) thus
reducing growth of prostate
■ phytotherapy (e.g saw palmetto berry extract, Pygeum africanum)
◆ more studies required before this can be recommended as standard therapy (considered safe)
Surgical management options for BPH
TURP (transurethral resection of the prostate)
TUIP (transurethral incision of the prostate, for
prostates <30 g)
Absolute indications for surgical management of BPH
failed medical therapy
intractable urinary retention
benign prostatic obstruction leading to renal insufficiency
Surgical management of BPH potential complications
impotence
incontinence
ejaculatory difficulties (retrograde ejaculation)
decreased libido
What is the definition of acute bronchitis
acute infection of the tracheobronchial tree causing inflammation leading to bronchial edema and
mucus formation
Clinical triad of pericarditis
Pleuritic chest pain (increases with inspiration or when
reclining, and is lessened by leaning forward)
Pericardial friction rub
ECG changes (diffuse ST segment elevation and PR interval depression without T wave inversion
How can MI present in elderly females?
Elderly women can often present with dizziness, lightheadedness, back pain, or weakness, in the absence of chest pain
How can MI present in diabetic patients?
May present with dyspnea, syncope, and
fatigue in the absence of chest pain
Management of angina/ischemic heart disease?
nitroglycerin (NTG): wait 5 min between sprays and if no effect after 3 sprays, send to ED
Management of myocardial infarction?
■ ASA (160-325 mg, chewed stat), clopidogrel (Plavix®), LMWH (enoxaparin)
■ morphine, oxygen, NTG
■ ± reperfusion therapy with fibrinolytics if within 12 h (ideally <30 min)
or percutaneous intervention (cath lab) if <90 min
■ start β-blocker (e.g. metoprolol starting dose 25 mg PO q6h or bid, titrating to HR goal of 55-60 bpm)
Flu vs cold?
Onset
Sudden vs slow
Fever
High vs none
Exhaustion
Severe vs mild
Cough
Dry, severe or hacking vs might have
Throat
Fine vs sore
Nose
Dry vs runny
Head
Achy vs headache free
Appetite
Decreased vs normal
Muscles
Achy vs fine
Chills
Yes vs no
What is the role of echinacea in preventing and treating the common cold?
Echinacea products have not been shown to
provide benefits for treating colds, although it is possible
here is a weak benefit from some Echinacea products.
Individual prophylaxis trials consistently show positive (if
no -sign ficant) trends, although potential effects are of
questionable clinical relevance
What is the definition of the common cold (acute rhinitis)
viral URTI with inflammation
Most common organism that causes acute rhinitis
Rhinovirus
Clinical features of acute rhinitis
symptoms
■ local: nasal congestion, clear to mucopurulent secretions, sneezing, sore throat, conjunctivitis, cough
■ general: malaise, headache, myalgias, mild fever
signs
■ erythematous nasal/oropharyngeal mucosa, enlarged lymph nodes
■ normal chest exam
Complications of acute rhinitis
■ secondary bacterial infection: otitis media, sinusitis, bronchitis, pneumonia
■ asthma/COPD exacerbation
Acute rhinitis management
• patient education
■ symptoms peak at 1-3 d and usually subside within 1 wk
■ cough may persist for days to weeks after other symptoms disappear
■ no antibiotics indicated because of viral etiology
■ secondary bacterial infection can present within 3-10 d after onset of cold symptoms
• prevention
■ frequent hand washing, avoidance of hand to mucous membrane contact, use of surface disinfectant
■ yearly influenza vaccination
• symptomatic relief
■ rest, hydration, gargling warm salt water, steam, nasal irrigation (spray/pot)
■ analgesics and antipyretics: acetaminophen, ASA (not in children because risk of Reye’s syndrome)
■ cough suppression: dextromethorphan or codeine if necessary (children under 6 yr of age should
not use any cough/cold medications)
■ decongestants, antihistamines
• patients with reactive airway disease will require increased use of bronchodilators and inhaled steroids
When can hormonal emergency contraception be used to be effective
If taken within 72 h of unprotected intercourse (reduces chance of pregnancy by 75-85%)
Most effective if taken within 24 h
Does not affect an established pregnancy
When can copper IUD emergency contraception be used to be effective
Copper IUDs inserted within 5 d of unprotected intercourse are significantly more effective than hormonal EC (reduces chance of pregnancy by ~99%)
What are the leading causes of dementia (major neurocognitive disorder)
Alzheimer’s dementia (40-50%)
Mixed dementia (20-25%)
Lewy-Body dementia (5-15%)
Vascular dementia (5-10%)
Frontotemporal dementia (5-10%)
What percentage of Canadians live with dementia and what is the risk rate
15% of Canadians ≥65 yr are living with dementia
risk for dementia doubles every 5 years after age 65
What types of dementia have a higher prevalence of depression
Vascular and mixed dementias have a higher prevalence of depression
Dementia quick screen procedure and scoring
Dementia quick screen = mini cog + animal naming
Mini Cog = 3-word recall + clock drawing • Clock Drawing – including numbers and hands so time shows 10 min past 11 (normal = correct number/hand placing or only minor spacing problems) • 0 word recall = impairment •1-2 words and clock drawing abnormal = impairment •3-word recall = normal.
• Naming animals in 1 min (normal = >15
in one min)
- Interpretation: If all 3 results within normal range, cognitive impairment unlikely
- Return for further evaluation if:
- <15 animals named
- 0-1 words recalled
- Clock Drawing Abnormal
Pharmacological management for dementia
NMDA receptor antagonists and cholinesterase inhibitors slow rate of cognitive decline
low-dose neuroleptics and antidepressants can be used to treat behavioural and emotional symptoms (20% develop clinical depression)
Criteria for depression
Criteria for Depression (≥5/9 with at least one
of anhedonia or depressed mood for ≥2 wk)
M-SIGECAPS M Depressed Mood S Increased/decreased Sleep I Decreased Interest G Guilt E Decreased Energy C Decreased Concentration A Increased/decreased Appetite and weight P Psychomotor agitation/retardation S Suicidal ideation
You start a patient on antidepressant therapy. When would you expect improvement/when would you take different action for management?
