general Flashcards
Harms of periodic screening
Overdiagnosis
False positive, anxiety, quality of life and consequences
Follow-up testing (infection, bleeding), medical intervention, hospitalization
cervical cancer screening age
25-69
≥ 70yo, stop if 3 successive negative Pap tests in last 10 years
Consider 21-69yo as per SOGC
Consider 21-65yo as per INSPQ
mammography screening age
Women 50-74yo q2-3y
recommends shared decision-making with women
colorectal cancer screening age and frequency in general population
50-74yo FOBT (or FIT) q2y or flexible sigmoidoscopy q10y (weak recommendation 50-59yo, strong recommendation 60-74yo)
risk factors of colon cancer and age of screening
1st degree relative ≤60yo CRC, high risk adenomas, or 2+ relatives
40yo or 10y prior to index case
lung cancer screening age and criteria
55-74yo with ≥30 py smoking history (current or quit <15y ago) low-dose CT q1y x 3 (weak recommendation; low quality evidence)
: USPSTF 2021 recommends annual screening with low-dose CT for 50-80yo with 20py smoking history, and to discontinue once a person has not smoked for 15 years or develops a health problem that limits life expency or ability/willingness to have curative lung surgery
age and criteria of screening for AAA
Men 65-80yo with one-time screening ultrasound for abdominal aortic aneurysm
age and frequency of db screening
≥40yo A1C or FPG q3y or earlier if high risk
age and frequency of DLP screening
≥40yo non-fasting lipids q5y (annually >20%) or earlier if risk
vit D and ca supplement doses
vitamin D 400-2000 IU daily, if age>50 years (or risk) 800-2000IU daily
Calcium 1200 mg/d from diet (increase to 1500-2000 mg/d if pregnant or lactating)
when to screen for osteoporosis and risk factors
All men and women ≥ 65yo
≥ 50yo if risk factor:
Fragility fracture after age 40 (low trauma fractures) and risk of future fractures
Vertebral compression fracture or osteopenia on X-ray
Parental hip fracture
Prolonged use of glucocorticoids (3mo of >7.5 mg prednisone daily in past year)
Rheumatoid arthritis, malabsorption syndrome
Current smoker
High alcohol intake (>3 units/day)
Major weight loss (10% below body weight at age 25)
<50 yo if disorder associated with rapid bone loss
Fragility fractures
High-risk medications
Malabsorption
Inflammatory
Primary hyperparathyroidism
tests for secondary causes of osteoporosis
Calcium, Albumin
CBC
Creatinine
Alk phos
TSH
SPEP (if vertebral fractures on X-ray)
25-OH Vitamin D checked once after 3 month of supplementation in impaired instesinal absorption, or osteoporosis requiring pharmacotherapy
ways to prevent osteoporosis
Smoking cessation, alcohol reduction <3 drinks/day
Vitamin D 1000-2000 IU PO daily
Calcium intake 1200mg/day from diet (three servings of low fat milk products)
Can consider Calcium supplement ≤500mg PO daily in those who cannot meet recommended dietary allowance at high risk of fractures
Sufficient protein intake (1g/kg/day)
Exercise Multicomponent program includes
Resistance training ≥ 2x/wk
Back extensor muscles daily
Balance training daily
Aerobic physical activity 150 mins/week of moderate intensity
Fall awareness and prevention
Assistive devices
Medication review (fall risk)
Environmental hazards
Hip protectors
Urinary incontinence
Name 6 classes of medication for osteoporosis treatment and an example
Oral bisphosphonate: Alendronate 70mg PO weekly or Risedronate 35mg PO weekly or 150mg PO monthly
Take 1 hour before breakfast with 250mL water, upright 30 mins, avoid any calcium for 2-3h
Adverse: Osteonecrosis of the jaw, atypical femur fractures, esophagitis, esophageal ulcers
