Family Medicine Flashcards
Describe the NYHA criteria for functional assessment of HF
Class I - no impairment Class II - some limitation by SOB / fatigue during moderate exertion Class III - symptoms with minimal exertion that interfere with normal daily activity Class IV - inability to carry out any physical activity
What is an example of a disease that follows this trajectory?
Organ failure e.g. HF or COPD with exacerbations.
What is the surprise question and how predictive is it?
Would you be surprised if this patient died in the next 12 months?
Crap sensitivity, moderate specificity.
What kinds of illness have this course?
Progressive neuromuscular diseases, dementia.
How do you use the paliative prefromance scale?
Start from the left; ambulation and then move down until you reach their level of function and then work across down to the lowest score in each category. Left-sided categories are “more important” as predictors. Lower scores are more prognostic.
What is the difference between pacemakers & ICDs and CRT?
Pacemaking sends gentle electrical signals to maintain a minimum heart rate above a minimum bradycardia.
ICDs defibrillate VFib or VTach. When someone is in advanced decline / comfort, these can be uncomfortable.
CRT can resynch the ventricles to get more effective pumping.
What are some examples of nociceptive pain? What would you use to treat it?
Well-localized constant achy or throbbing pain: OA, mecahnical back pain, injuries & surgical pain.
Treat with: non-opioids, acetaminophen, NSAIDs or opioids
What are some examples of neuropathic pain? What do we use to treat it?
Burning, shooting pain e.g. dysthesia
Spontaneous pain or allodynia
Hyralgesia or hyperpathia
1st line: TCA or SNRI, gabapentin or pregabalin, lidocaine, nerve block
2nd line: opioids
What can methadone also be used for in additions to substance use disorder?
Chronic pain.
What is an appropriate starting dose for hydromorphone or morphine?
0.5mg-1mg PO hydromorphone q4h
or 2.5-5mg PO q4h
What can you use for breakthrough pain?
10% of their total daily dose q1-2h PRN.
What is the dosage to convert PO opioids into SQ or IV?
Divide dose by half.
What information must be provided on a prescription for an opioid?
You must spell out in letters the exact number of tablets to be dispensed.
What are some side effects of opioid use?
1: overdosing
2: side effects: N/V, pruritis, constipation, sedation
3: toxicitiy: kidney failure, delirium, seizures, myoclonus, seizures and respiratory depression.
When do we suggest moving someone to PCU or hospice.
When home supports are maxed out (4h / day of care). For patients in their last 3 months of life, a palliative care unit (in a hospital) or hospice (standalone building), with round-the-clock nuring and PSWs there to try to help them be comfortable.
What diseases would be “good” candidates for tube feeding or TPN? What are the complications of tube feeding or TPN.
Neuromuscular disease or bowel obstruction or cancer where functional status is otherwise ok and intake would be life-limiting are “better candidates”.
With other life-limiting disease, there is no good evidence for tube feeding or TPN. Complications include electrolyte abnormalities, infection, aspiration (with tube feeding), liver faiilure, blood clots.
What are some signs of immenent death?
Cool, mottled extremities
Irregular HR, weak pulse, irregular breathing (both rate & depth)
Lots of secretions in upper airway due to saliva pooling.
Unable to swallow / rattling sound
Periodically unresponsive
How do you pronounce the patient dead?
Let family know what you want to do, say that they can leave the room or be present.
Auscultate heart for 1 minute, lungs for 1 minute, no pulses, no respiration, fixed pupils. Need at least 2 organ systems failed.
Fill out the death certificate.
How do you fill out the immediate, antecedent and underlying cause of death? What do you do for MAID? If you have a suspicious death what do you do?
Do not use vague terms. Use the actual medical conditions no abbreviations, even if best guess. For MAID write the underlying disease that cause them to seek MAID & you need to call the coroner)
Immediate - what caused them to die…NOT “old age”
Antecedent - anything that directly contributes to the immediate cause of death (in reverse chronological order)
Can add other comorbidities in part II.
Can call the coroner if you are unsure,
What are 3 domains that impact aging well?
Psychological factors, outlook on life
Physical factors
Connections
What is the overall approach to the older patient?
Understand (What’s changed? Are there any new safety concerns? Prioritize (urgent/emergent vs routine)?)
Reflect (What is the most likely explanation, context? Common gorund? Priorities?)