reassessment and referral recommended if no improvement after 6-8 wk of treatment
Examples of SSRIs
paroxetine (Paxil®) fluoxetine (Prozac®) sertraline (Zoloft®) citalopram (Celexa®) fluvoxamine (Luvox®) escitalopram (Cipralex®)
SSRI MOA
Block serotonin reuptake
SSRI side effects
Sexual dysfunction
Headache
GI upset, weight loss
Tremors
Insomnia, fatigue
Increase QT interval (baseline ECG is suggested)
Which SSRIs are generally used or avoided in youth
First line therapy for youth is fluoxetine
Paroxetine is not recommended for youth (controversial)
What are examples of SNRIs
venlafaxine (Effexor®)
duloxetine (Cymbalta®)
SNRI MOA
Block serotonin and NE reuptake
SNRI side effects
Insomnia, tremors, tachycardia,
sweating
SDRI examples
bupropion
SDRI MOA
Block dopamine and NE reuptake
SDRI side effects
Headache, insomnia, nightmares
Seizures
Less sexual dysfunction than SSRIs
What is the usual indication for using an SDRI
Often chosen for lack of sexual side effects, can be used for augmentation of anti-depressant effects with other classes of medication
TCA examples
Amitriptyline
TCA MOA
Block serotonin and NE reuptake
TCA side effects
Sexual dysfunction
weight gain
tremors, tachycardia, sweating
What is an important consideration when prescribing TCAs
Narrow therapeutic window, lethal in overdose
What is the prognosis of depression
- up to 40% resolve spontaneously within 6-12 mo
* risks of recurrence: 50% after 1 episode; 70% after 2 episodes; 90% after 3 episodes
Hyperglycemia symptoms
Polyphagia, polydipsia, polyuria
Weight change
Blurry vision
Yeast infections
DKA symptoms
fruity breath
anorexia, N/V, abdominal pain
fatigue
Kussmaul breathing
dehydration
Hypoglycemia symptoms
Hunger
anxiety, tremors, palpitations, sweating, headache
fatigue
confusion, seizures, coma
Diabetes mellitus definition
metabolic disorder characterized by the presence of hyperglycemia due to defection insulin secretion,
defective insulin action or both
Micro and macrovascular complications of diabetes
- Microvascular: nephropathy, retinopathy, neuropathy
* Macrovascular: CAD, CVD, PVD
What are medications that are risk factors for diabetes mellitus
glucocorticoids
atypical antipsychotics
HAART
Who should be screened for T2DM
■ FBG in everyone ≥40 q3yr, or at high risk using the CANRISK calculator
■ more frequent and/or earlier testing if presence of ≥1 risk factor (see above)
How to calculate total insulin units required per day
type 1 DM: 0.5-0.7 units/kg/d
type 2 DM: 0.3 units/kg/d
When should ophthalmology consult occur for patients with diabetes
type 1 DM within 5 yr
type 2 DM at diagnosis
By how much can diet affect HBA1c
Decrease HbA1c by 1-2%
How often should patient be monitoring their sugars
type 1 DM: 3 or more self-tests/d is associated with a 1% reduction in HbA1c
• type 2 DM: recommendations vary based on treatment regimen
What to do if FBG >14 mmol/L
perform ketone testing to rule out DKA
What to do if bedtime sugar level is <7 mmol/L
have bedtime snack to reduce risk of nocturnal hypoglycemia
Management of T2DM with monitoring by HBA1C
- Diagnosis - Start lifestyle intervention (nutrition therapy and physical activity) ± Metformin
- If A1C <8.5% - start or increase Metformin if do not hit glycemic target in 2-3 months
- If A1C 8.5% + start metformin immediately
Conside initial combination with another antihyperglycemic agent - If symptomatic or metabolic decompensation then start insulin +/- metformin immediately
- For all of these above, if not at glycemic targets add another agent based on patient characteristics
Clinical cardiovascular disease –> add SGLT2 inhibitor with demostrated CV outcome benefit
Insulin side effects
Risk of hypoglycemia
Weight gain
Insulin secretagogue (Meglitinide, sulfonylureas) side effects
Risk of hypoglycemia
Some weight gain
Examples of sulfonylureas
Gliclazide
Glyburide
acarbose side effects
gi side effects
SGLT2 inhibitors side effects
Genital infections, UTI
hypotension
dose related changes in LDL-C
caution with renal dysfunction and loop diuretics
dapagliflozin not to be used if bladder cancer
rare diabetic ketoacidosis (may occur with no
hyperglycemia)
Thiazolidediones side effects
CHF, edema
fractures
rare bladder cancer (ploglitazone)
cardiovascular controversy (rosiglitazone)
6-12 wk required for max effect
What are ototoxic drugs that can cause dizziness
Aminoglycosides (gentamicin, streptomycin, tobramycin)
Erythromycin
ASA
antimalarials
Screening tools for domestic violence
Woman Abuse Screening Tool (WAST)-SHORT 1. In general how would you describe your relationship? a. A lot of tension b. Some tension c. No tension 2. Do you and your partner work out arguments with . . .? a. Great difficulty b. Some difficulty c. No difficulty
Endorsing either question 1 (“a lot of tension”)
or question 2 (“great difficulty”) makes
intimate partner violence exposure likely
B) HITS How often does your partner: 1. Physically hurt you? 2 Insult you? 3 Threaten you with harm? 4. Scream or curse at you?