Consider oral bisphosphonate holiday after 5y (10y in high risk, eg. previous fracture and T<-2.5)
IV bisphosphonate: Zoledronic acid 5mg IV once yearly if GI/esophageal disorders, or inability to tolerate (eg. sit upright for 30-60 mins)
Consider Drug Holiday after 3y (6y in high risk)
Monoclonal Ab (RANKL inhibitor): Denosumab (Prolia) 60mg sc twice yearly if impaired renal function
No drug holiday on Denosumab
Adverse: Joint/muscle pain, osteonecrosis of jaw, contraindicated in pregnancy
PTH Analog: Teriparatide (Forteo) 20mcg sc daily in severe osteoporosis who cannot tolerate bisphosphonate
Adverse: Hypercalciuria/emia, angioedema
SERM (Selective estrogen receptor modulators ): Raloxifene
Risk of thromboembolism
Other: Calcitonin intranasal, Hormone therapy (in menopausal symptoms)
when to refer osteoporosis to a specialist
Multiple fractures despite adherence to therapy
Secondary causes of osteoporosis/metabolic bone disease outside expertise
Extremely low BMD not explained by risk factors
CKD (eGFR<30mL/min)
age group in croup
6m-3yo
differential ddx of croup, name 6
bacterial tracheitis
retropharyngeal/ peritonsillar abscess
epiglottitis
aspiration of foreign body
allergic reaction
treatment of croup
Dexamethasone 0.6mg/kg po or IM x 1
mod severe: nebulized epi over 15 min
when can u d/c croup
after observing 2- 4h after meds
T or F:
No evidence for Heliox (or helium-oxygen mixture), antibiotics, short-acting beta-2-agonist bronchodilators in treatment of croup
True
3 categories of croup and their caracteristics
Mild: no stridoe or significant wob - dex + d/c
Mod: stridor and chest wall indrawing at rest but no agitation - dex + observe
severe: stridor and chest wall indrawing at rest with lethargy or agitation : dex + epi + observe
when to give antibiotics in acute bronchitis
consider antibiotics in ≥ 75 years, >3 weeks or suspect B. pertussis (Whooping cough, >3 weeks, vomiting (related to coughing), exposure to pertussis, not vaccinated)
name 6 symptomatic therapies for an URTI
Analgesics (Acetaminophen/NSAIDs)
Combination products (Antihistamine, decongestant, analgesics)
Consider Zinc lozenges 75mg PO daily, Pleragonium sidoides, Andrographis paniculata
Risk of irreversible anosmia in intranasal zinc preparations
Nasal symptoms
Nasal saline irrigation (poor evidence)
Intranasal cromolyn sodium 1 spray (5.2mg) in each nostril q2h PRN x 2 days then 4 times daily x 5 days
Intranasal ipratropium bromide 0.06% solution two sprays (42mcg/spray) in each nostril 3-4 times daily PRN x 4 days
Cough suppressant
Brompheniramine plus sustained-release pseudoephedrine
Ipratropium bromide inhaled
Dextromethorphan 30mg PO q6-8h PRN
two medication to help with flu
Zanamivir (Relenza) two inhalations (10mg) PO BID x 5d or oseltamivir (Tamiflu) 75mg PO BID x 5d
when to consider antiviral in elderly
Severe disease (requiring hospitalization or evidence of lower respiratory tract infection, eg. dyspnea, tachypnea, oxygen desaturation)
High risk for complications (pregnancy)
start within 48h
5 indication to consider CXR in URTI
Hemoptysis
Pleuritic chest pain
Dyspnea
Systemic symptoms (fever, tachycardia >100, tachypnea>24)
Abnormal physical exam (crackles, decreased breath sounds, bronchial breathing)
4 criterias for complicated UTI
Anatomic or functional abnormality of urinary tract (enlarged prostate, stone, diverticulum, neurogenic bladder)
Immunocompromised host
Multi-drug resistant bacteria
Pyelonephritis
name 5 common bacterias for UTI
Klebsiella pneumoniae
E Coli – most common (75-95%), especially in women
Enterococci – most common in LTC facilities