Act (What do you need to do NOW? What needs to be investigated or monitored? Who do I need to contact/collaborate?)
Follow-up (when do we need to reconnect with patient/family? Who will do what? What red flags are there?)
When there is a change in behaviour or an older adult, what do you want to consider on the differential?
Stressors, depression, delirium/psychosis or dementia, or substance use. Functional status, elder abuse.
How is frailty defined?
Functional dependence, multiple comorbidities with limited comorbidities
How does the clinical frail scale correlate with mortality?
CFS 7-9 is correlated with mortality within 6 months
Which vaccines are covered in the older adult?
Influenza, shingrix and pneumovax.
What are important factors for health maintenance and health promotion?
May continue cancer screening, encourage exercise and bone health, screen for hearing loss and vision changes, keep doing BPs.
What are important predictors of frailty?
Low income, psychosocial support, physiologic reserve.
What is the approach to multimorbidity in older adults?
Provide continuity of care with a central provider.
Focus on functional optimization and common risk factors.
Extended appointment times
Multidisciplinary care; combine visits
Patient centred care.
What is the frailty five checklist?
Feelings (mood, cognition & pain)
Flow (incontinence and constipation)
Farmacy (med rec, go over how they’re taking, what they’re taking, what they’re not taking).
Function & Falls
Future & Family
How do you ask about mood / depression in the older adult?
Ask about mood generally?
Ask about loss of interest in activities?
Ask “have you felt sad or blue in the last 2 weeks?”
How do you diagnose dementia?
Take hx family & close caregiver’s concerns seriously.
Need objective evidence of memory loss
Need functional loss
Focus physical, labs +/- imaging.
How do you ask about incontinence and constipation?
“Do you ever leak urine and get wet?”
“Do you have painful bowel movements or trouble moving your bowels?”
What is the concern for SSRI use in the elderly? How should you manage deprescribing?
Falls risk, GI bleed, hyponatremia. Make sure you taper and plan follow up and do one at a time.
What are the STOP / START criteria
STOP high risk drugs: anticholinergic, opiate, CV drugs, psychotropics, insulin, NSAIDs and PPI.
STOP drugs for inappropriate targets or unecessary drugs
START drugs with known benefits eg. vitamin D, A fib.
What are the risk factors for falls in the elderly?
Previous fall, balance impairment or decreased strength, medications/polypharmacy, gait impairment, visual impairment, arthritis, cognitive impiarment, pain, depression. dizziness / orthostatic hypotension, functional limitation, advanced age, female sex, low BMI, incontinence diabetes.
What is an appropriate physical exam for falls?
Orthostatic vitals, height, vision, balance / gait e.g. timed up and go, chair rise, focused neurologic, MSK and Cardiovascular exam.
How do you send a request for a home assessment from OT
Contact LHIN, request home safety assessment and gait assessment for gait aid – request report copied to MD.
how do we manage falls?
Recommend strength and balance assessment (PT) + exercise program as well as home hazard assessment (OT).
Vision assessment and referral
Med rec, add vitamin D and calcium; may want bone density, treat osteoporosis.
Discuss future / family: SDM and patient’s wishes and values. Normalize advance care planning.
What are some examples of mandatory reporting?
Child abuse
Unsafe driving
Communicable disease
LTC resident abuse or neglect
Sexual abuse of a patient
Preferential access or health care fraud
Privacy breach
Malpractice
What is motivational interviewing?
Person-centered counseling that addresses ambivalence to change.
It is collaborative and goal-oriented.
What does DARN CAT stand for in motivational interviewing?
Desire to change
Ability to change
Reasons to change
Need to change
_________________
Commitment
Activation
Taking Steps
What is the side effect profile of the 5 classes of HTN medication.
Thiazide diuretics - hypo Na+ hypo K+ worse uric acid/gout
ACE-i: Cough, hyper K+, angeoedemia
ARB: hyper K+, creatinine
CCB: dihydropuridines - less heart effects; verapamil > diltiazem
What are the indications for BP meds in heart disease
Recent MI is beta-blocker + ACEi
CVD is ACEi + diuretic
Other heart disease is ACEi or ARB adding beta blocker or CCB for no HF
What are the indications for blood pressure meds for diabetes
ACE-i for renal protection
What are important questions on the fatigue history?