Each question on HITS to be answered on a 5
point scale ranging from 1
(= never) to 5 (= frequently)
A total score of 10.5 is significant
What are the medicolegal guidelines for dealing with partner and child abuse
reporting suspected or known child abuse is mandatory
spousal abuse is a criminal act, but not reportable without the woman’s/man’s permission
DOCUMENT all evidence of abuse-related visits for medico-legal purposes
H. Pylori eradication treatment with quadruple therapy
1) PPI 1 tablet 2x/d for 10 d and
2) Amoxicillin 1 g twice a day for 5 d (day 1-5)
Followed by
3) Clarithromycin 500 mg 2x/d (day 6-10) and
4) Metronidazole 500 mg 2x/d (day 6-10
What is the cardiovascular risk of Rosiglitazone
Rosiglitazone continues to demonstrate
increased risk of MIs, though it is not associated
with increased risk of CV or all-cause mortality
Pharmacological management of dyspepsia
■gastric acid suppression: H2 blockers, PPI’s
both are effective for PUD and GERD
■ prokinetics: e.g. Metoclopramide
effective for functional dyspepsia
What needs to be done to keep a patient on a PPI
do not keep patients on PPI without at least 1 trial off the medication per year
Investigations in dyspepsia
for new onset dyspepsia, test for H. pylori using the urea breath test or serology
upper endoscopy (preferred), upper GI series (not in patients with alarm symptoms)
for non-responders, gastroscopy should be considered
Indications for treatment for urinary symptoms
- Dysuria
- +Leukocytes
- +Nitrites
If 2 or more criteria MET, then treat without culture, otherwise culture required prior to treatment
Most common etiology of UTI/cystitis
KEEPS bacteria (Klebsiella, E. coli, Enterobacter, Proteus mirabilis, Pseudomonas, S. saprophyticus)
vardenafil (Levitra®) dosing, routine, side effects, contraindications
2.5-20 mg/dose
Take 1 h prior to intercourse
As above
As above
Most common etiology of urethritis
C. trachomatis, N. gonorrhoeae, Trichomonas,
Candida, herpes
Urethritis presentation
Initial dysuria, urethral/vaginal discharge, history of STI
Vaginitis most common etiology
Candida, Gardnerella, Trichomonas, C. trachomatis,
atrophic, herpes, lichen sclerosis
Vaginitis presentation
External dysuria/pain, vaginal discharge, irritation,
dyspareunia, abnormal vaginal bleeding
Prostatitis most common etiology
E. coli, C. trachomatis, S. saprophyticus, Proteus
mirabilis, Enterobacter, Klebsiella, Pseudomonas
Prostatitis presentation
Dysuria, fever, chills, urgency, frequency, tender prostate,
rectal pain
Headache red flags
SNOOP
Systemic symptoms of illness • fever • anticoagulation • pregnancy • cancer
Neurologic signs/symptoms • impaired mental status • neck stiffness • seizures • focal neurological deficits
Onset
• sudden and severe
• new headache after age 50
Other associated conditions • following head trauma • awakens patient from sleep • jaw claudication • scalp tenderness • worse with exercise, sexual activity or Valsalva
Prior headache history
• different pattern
• rapidly progressing in severity/frequency
Tips for prevention of UTIs
•Maintain good hydration (especially with
cranberry juice) (recommendation level I)
• Wipe urethra from front to back to avoid
contamination of the urethra with feces
from the rectum
• Avoid feminine hygiene sprays and scented
douches
• Empty bladder immediately before and after
intercourse
Follow up for pregnant patients with UTI/cystitis
need to follow with monthly urine cultures and retreat if still infected
Indications for prophylactic antibiotics in UTI/cystitis
patients with recurrent UTIs (>3/yr) should be considered for prophylactic antibiotics
Follow up for urethritis
■ when swab or PCR is positive for chlamydia or gonorrhea must report to Public Health
■ all patients should return 4-7 d after completion of therapy for clinical evaluation
Erectile dysfunction definition
consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual
performance of ≥3 mo duration
Erectile dysfunction etiology
• organic:
vascular (90%) (arterial insufficiency, atherosclerosis)
endocrine (low testosterone, DM)
anatomic (structural abnormality, e.g. Peyronie’s)
neurologic (post-operative, DM)
medications (clonidine, antihypertensives, psychotropics)
• psychogenic (10%)
PENIS Psychogenic Endocrine (type 2 DM, testosterone) Neurogenic (type 2 DM, post-operative) Insufficiency of blood (atherosclerosis) Substances
Examples of hypoglycemic agents used in T2DM
oral
■ biguanide: metformin (Glucophage®)
■ thiazolidinedione: troglitazone (Rezulin®), rosiglitazone (Avandia®)
■ α-glucosidase inhibitor: acarbose (Precose®)
■ nonsulfonylureas: nateglinide (Starlix®), repaglinide (Gluconorm®)
■ sulfonylureas: glyburide (DiaBeta®), glimepiride (Amaryl®), gliclazide (Diamicron®)
■ DPP-4 inhibitor: sitagliptin (Januvia®)
injectable
■ GLP-1 analogue: liraglutide (Victoza®)
Indications for ACEi/Arb use in DM2 patients
■ clinical macrovascular disease
■ age ≥55
■ age <55 and microvascular complications
Indications for statin use in DM2 patients
■ clinical macrovascular disease ■ age ≥40 ■ age <40 and any of the following: - diabetes duration >15 yr and age >30 yr - microvascular complications - other cardiovascular risk factors
Indications for low dose ASA (81-325 mg) in DM2 patients
For secondary prevention in people with established CVD (NOT to be used routinely for primary
prevention)
What is the cardiovascular risk of Rosiglitazone
Rosiglitazone continues to demonstrate
increased risk of MIs, though it is not associated
with increased risk of CV or all-cause mortality
What are pharmacological treatments for erectile dysfunction
■ phosphodiesterase type 5 inhibitors
■ α-adrenergic blockers (eg yohimbine)
■ serotonin antagonist and reuptake inhibitor (e.g. trazodone)
■ testosterone
What are absolute contraindications to testosterone supplementation
Breast/postate cancer are absolute contraindications
What is indication for testosterone administration
currently only indicated in patients presenting with hypogonadism and testosterone deficiency
Sildenafil (Viagara) dosing, routine, side effects, contraindications
25-100 mg/dose
Take 0.5-4 h prior to intercourse
May last 24 h
Flushing, headache, indigestion
Not to be used in patients taking nitrates
Taldalafil (Cialis) dosing, routine, side effects, contraindications
5-20 mg/dose
Effects may last 36 h
As above
As above
vardenafil (Levitra®) dosing, routine, side effects, contraindications
2.5-20 mg/dose
Take 1 h prior to intercourse
As above
As above
Chronic fatigue syndrome criteria
must meet both criteria
- new or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not
relieved by rest, which results in occupational, educational, social, or personal dysfunction - concurrent presence of ≥4 of the following symptoms for a minimum of 6 mo
■ impairment of short-term memory or concentration, severe enough to cause significant decline in
function
■ sore throat
■ tender cervical or axillary lymph nodes
■ muscle pain
■ multi-joint pain with no swelling or redness
■ new headache
■ unrefreshing sleep
■ post-exertion malaise lasting >24 h
• exclusion criteria: medical conditions that may explain the fatigue, certain psychiatric disorders
(depression with psychotic or melancholic features, schizophrenia, eating disorders), substance abuse,
severe obesity (BMI >45)
Role of exercise therapy in chronic fatigue syndrome
Exercise therapy may be beneficial
to overall health and may decrease fatigue in CFS
patients, and is not associated with worsening
outcomes. Therapy may also have a positive impact
on sleep, physical function and self-perceived
general health. In general, exercise therapy appears
more effective than pacing strategies, and similar
to CBT.
When can tympanic membrane temp be used
• TM not accurate for measurement until child is >5 yr
Route of temperature measurement for children <2
fever in children under 2 must be a rectal temperature for accuracy
Definition of a fever
oral temperature >37.2°C (AM), 37.7°C (PM)
Migraine screen history
POUND Pulsatile quality Over 4-72 h Unilateral Nausea and vomiting Disabling intensity
if ≥4 present then a diagnosis is likely
Headache red flags
SNOOP
Systemic symptoms of illness • fever • anticoagulation • pregnancy • cancer
Neurologic signs/symptoms • impaired mental status • neck stiffness • seizures • focal neurological deficits
Onset
• sudden and severe
• new headache after age 50
Other associated conditions • following head trauma • awakens patient from sleep • jaw claudication • scalp tenderness • worse with exercise, sexual activity or Valsalva
Prior headache history
• different pattern
• rapidly progressing in severity/frequency
Migraine duration
4-72 hours
Symptoms of HTN
Symptoms of HTN are usually NOT PRESENT
(this is why it is called the “silent killer”)
May have occipital headache upon awakening
or organ-specific complaints if advanced
disease
Cluster h/a duration
<3 h at same time of day
Caffeine withdrawal h/a duration
Begins 12-24 h after last caffeine intake, can last ~1 wk
Migraine pain description
Classically unilateral and pulsatile, but 40% are
bilateral
moderate-severe intensity
N/V, photo-/phonophobia
Migraine triggers
Numerous (e.g. food, sleep disturbance, stress, hormonal, fatigue, weather, high altitude) Aggravated by physical activity
Acute migraine management
1st line: acetaminophen, NSAIDs, ASA ± caffeine
2nd line: NSAIDs
3rd line: 5-HT agonists± antiemetic
Migraine prophylactic therapy
1st line: β blockers
2nd line: TCAs
3rd line anticonvulsants
Tension h/a pain description
Mild to moderate pain
bilateral, fronto-occipital or generalized pain, band-like
pain
± contracted neck, scalp muscles
associated with little disability
Tension h/a triggers
Stressful events NOT
aggravated by physical
activity
Tension h/a acute treatment
Rest and relaxation
NSAIDs or acetaminophen
Tension h/a prophylactic therapy
Rest and relaxation, physical activity, biofeedback
Cluster h/a pain description
Sudden, unilateral, severe, usually centred around eye
frequently awakens patient
Associated conjunctival injection and tearing
“Suicide” headache
Cluster h/a triggers
Often alcohol
Cluster h/a acute treatment
Sumatriptan
Dihydroergotamine
High-flow O2
Intranasal lidocaine
What investigations should a patient with a suspected pheochromocytoma causing hypertension undergo
24 h urine for metanephrines and creatinine
Caffeine withdrawal h/a pain description
Severe, throbbing
associated with drowsiness, anxiety, muscle stiffness, nausea, waves of hot or cold sensations
Caffeine withdrawal h/a acute treatment
Caffeine
Acetaminophen or ASA ± caffeine
Caffeine withdrawal h/a prophylactic therapy
Cut down on caffeine
Role of acupuncture in migraine prophylaxis
Adding acupuncture to symptomatic treatment of attacks reduces frequency of headaches. Acupuncture is more effective than sham, and is similarly effective to pharmacological interventions for migraine prophylaxis.
Appropriate screening for hearing impairment in elderly patients
Elderly patients acknowledging a hearing impairment require audiometry, while those
who indicate they do not have hearing impairment
should be screened with a whispered voice-test
A normal whispered voice-test requires no further
workup
Those unable to perceive the whisper require audiometry
Weber and Rinne tests are not suitable for general hearing impairment screening
How to complete whipered voice test
Whisper 6 test words 6 in-2 ft away from the patient’s ear out of the visual field, ask patient to
repeat the words (with non-test ear distraction)
What investigations should be conducted in patients with unexplained sensorineural hearing loss
blood sugar
CBC and differential
TSH
syphilis testing
Management of sudden sensorineural hearing loss
High dose oral steroids and urgent ENT referral
Management of progressive assymetrical sensorineural hearing loss
MRI/CT scan to exclude vestibular schwannoma (acoustic neuroma)
Symptoms of HTN
Symptoms of HTN are usually NOT PRESENT
(this is why it is called the “silent killer”)
May have occipital headache upon awakening
or organ-specific complaints if advanced
disease
What antihypertensive combinations are not recommended
■ caution with combination of non-DHP CCB and β-blocker
■ combination of ACEI and ARB is not recommended
Hypertension definition
BP ≥140/90 mmHg, unless DM (≥130/80 mmHg), or age ≥80 yr (≥150/90 mmHg)
Hypertensive urgency definition
BP >210 or dBP >120 with minimal or no target organ damage
Hypertensive emergency definition
severe HTN (dBP > 120) + acute target-organ damage
Accelerated HTN definition
significant recent increase in BP over previous hypertensive levels associated with evidence of
vascular damage on fundoscopy, but without papilledema
Malignant HTN definition
sufficient elevation in BP to cause papilledema and other manifestations of vascular damage
(retinal hemorrhages, bulging discs, mental status changes, increasing creatinine)
When should you suspect hyperaldosteronism
Suspect Hyperaldosteronism when
- HTN refractory to treatment with ≥3 drugs
- Spontaneous hypokalemia
• Profound diuretic-induced hypokalemia
(<3.0 mmol/L)
• Incidental adrenal adenomas
Types of hypertensive emergencies
• Malignant HTN
• Cerebrovascular Hypertensive encephalopathy Stroke Intracerebral hemorrhage SAH
• Cardiac Acute aortic dissection Acute refractory LV failure Myocardial infarction/ischemia Acute pulmonary edema
• Renal failure
Causes of secondary hypertension
Renal
- Renovascular HTN
- Renal parenchymal disease, glomerulonephritis, pyelonephritis, polycystic kidney
Endocrine
- 1º hyperaldosteronism
- Pheochromocytoma
- Cushing’s syndrome
- Hyperthyroidism/hyperparathyroidism
- Hypercalcemia of any cause
Vascular
- Coarctation of the aorta
- Renal artery stenosis
Drug-Induced
- Estrogens/OCP
- MAOIs
- Cocaine
- Steroids
- Lithium
- Amphetamines
- NSAIDs
- Decongestants
- Alcohol
What investigations should all patients with hypertension undergo