Malignancy (b symptoms)
Bleeding (from anywhere)
Inflammatory / autoimmune (joints, rashes)
Cardioresp (SOB)
Sleep / sleep apnea
Psychological symptoms / SDOH
New drug drug/interaction
Impact on day to day life
What is a helpful first question for fatigue
Is this muscle weakness, sleepiness, low energy?
What physical exam would be appropriate for fatigue?
Cardioresp, abdo, thyroid
What investigations are appropriate for fatigue?
CBC, TSH, maybe ferritin
Can add creatinine, lytes, liver function, CK, ESR if needed.
How do you approach the patient with substance use, depression and difficulty sleeping?
Figure out what the primary problem (what came first?) then focus on treating that.
What is the approach to management of depression?
Nonpharm: therapy, lifestyle (exercise, eating well, sleep hygiene)
Pharm: SSRIs - sertraline, escitalopram (better side effect profile), mirtazapine (for older adults, makes you sleepy & hungry), bupropion (don’t give to bulemia or risk of seizures), venlafaxine (can raise BP). People will often add bupropion to the SSRI as an adjunct or for sexual function
Regular follow-up with PHQ-9
At what point after starting a medication should you expect to see improvement?
2-3 weeks with some effect - if no effect switch meds.
What are the recommendations for when to discontinue or continue SSRIs?
After 6 mos since last depressive episode can taper
If recurrence, stay on for 2 years then taper
If recurrence, then stay on for life.
How do you assess risk for suicide?
SAAD persons
Sex: male (more likely to complete)
Age (v. 25-44, 65+)
Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social support lacking
Organized plan
No spouse
Sickness / intractable pain
(Passive vs active suicidality)
What is the process for bringing in a patient to get assessed on a form 1?
If active suicidality and have taken steps for the plan then need to issue Form 1
72 hrs in hospital to be assessed.
If they are not in hospital, then need to get police.
What are criteria for earlier BMD screening? When do we usually do it?
Hx of fracture, fragility fracture after 40
Smoking, alcohol use
Low body weight
Inflammatory disorders
Steroid use
Screen 50-65s
After 65, can screen anyone.
What are some important questions for history for osteoporosis?
Risk factors, previous hx of falls and fractures, and lifestyle
What are some specific physical tests that can be done in the setting of osteoporosis?
O
Timed up and go (15s to get up, walk 3m turn around and sit down)
Occiput to wall distance
two fingers or more between bottom rib and pelvis
What is the cutoff for osteoporosis
Femoral neck t score < -2.5
What is the recommendation for vitamin D and Calcium for bone health?
1000 IU vitamin D.
1200 mg of calcium from diet + supplementation
What is the recommendation for follow-up BMD testing?
Low risk 3-5 years
Moderate ??
What bloodwork is indicated in a new diagnosis of osteoporosis?
ALP, Ca2+ albumin, kidney function, CBC
How do you manage moderate or severe falls risk?
If moderate - send for thoracolumbar spine Xray to rule out occult fractures and have a conversation
If severe - start bisphosphonates (esophagitis, can perversely increase risk of fracture), Prolia / denosumab (injection, need to stay on it for life), SERMS/estrogen (endo)
What are the side effects of bisphosphonate therapy?
GI upset, myalgia, acute phase reaction
Esophagitis - need to take with food/water, need to stay upright for an hour
Atypical femur fractures, osteonecrosis of the jaw
What are the key questions you have to ask before putting someone on OCP?
Contraindications: Stroke, clot, blood pressure, migraine + neuro symptoms, smoking
Sexual history / pap hx, STI history
must do BP
How do you start an OCP?
1st day of your period
Sunday start - 1st sunday after your period
Or start anytime (no immediate protection against pregnancy, at least a week of backup, can have more side effects / bleeding)
What are the medications that are contraindicated with OCPs?
Antibiotics, Antivirals, Anticonvulsants
When do you follow up after starting cOCP?
1-3 months afterwards
When do you follow up after inserting an IUD? What do you want to check on?
Ask about satisfaction, bleeding, STI / infection
Remind them to still use condoms
How do you diagnose hypertension? What are the cutoffs?
Any measurement >180/110 is hypertensive emergency and a spot diagnosis
If diabetic, cutoff is >130/80 x3 on different days
If not diabetic
2+ Serial visits > 140/90 or automated measurements with a mean of >135/85 with end-organ damage
or 3+ serial visits >160/100 avg + visit 4/5 average >140/90
What investigations should you perform in all patients with a new diagnosis of HTN?