electrolytes Cr fasting glucose and/or HbA1c lipid profile 12-lead ECG urinalysis
■ self-measurement of BP at home is encouraged
■ echocardiography for left ventricular dysfunction assessment if indicated
What investigation should a patient with DM or chronic kidney disease and hypertension undergo
Urinary protein excretion
What investigations should a patient with suspected renovascular hypertension undergo
Renal ultrasound
captopril renal scan (if GFR >60 mL/min)
MRA/CTA (if normal renal function)
What investigations should a patient with a suspected endocrine cause of hypertension undergo
◆ plasma aldosterone, plasma renin (aldosterone-to-renin ratio)
◆ measured from morning samples taken from patients in sitting position after resting 15 min
◆ discontinue aldosterone antagonists, ARBs, β-blockers and clonidine prior to testing
What investigations should a patient with a suspected pheochromocytoma causing hypertension undergo
24 h urine for metanephrines and creatinine
HTN management in asthma medications to avoid
BB unless angina or post MI
In what patient population should beta blockers be avoided when managing hypertension
Not recommended as first line for patients
of age ≥60
In what patient population are ACEi avoided when managing hypertension
Not recommended as monotherapy in people
of African descent
Examples of calcium channel blockers
Dihydropyridine CCBs (FAN)
• amlodipine
• nifedipine
• felodipine
Non-Dihydropyridine CCBs (Very Dull)
• diltiazem
• verapamil
What is the premise of the DASH diet
reduced cholesterol and saturated fat
Na limit for patients with hypertension
◆ limit daily sodium intake to 5 g or 87 mmol per day
Role of electrolyte supplementation in patients with hypertension
potassium/magnesium/calcium supplementations are NOT recommended for HTN but an increase in dietary potassium may help
When might lifestyle modification be sufficient hypertension treatment
may be sufficient in patients with stage 1 HTN (140-159/90-99)
Indications for pharmacological treatment for hypertension patients
indications regardless of age (caution with elderly patients)
◆ dBP ≥90 mmHg with target organ damage or independent cardiovascular risk factors
◆ sBP ≥140 with target organ damage
◆ dBP ≥100 mmHg or sBP ≥160 mmHg without target organ damage or cardiovascular risk factors
What are first line pharmacological agents for managing hypertension
Thiazide/thiazide-like diuretic
ACEI (for non African patients), ARB
long-acting CCB
β-blocker (if age <60)
What antihypertensive combinations are not recommended
■ caution with combination of non-DHP CCB and β-blocker
■ combination of ACEI and ARB is not recommended
You have a patient on thiazide/thiazide like diuretic monotherapy for their hypertension management, what investigations do you want to follow up on
be cautious of hypokalemia in patients treated with thiazide/thiazide-like diuretic monotherapy
How to combine antihypertensives in general
A and B
C and D
do not go together
Every other combination of A, B, C, D
ACEi, beta blocker, CCB, diuretic
Isolated diastolic HTN recommended treatment
ACEI, ARB β-blocker, long-acting CCB Thiazide diuretic (consider ASA and statin in select patients)
Isolate systolic HTN recommended treatment
ARB
long acting dihydropyridine CCB
Thiazide diuretic
HTN treatment for patients with CAD
ACEI or ARB
β-blocker for patients with stable angina
HTN treatment for patients with prior MI
ACEI or ARB
β-blocker
HTN treatment for patients with LVH
ACEI, ARB
long-acting CCB
Thiazide diuretic
What medications should be avoided in LVH
Hydralazine and minoxidil can increase LVH, thus not recommended
HTN treatment for patients with CVA
ACEI, ARB
Thiazide diuretic
HTN treatment for patients with heart failure
ACEI, ARB
β-blocker
Spironolactone for patients with NYHA class II - IV
HTN treatment for patients with DM with albuminuria
ACEI, ARB
Non diabetic CKD with proteinuria HTN treatment
ACEI, ARB
Thiazide diuretic
HTN management in asthma
K sparing or thiazide diuretic for patients on Salbutamol
HTN management in asthma medications to avoid
BB unless angina or post MI
Antihypertensives to avoid in gout
Thiazide diurectics
HTN management in patients that smoke
ACEI, ARB
Thiazide diuretic
HTN medications to use in pregnancy
Hydralazine
Methyldopa
HTN medications contraindicated in pregnancy
ACEi
Management for BP >160/90
Labetalol
Nifedipine
Indications for loop diuretic in HTN treatment
DM with albuminuria - Cr >150 use loop instead of thiazide
Non diabetic CKD with proteinuria for volume overload
What are seropositive spondyloarthropathies
RA SLE Scleroderma Polymyositis/Dermatomyositis Sjögren’s syndrome
What are seronegative spondyloarthropathies
Ankylosing spondylitis
Inflammatory bowel disease
Psoriatic arthritis
Reactive arthritis
What are crystal arthropathies
Gout
Pseudogout
Hydroxyapatite
Back pain red flags
Bowel or bladder dysfunction
Anesthesia (saddle)
Constitutional symptoms/malignancy
Chronic disease
Paresthesias
Age >50 and mild trauma
IV drug use/Infection
Neuromotor deficit
Indications for lumbar xray in low back pain
- No improvement after 6 wk
- Fever >38oC
- Unexplained weight loss
- Prolonged corticosteroid use
- Significant trauma
- Progressive neurological deficit
- Suspicion of ankylosing spondylitis
- History of cancer (rule out metastases)
- Alcohol/drug abuse (increased risk of osteomyelitis, trauma, fracture)
What is the timeline for characterization of back pain
Acute <6 weeks
Subacute 6-12 weeks
Chronic >12 weeks
Low back pain prognosis
90% resolve in 6 wk, <5% become chronic
Role of spinal manipulative therapy for low back pain
SMT is not more effective than inert interventions, sham SMT or as an adjunct to another intervention for patients with acute low back pain, and does not appear any better than other recommended therapies either. Decision to refer patients for SMT should be based on costs, patient and provider preferences, and the relative safety of SMT relative to other reatment options.
Role of massage in low back pain
Massage may be beneficial for subacute and chronic non-specific low back pain, especially in combination with exercise and education; it is more effective than classic massage.
Acute (within 12 weeks of pain onset) management of low back pain
- Educate patient that low back pain typically resolves within a few weeks (70% in 2 wks, 90% in 6 wks)
- Prescribe self-care strategies including alternating cold and heat, continuation of usual activities as tolerated
- Encourage early return to work
- Recommend physical activity and/or exercise
• Consider analgesics in this order: » Acetaminophen (1st line) » NSAIDs (2nd line) » Short course muscle relaxants » Short-acting opioids (rarely, or severe pain)
- Spinal traction, TENS not recommended
- f/u in 1-6 weeks (symptoms and red flags) and refer if not returning to normal functioning or worsening
Chronic (>12 weeks since pain onset) management of low back pain
• Prescribe physical or therapeutic exercise
• Analgesic Options » Acetaminophen » NSAIDs (consider PPI) » Low dose tricyclic antidepressants » Short term cyclobenzaprine for flare-ups
• Referral Options
» Community-based active rehabilitation program
» Community-based self management/cognitive behavioural therapy program
• Additional Options » Progressive muscle relaxation » Acupuncture » Massage therapy, TENS as adjunct to active therapy » Aqua therapy and yoga
MODERATE TO SEVERE PAIN
• Opioids
• Referral Options
» Multidisciplinary chronic pain program
» Epidural steroids (for short-term relief of radicular pain)
» Prolotherapy, facet joint injections, and surgery in carefully selected patients
Patterns of Back Dominant pain (Pain greatest above gluteal fold)
Pattern 1
- Worse with flexion
- Constant/intermittent
Pattern 2
- Worse with extension
- Never worse with flexion
- Always intermittent
Pattern 1 back pain physical exam
Normal neuro exam
Fast responder - Improves with extension
Slow responder - No change or worsens with extension
Pattern 2 back pain physical exam
Normal neuro exam ± improves with flexion
Worse with extension
Pattern 1 back pain likely pathology
Arising from intervertebral discs or adjacent ligaments
Pattern 2 back pain likely pathology
Posterior joint complex (associated ligaments and capsular structures)
Pattern 1 back pain management
Scheduled extension
Lumbar roll
Night lumbar roll
Medication as required
Pattern 2 back pain management
Scheduled flexion
Limited extension
Night lumbar roll
Medication as required
Patterns of Leg Dominant (Pain greatest below gluteal fold) pain
Pattern 3
Pain changes with back movement/ position Currently/previously constant
Pattern 4
Worse with activity
Improves with rest and posture change
Intermittent/short duration
Pattern 3 leg pain physical exam
Leg pain can improve but not disappear
Positive straight leg raise ± conduction loss
Fast responder - Improves with specific back position Slow responder - Not better with position changes
Pattern 4 leg pain physical exam
No irritative findings ± conduction loss
Pattern 3 likely diagnosis
Sciatica
Pattern 4 likely diagnosis
Neurogenic claudication
Pattern 3 leg pain management
Prone extension Supine “Z” lie Lumbar roll Night lumbar roll Medication as required
Pattern 4 leg pain management
Abdominal exercises Night lumbar roll Sustained flexion Pelvic tilt Medication as required
Mean age of menopause
51.4 yr
What are the clinical features of menopause
associated with estrogen deprivation
- urogenital tract: atrophy, vaginal dryness/itching, urinary frequency/urgency/incontinence, bleeding
- blood vessels and heart: vasomotor instability (e.g. hot flashes), increased risk of heart disease
- bones: bone loss, joint/muscle/back pain, fractures, loss of height
- brain: depression, irritability, mood swings, memory loss
Menopause management
encourage physical exercise, smoking cessation, and a balanced diet with adequate intake/ supplementation of calcium (1,200-1,500 mg/d) and vitamin D (800-2,000 IU/d)
• hormone replacement therapy (HRT)
■ prescribe for moderate to severe symptoms for no longer than 5 yr; routine use is not recommended
■ regimens: cyclic estrogen-progestin, continuous estrogen-progestin, estrogen only (if no uterus), estrogen patch/gel/cream/ring/vaginal tablet
■ decreases risk of osteoporotic fractures, colorectal cancer
■ increases risk of breast cancer, coronary heart disease, stroke, DVT, and PE
■ initiation of HRT requires a thorough discussion of short- and long-term benefits and risks
• consider venlafaxine, SSRIs, or gabapentin to ease vasomotor instability
Pharmacological management of osteoarthritis
Note: medications do not alter natural course of OA
1st line: acetaminophen up to 4 g/d (OA is not an inflammatory disorder)
2nd line: NSAIDs in the lowest effective dose for the shortest duration of time, along with gastroprotection; COX-2 selective inhibitors (celecoxib/Celebrex®, Meloxicam/Mobicox®) are recommended if long-term treatment or if high risk for serious GI problems
combination analgesics (e.g. acetaminophen and codeine)
intra-articular hyaluronic acid injections
intra-articular corticosteroid injections (no more than 3-4x/yr) may be helpful in acute flares (benefits last 4-6 wk, can be up to 6 mo)
topical NSAID (diclofenac/Pennsaid®)
capsaicin cream (Zostrix®)
oral glucosamine
Surgical indications and management of osteoarthritis
Consider if persistent significant pain and functional impairment despite optimal pharmacotherapy (eg. debridement, osteotomy, total joint arthroplasty
What are basic bone health tips that should be provided to everyone over the age of 50
Regular active weight-bearing exercise
Calcium (diet and supplements) 1,200 mg daily
Vitamin D 800-2,000 IU (20-50 µg) daily
Fall-prevention strategies
What are disorders strongly associated with osteoporosis
Primary hyperparathyroidism
Type 1 DM
Osteogenesis imperfecta
Uncontrolled hyperthyroidism
Hypogonadism or premature menopause (<45 yr)
Cushing’s disease
Chronic malnutrition or malabsorption
Chronic liver disease
COPD
Chronic inflammatory conditions (e.g IBD)
Who should receive initial BMD testing
Age <50 years • Fragility fractures • Use of high-risk medications • Hypogonadism • Malabsorption syndromes • Chronic inflammatory conditions • Primary hyperparathyroidism • Other disorders strongly associated with rapid bone loss or fractures
Age 50-64 years
• Fragility fracture after age 40
• Prolonged use of glucocorticoids or other high-risk medications
• Parental hip fracture
• Vertebral fracture or osteopenia identified on radiography
• High alcohol intake or current smoking
• Low body weight (<60 kg) or major weight loss (>10% of body weight at age 25)
• Other disorders strongly associated with osteoporosis
All men and women 65 years +
Management of low fracture risk (10 year <10%) in osteopenia
Unlikely to benefit from pharmacotherapy
Reassess risk in 5 yr
Management of moderate fracture risk (10 year fracture risk 10-20%) in osteopenia
Lateral thoracolumbar radiography (T4- L4) or vertebral fracture assessment may aid in decision-making by identifying vertebral fracture
Factors warranting pharmacotherapy
• Additional vertebral fracture(s) (by vertebral fracture assessment or lateral spine radiograph)
• Previous wrist fracture in individuals aged >65 and those with T-score ≤-2.5
• Lumbar spine T-score «_space;femoral neck T-score
• Rapid bone loss
• Men undergoing androgen-deprivation therapy for prostate cancer
• Women undergoing aromatase inhibitor therapy for breast cancer
• Long-term or repeated use of systemic glucocorticoids (oral or parenteral) not meeting conventional criteria for recent prolonged use
• Recurrent falls (≤2 in the past 12 mo)
• Other disorders strongly associated with osteoporosis, rapid bone loss, or fractures
Repeat BMD in 1-3 years and reassess risk
High risk (10 yr fracture risk >20% or prior fragility fracture of hip or spine or >1 fragility fracture)
Good evidence of benefit from pharmacotherapy
Alcohol intake considered at risk for osteoporosis
≥3 units per day
Physical examination for osteoporosis
◆ height annually (prospective loss >2 cm or historical loss >6cm) and weight (weight loss >10% since age 25)
◆ rib-to-pelvis distance ≤2 fingers’ breadth
◆ occiput-to-wall distance >5 cm
◆ assess fall risk by ability to get up from chair without support with arms, and walking several steps and return
Efficacy of human papillomavirus vaccine
Prophylactic vaccination can prevent HPV infection in women aged 9 to 26 years not previously infected with HPV subtypes covered by the vaccines.