U/A
Lytes + creatinine
A1C
Lipid panel
ECG
What are the targets for the treatment of HTN?
Non-diabetic < 140/90
Diabetic < 130/80
What are the non-pharm recommendations for HTN management? When is non-pharm mgmt alone appropriate?
30-60 minutes of moderate intensity dynamic exercise 4-7 days / week
Weight loss if BMI >=25 or waist circ >102cm for men or 88 for women
Alcohol reduction if >2 drinks per day (or 14/9 per week M/F)
Reduce salt intake <2000mg/day + increase K+ intake / DASH diet
Stage 1 HTN < 159/99
What are the pharmacologic options for BP management? How would you start?
Initial therapy can be ACEi (esp if DM or heart disease), Thiazide, Beta blocker if < 60 / recent MI or CCB
ARB if ACEi not tolerated
When do we start screening for diabetes and dyslipidemia? How often do we screen
routine men @40 and women @50 q3 years unless risk factors including at-risk pop
yearly if elevated Framingham score
How do you diagnose diabetes?
Fasting glucose >7 or 2hr OGTT >11.1 or A1C >6.5
Must have 2 tests on different days if asymptomatic
What are the key side effects for different HTN treatments?
Thiazides: low Na+, K+ and hyperuricemia (don’t use if gout)
ACE-i = cough, high K+, high creatinine, angioedema, teratogenic
ARB, similar to ACE-i, minus the cough and the angioedema
beta-blocker: fatigue, contraindicated if asthma
CCB: pedal edema, flushing, HA
What is the physical exam for diabetes / metabolic syndrome?
HTN (BP, vitals, weight, height and waist circ)
Acanthosis nigricans
Foot inspection
Annual dilated eye exam
eGFR/ ACR annually
ECG every 3-5 years
What are the lipid and HbA1C and Post-prandial glucose targets for DM?
LDL <= 2
A1C < 7
If older 7-7.9, up to 8.5 if frail
5-12 mmol post-prandial
When should you screen for lipids?
Same as diabetes 40 for men or 50 for women, earlier with CVD risk factors
Re-evaluate q5yrs if not on lipid-lowering therapy
At what risk stratification do you start a statin?
Secondary prevention
Or primary if 10-year risk > 10%
What is the first line treatment pharm for diabetes. What do you add on next?
When do you screen women with mammography?
q2years from 50-74 y old
How should you approach the patient presenting with chest pain in the office?
Determine if it is likely CAD / unstable angina or MI -> these need to send pt to emerg.
Consider other potential emergencies: PE, Aortic dissection or aneurysm, pericarditis
Non emergent diagnoses include GERD, anxiety disorder and chest wall pain
What rule can you use to identify patients with chest pain caused by CAD?
5 questions, LR 11.2 if 4-5 YES
Age 55+M or 65+F
Known CAD or cerebrovascular dis
Not reproducible by palpation
Worse during exercise
Patient thinks it’s heart pain
What are the red flags on hx that you must watch out for in the patient presenting with headache (9)
- Recent trauma
- Sudden onset
- New headache in pt < 5yo or >50 yo
- Worst headache of my life
- Progressively worse over weeks-to-months
- Worse in AM, when supine or when bending over
- N/V
- Visual changes
- Jaw claudication
What are the red flags on PE that you must watch out for in the patient presenting with headache?
- Decreased LOC
- Fever
- Focal neuro signs
- Meningismus (headache + photophobia + nuchal rigidity)
- Petichial rash
- Papilledema
- Red eye or cloudy cornea
- Mid-fixed dilated pupil
- Tenderness to palpation of temporal artery.
In the patient with undifferentiated lower abdo pain, what investigations are indicated?
CBC (check for bleeding, leukocytosis), abdo U/S and pelvis and/or scrotal if M, U/A
What are risk factors for asthma relapse?
Depression, poverty, slow response to treatment in ED, anaphylactic trigger, previous severe asthma attack, admission in last 1 yr, recent ER visit.
What are the screening recommendations for colorectal cancer? What are the criteria for colonoscopy?
Screeining: FIT test q2 years from 50-74
Colonoscopy at age 50 or 10y prior to earliest diagnosis of relative, q10y thereafter
Previous CRC or adenomatous polyp
IBD
1st degree FHx of CRC
FAP or Lynch syndrome
When should you screen for dyslipidemia?