What are the 3 most common infections associated with vaginal discharge in an adult woman
Bacterial vaginosis
Vulvovaginal Candidiasis
Trichomoniasis
What are STIs that require mandatory reporting
chlamydia, gonorrhea, hepatitis B, HIV, syphilis
Bacterial STI or trichomonal infection return to sexual activity
should abstain from sexual activity until treatment completion and for 7 d after treatment for both partners, or until test of cure completed
Gonnococcal cervicitis/urethritis signs and symptoms
M: urethral discharge, unexplained pyuria, dysuria, irritation, testicular swelling, Sx of epididymitis
F: mucopurulent endocervical discharge, vaginal bleeding dysuria, pelvic pain, dyspaurenia
M and F: often asymptomatic, can involve rectal symptoms in cases of unprotected anal sex
Gonnococcal cervicitis/urethritis investigations
M: urethral swab for gram stain and culture
F: urine PCR, endocervical swab for Gram stain and culture, vaginal swab for wet mount (to rule out trichomonas)
M and F: urine PCR, rectal/ pharyngeal swabs if indicated
Gonococcal cervicitis/urethritis treatment
Ceftriaxone 250 mg IM single dose
If risk factors for treatment failure (e.g. pregnancy, pharyngeal/rectal infection, potentially reduced susceptibility) Test of cure: culture 4 d post-treatment (preferred) or urine PCR 2 wk post treatment (alternative)
If no risk factors, rescreen 6-12 months post treatment
Gonococcal cervicitis/urethritis complications
M: urethral strictures, epididymitis, infertility
F: PID, infertility, ectopic pregnancy, perinatal infection, chronic pelvic pain
M and F: Arthritis, increased risk of acquiring and transmitting HIV
Non gonococcal cervicitis/urethritis (usually chlamydia) signs and symptoms
~70% asymptomatic
If symptoms appear (usually 2-6 wk after infection) then similar to gonococcal symptoms
Non gonococcal cervicitis/urethritis (usually chlamydia) investigations
same as gonorrhea
Non gonococcal cervicitis/urethritis (usually chlamydia) treatment
Azithromycin 1 g PO single dose + gonococcal treatment
Same follow up as gonococcal treatment
Non gonococcal cervicitis/urethritis (usually chlamydia) complications
Same as gonococcal
HPV signs and symptoms
Most are asymptomatic
M: cauliflower lesions (condylomata acuminata) on skin/mucosa of penile or anal area
F: cauliflower lesions and/or pre-neoplastic/neoplastic lesions on cervix/vagina/vulva
HPV investigations
None needed if simple condylomata
Potential biopsy of suspicious lesions
F: screening for cervical dysplasia through regular Pap smears
HPV treatment
For condylomata: cryotherapy, electrocautery, laser excision, topical therapy (patient-applied or office-based)
For cervical dysplasia: colposcopy and possible excision, dependent on grade of lesion
HPV complications
M and F: anal cancer
MSM and F who have receptive anal sex: rectal cancer
F: cervical/vaginal/vulvar cancer
Genital herpes signs and symptoms
1° episode: painful vesicoulcerative genital lesions ± fever, tender lymphadenopathy, protracted course
Recurrent episodes: less extensive lesions shorter course may have “trigger factors”
Genital herpes investigations
Swab of vesicular content for culture, type-specific serologic testing for HSV-1 vs. HSV-2 antibodies and to determine 1° vs. recurrent episode
Genital herpes treatment
1° Episode
Acyclovir 200 mg PO 5x/d x 5-10 d
or Famciclovir 250 mg PO tid x 5 d
or Valacyclovir 1,000 mg PO bid x 10 d
Recurrent Episode
Acyclovir 200 mg PO 5x/d x 5d or 800 mg PO tid x 2 d or Famciclovir 125 mg PO bid x 5 d
or Valacyclovir 500 mg PO bid x 3 d or 1,000 mg PO OD x 3 d
Genital herpes complications
Genital pain, urethritis, cervicitis, aseptic meningitis, increased risk of acquiring and transmitting HIV
Syphilis signs and symptoms
1°: chancre (painless sore), regional lymphadenopathy
2°: rash and flu-like symptoms, meningitis, headache, uveitis, retinitis, condyloma lata, mucus lesions, alopecia
Latent Phase: asymptomatic
3°: neurologic, cardiovascular, and tissue complications
Syphilis investigations
Specimen collection from 1° and 2° lesions, screen high risk individuals with serologic syphilis testing (VDRL), universal screening of pregnant women
What can present with a false positive syphilis screen
Endocarditis
Syphilis treatment
Benzathine penicillin G IM (dose depends on stage and patient population. Check Public Health Canada guidelines )
Notify partners (last 3-12 mo)
Continuous follow-up and testing until patients are seronegative
Syphilis complications
Chronic neurologic and cardiovascular sequelae, increased risk of acquiring and transmitting HIV
Common etiologies of sinusitis
viral etiology is more common
- viral: rhinovirus, influenza, parainfluenza
- bacterial: S. pneumoniae, H. influenzae, M. catarrhalis
Management of acute sinusitis
- may provide symptom relief:
oral analgesics (acetaminophen, NSAIDs),
nasal saline rinse,
short-term use of topical or oral decongestants
• do not prescribe antihistamines - • intra-nasal corticosteroids if diagnosed with mild to moderate acute bacterial sinusitis
- • antibiotics and intra-nasal corticosteroids if diagnosed with severe acute bacterial sinusitis
Acute sinusitis antibiotics
■ first-line antibiotic is amoxicillin
second line is amoxicillin-clavulanic acid or a fluoroquinolone
When is an ENT referral warranted in patients with acute sinusitis
Anatomic defect (e.g. deviated septum, polyp, adenoid hypertrophy)
Failure of second-line therapy
≥4 episodes/yr
Refer urgently when there is development of complications (e.g. orbital extension, meningitis, intra-cranial abscess, venous sinus thrombosis), altered mental status, headache, systemic toxicity, or neurological finding
You have a patient with recurrent sinusitis or acute bacterial rhinosinusitis. What are the next actions you take?
With multiple recurrent episodes, consider radiology (standard 3 view sinus x-ray or CT) to confirm ABRS during episode or to eliminate other causes
Refer for expert assessment
How do you diagnose acute bacterial rhinosinusitis
For diagnosis of ABRS, patient must have:
- nasal obstruction or nasal purulence/discoloured postnasal discharge
AND - at least one other PODS symptom
P Facial Pain/pressure/fullness
O Nasal Obstruction
D Nasal purulence/discoloured postnasal Discharge
S Hyposmia/anosmia (Smell)
What presentations should raise your suspicion of ABRS (acute bacterial rhinosinusitis)
Consider ABRS under any one of the following conditions:
Worsening after 5-7 d (biphasic illness) with similar symptoms
Symptoms persist more than 7 d without improvement
Presence of purulence for 3-4 d with high fever
When do you consider a diagnosis of chronic rhinosinusitis
When symptoms persist for 4+ weeks
Primary insomnia management
1st line - CBT
2nd line -
Pharmacologic treatment (used to supplement CBT; short-term prescription of <14 d with appropriate follow-up in 7-14 d):
◆ short-acting benzodiazepines (e.g. lorazepam, oxazepam, temazepam) at the lowest effective dose should be used <7 consecutive nights to break cycle of chronic insomnia or to manage an exacerbation of previously controlled primary insomnia
◆ non-benzodiazepines: zoplicone (Imovane®), zolpidem (Sublinox®), melatonin, low dose antidepressants with sedating properties (amitriptyline, trazadone, mirtazapine)
◆ if no progress or limited improvement, consider referral to sleep medicine program
Apnea definition
no breathing for ≥10 s
Diagnosis of OSA
Based on nocturnal polysomnography: >15 apneic/hypopneic episodes per hour of sleep with arousal recorded
Consequences of OSA
◆ daytime somnolence, non-restorative sleep
◆ poor social and work performance
◆ mood changes: anxiety, irritability, depression
◆ sexual dysfunction: poor libido, impotence
◆ morning headache (due to hypercapnia)
◆ HTN (2x increased risk), CAD (3x increased risk), stroke (4x increased risk), arrhythmias
◆ OSA is an independent risk factor for CAD
◆ p lmonary HTN, right ventricular dysfunction, cor pulmonale (due to chronic hypoxemia) memory loss, decreased concentration, confusion
OSA treatment
◆ modifiable factors: avoid sleeping supine; weight loss; avoid alcohol, sedatives, opioids; inhaled steroids if nasal swelling present; dental appliances to modify mandibular position
◆ primary treatment of OSA is CPAP: maintains patent airway in 95% of OSA cases
◆ surgery: somnoplasty, uvulopalatopharyngoplasty (UPPP), tonsillectomy, and adenoidectomy (in children)
◆ report patient to Ministry of Transportation if OSA is not controlled by CPAP
OSA investigations
◆ evaluate BP, inspect nose and oropharynx (enlarged adenoids or tonsils)
◆ blood gas not helpful, TSH if clinically indicated
◆ nocturnal polysomnography
Risk factors for OSA
- 2% of women, 4% of men between ages 30-60
- Obesity (due to upper airway narrowing). BMI >28 kg/m2 present in 60-90% of cases
- Children (commonly due to large tonsils and adenoids)
- Aging (due to decreased muscle tone)
- Persistent URTIs, allergies, nasal tumours, hypothyroidism (due to macroglossia), neuromuscular disease
- Family history
Most common bacterial cause of sore throat
GABHS (Group A β Hemolytic Streptococcal Infections)
Coxsackie virus presentation
– primarily late summer, early fall
– sudden onset of fever, pharyngitis, headache, abdominal pain, and vomiting
– appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharynx
– ulcers are pale grey and several mm in diameter, have surrounding erythema, and may appear on hands and feet
EBV (infectious mononucleosis) presentation
pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash
Herpes simplex virus presentation
Like coxsackie virus but ulcers are fewer and larger – pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash
Investigations for sore throat due to suspected GABHS
■ gold standard for diagnosis is throat culture
■ rapid test for streptococcal antigen: high specificity (95%) but low sensitivity (50-90%)
Investigations for sore throat due to suspected EBV (infectious mononucleosis)
◆ peripheral blood smear, heterophile antibody test (i.e. the latex agglutination assay or “monospot”)
Approach to Diagnosis and Management of GABHS
Modified Centor Score Cough absent? 1 History of fever >38ºC? 1 Tonsillar exudate? 1 Swollen, tender anterior nodes? 1 Age 3-14 1 Age 15-44 0 Age >45 –1
Management of Centor score 0-1
Suggested action NO culture or antibiotic
Management of Centor score 2-3
Culture all, treat with antibiotics only if culture is positive
Management of Centor score 4+
Culture all, treat with antibiotics if clinically unwell, discontinue antibiotics if culture comes back negative
Viral pharyngitis management
■ antibiotics not indicated
■ symptomatic therapy: acetaminophen/NSAIDs for fever and muscle aches, decongestants
Management of GABHS
■ antibiotic treatment decreases severity and duration of symptoms, risk of transmission (after 24 h of treatment), and risk of rheumatic fever and suppurative complications
■ incidence of glomerulonephritis is not decreased with antibiotic treatment
■ no increased incidence of rheumatic fever with 48 h delay in antibiotic treatment; if possible, delay antibiotic treatment until culture confirms diagnosis
■ routine F/U and/or post-treatment throat cultures are not required for most patients
■ F/U throat culture only recommended for: patients with history of rheumatic fever, patients of family member(s) with history of acute rheumatic fever, suspected streptococcal carrier
Infectious mononucleosis management
■ self-limiting course; antibiotics are not indicated
■ symptomatic treatment: acetaminophen/NSAIDs for fever, pharyngitis, malaise
■ avoid heavy physical activity and contact sports for at least one month or until splenomegaly resolves because of risk of splenic rupture
■ if acute airway obstruction, give corticosteroids and consult ENT