Nonfasting lipids (fasting if Hx of triglycerides > 4.5 mmol/L)
Men and women age 40-75 q5 years in concordance with Framingham Risk Score assessment
When should you check fasting plasma glucose or HBA1C?
Age 40, earlier if high risk, q3years
When do you screen with DEXA for bone density?
all patients once 65+, earlier if risk factors
Rescreen depending on risk profile
When do you stop screening with pap test?
70, if 3+ normal results in the last 10 years
What is the recommendation for Ca2+ and vitD supplementation to prevent bone loss?
1200mg/Day of Ca2+ (either diet or supplements) and 1000 IU vit D
What vaccines are recommended by NACI in the older adult?
Herpes Zoster vaccine > 60 (currently shingrix funded)
Pneumovax at age 65 (revaccinate if given < 65, offer conjugate vaccine if immunocompromised)
Seasonal influenza yearly (high dose > 65)
Adacel or boostrix once during adulthood, Td q10 years
What are the contraindications to patients recieving “live-attenuated” vaccine?
Immunocompromise, pregnant or could get pregnant in 1 month, untreated TB, recent blood transfusion or blood product within last 90 days
When do you give MMR?
12 months and between 4-6 years
How do glycemic targets change in the older adult? What is the theshhold for hypoglycemia in the older adult?
Functional dependent <8 A1C or tighter control if insulin or SU
Frail +/- dementia <8.5 A1C
<5 mmol/L is hypoglycemia
How do you adjust medications in the older adult with diabetes and falls risk?
Remove short-acting insulin, lower dose of long-acting insulin, deprescribe sulfonylureas
Reduce doses of other medications as needed if under target
What is the differential diagnosis for orthostatic hypotension?
4D-AID
Deconditioning
Dysfunctional heart
Dehydration
Drugs (antiHTN, anti anginals, antiparkison, antidepressants, antipsychotics, anti-BPH meds)
Autonomic dysfunction
Idiopathic
Drugs (beta blockers)
What are the statin-indicated conditions?
Atherosclerosis
AAA
Diabetes if >40 or >30 + 15y duration or microvascular disease
CKD
LDL-C >5 mmol/L (genetic dyslipidemia)
What is the diagnostic criteria for osteoporosis?
Fragility fracture (fall from standing height or less)
OR
DEXA BMD of femoral neck T score <=-2.5
How should you treat insomnia in the older adult?
Do NOT prescribe benzos or Z-drugs as harms outweigh benefits and increased sleep is offset by less restful sleep
1st line is sleep hygiene, CBT
Melatonin may be helpful
What are some questions to help you nail down the etiology of urinary incontinence on hx?
Stress - does it happen when you cough / laugh / bear down
Urge - how often do you have to go to the bathroom? Have you ever not made it to the bathroom on time?
Toileting symptoms (dysuria, hematuria, constipation)
Fluid intake
Incontinence products & Impact on life
Prior Hx of abdo, pelvic surgeries or OBHx or prolapse
For men WISE: weak stream, incomplete emptying, straining / hesitancy, elevated PSA (indicates prostatic issues)
What should be assessed on the PE for urinary incontinence?
Mental status, personal hygiene, screening neuro
Abdo exam -> check for distended bladder, bladder pelvic tenderness
Rectal exam in men or pelvic exam in women
How do you treat urinary incontinence?
Address reversible conditions DRIP
Delirium
Restricted mobilitiy or urinary Retention
Infection Inflammation or fecal Impaction
Pharmaceutical or Polyuria
What are some non-pharm approaches to reduce UI?
Scheduled / prompted voiding
Pelvic floor physio
Reduce caffeine and alcohol - do not restrict water
Bowl regimen
Weight loss
Pessary for stress UI
What medications may be helpful in urge UI or stress UI?
Urge UI: anticholinergic medication (use with caution in older adult), mirabegron
Stress UI vaginal estrogen
What is the criteria for the modified centor score? How do you use it for management?
1 point each if
Fever >38
Tender anterior cervical lymphadenopathy
Tonsillar exudate or swelling
NO cough
if 0-1, no treatment, 2-3 swab and treat if positive, 4 swab and treat
How would you distinguish between strep throat and mono?
Mono has atypical lymphocytosis, positive monospot, and presents with ++ nodes and fatigue, with splenomegaly or hepatomegaly or liver enzymes
What is the 1st line treatment for streptococcal pharyngitis?
Penn V 600 mg BID x10 days for adult, pediatric dosing if < 27 kg
Does treatment of strep pharyngitis reduce the risk of post-strep glomerulonephritis?
No.
What are the cutoffs for acute, chronic and recurrent sinusitis?
<4 wks is acute
>12 weeks is chronic
recurrent is > 4 episodes per year
What are the key symptoms that should be present for a diagnosis of acute bacterial rhinosinusitis?
Nasal discharge + at least one of
facial pain, obstruction, discoloured discharge or hyposmia
How do you manage sinusitis?
Don’t give antibiotics. It will most likely resolve in 10-14 days on its own & it’s most likely viral or allergic. If symptoms are persistent and antiiotics are indicated, amoxicillin 500mg TID x5-10 days.
Try topical decongestants for 3-4 days, saline rinse, or intranasal steroids.
DO NOT use antihistamines
When should you refer folks to otolaryngology with sinusitis?
Anatomical abnormalities, recurrent or treatment-resistant chronic sinusitis or RED FLAGS?!
Abnormal vision, altered mental status, periorbital / forehead swelling, extraocular muscle dysfunction, meningitis
What is recommended in management of acute otitis media? When are antibiotics indicated? What would you treat with?
In general, do not treat with antibiotics and wait 24-48 hrs, provide acetaminophen.
Antibiotics if < 6mos, toxic appearance, fever > 39C, severe otalgia or not trustworthy for follow-up.
Amox 80mg/kg/d BID x 10 days.
How would you distinguish between bronchitis and pneumonia?
Bronchitis = not as sick, afebrile
Pneumonia = consolidation, tachycardia and tachypnea, leukocytosis.
How do you manage bronchitis?
Don’t give antibiotics, it’s 90% viral.
Counsel to avoid irritants and stop smoking.
How do you interpret a dipstick in the context of suspected UTI?
If 2 or more of dysuria, leuks or nitrites present, can treat w/o culture.
What are the characteristics of complicated UTI?
Male, immunocompromise, instrumentation or anatomical abnormalities
What is the appropriate management for uncomplicated UTI?
Nitrofurantoin 100mg BID x5 days
Trimethoprim 10mg BID 3 days
TMP/SMX 2 tabs BID x 3 days.
What do you do about asymptomatic bacteriuria?
Don’t treat it unless pregnant or pre-op for GU procedure.
How do you treat yeast vaginitis?
BV & trichomonas?
G/C?
Clotrimazole or miconazole topically or oral fluconazole
Metronidazole 500mg PO BID 7 days (+treat partner if trichomonas)
Ceftriaxone 250 mg IM + azithromycin 1g PO (one dose)
What are the 3 most common causes of chronic benign cough?
GERD, asthma and PND
How is asthma diagnosed in children and adults?
Children <0.9 LLN or <0.8 LLN for adults on FEV1/FVC and increase in FEV1 +12% with ventolin.
OR peak exp flow variability >20% after bronchodilator
OR +ve methacoline challenge test with PC20 <4mg/mL or exercise challenge with >10% increase in FEV1 post ex
How do you assess adequate asthma control?
<4 days / week with daytime symptoms and <4 doses of SABD/week
Mild, infrequent exacerbation
Normal exercise tolerance
No missed work/school and no nighttime symptoms
How do you diagnose COPD? What are the cutoffs for the various levels of severity?
Obstructive pattern on PFTs, irreversible
Very severe / 30 / severe / 50 / moderate / 80 / mild
What is the management of COPD?
Nonpharm: smoking cessation / exercise / education / self-mgmt / pulmonary rehab
Pharm: SABD, inhaled salbutamol, corticosteroid or muscarinic antagonist, oral therapy, long-term O2 therapy and noninvasive respiration, lung transplant.
what vaccines are given at 2mos and 4 months
pediacell (DTap, IPV, HiB), Pneumococcal C-13, Rotavirus
What vaccine is given at 6 months and 18 months (previously also at 2 and 4 months)?
DTap/IPV/HiB -> pediacell
What vaccines are given at the 12 month and 15 month appis?
12 - pneu C-13, men-C, MMR
15 Varicella
What vaccines are given between 4-6 yrs?
TDap IPV and MMRV
What vaccines are given at grade 7
Hep B, HPV (2 booster set, 6 months apart)