Proteus mirabilis – most common in men
Staph saprophyticus
6 risk factors for UTI
Age
Female
Neurogenic bladder/urinary incontinence, vesicoureteral reflux, posterior urethral valves, prolapse, BPH
Indwelling catheter, recent surgery/instrumentation
Diabetes, other comorbidities
Sexual activity
name 7 DDx of UTI
Infectious
Cystitis, Pyelonephritis, Urethritis
Vulvovaginitis, Cervicitis
Prostatitis, epididiymo-orchitis
Foreign body
Urolithiasis
Dermatologic
Irritant/Contact dermatitis, lichen sclerosus, lichen planus, psoriasis, Stevens-Johnson, Behçet syndrome
BPH, urethral stricture
Neoplastic
Trauma/surgery
Interstitial cystitis (bladder pain syndrome)
name 4 conditions that can put UTI at risk of complications
pregnant, co-morbidity, exposure to antibiotics in past 3 months, travel, previous drug-resistant infection, children, diabetes, urolithiasis
name 3 causes of underlying causes of reurrent UTI
post-coital urinary tract infection, atrophic vaginitis, retention
T or F:
A woman with dysuria/frequency, no risk factors for complicated infection, and no vaginal discharge had a 90% probability of UTI (LR+ = 24.6) and can be treated without :UA or UCx
true
When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.
When should u order UA for UTI
if history not clear
Both LE/Nitrites PPV+ 95%
LE alone consider urethritis
when is UCx considered positive for UTI
Urine culture indicates UTI only if accompanied by symptoms
Without indwelling catheter >10^5 cfu/mL of <2 species by void, or >10^2 by in-and-out
With indwelling catheter >10^5 cfu/mL taken from new catheter or <14d since insertion
simple cystitis tx
Nitrofurantoin 100mg PO BID x 5-7d (careful in reduced creatinine clearance)
TMP-SMX DS 1 tab BID x 3d (if resistance <20%, Quebec has 15% resistance)
Fosfomycin 3g PO x 1 (appropriate but inferior efficacy)
cystitis in pregnancy tx
Nitrofurantoin 100mg PO BID x 7d
Amoxicillin 875mg PO BID x 3-7d
Avoid TMP-SMX in first trimester and at term
acute Pyelonephritis or complicated cystitis tx
Acute Pyelonephritis or complicated cystitis
Ciprofloxacin 500mg PO BID x7d or Levofloxacin 500mg PO daily x 7d
Can consider initial intravenous dose: Ceftriaxone 1g IV or 24h dose of aminoglyocoside
If complicated pyelonephritis consider inpatient IV antibiotics initially and longer 14d course
treatment of UTI in men
Consider r/o prostatitis, urethritis
Empiric antibiotics
Fluoroquinolones (eg. Cipro 500mg PO BID or Levofloxacin 500mg PO daily) x 7-14d
If afebrile, consider 7d course rather than 14d as per latest JAMA 2021
Consider shorter courses of fluoroquinolones for uncomplicated pyelonephritis (eg. 7d as per ACP)
Consider TMP-SMX DS 1 tab BID if culture sensitive
how to properly tx uti with urinary catheter
Ideally remove catheter prior to antibiotics
Otherwise intermittent catheterization if possible
Otherwise replace catheter after antimicrobial therapy started
7-14 day antimicrobial treatment generally adequate
8 tips for prevention of UTI
Hydration, nutrition
Perineal hygiene
Healthy voiding habits
Avoid unnecessary urinary catheters (consider intermittent cathterization)
Aseptic technique for urinary catheters
May consider cranberry prophylaxis (eg. juice or tablet)
May consider discussing antibiotic prophylaxis (continuous x 1 year or postcoital) vs. self-treatment in recurrent UTI (eg. 2+/6mo, 3+/12mo)
May consider vaginal estrogen therapy in peri/post-menopausal women
Name FOUR medical conditions that could be contributing to insomnia?
Mental health disorders/Anxiety/Depression/Stress/Adjustment
Hormonal changes/perimenopause/menopause
Substance use/alcohol/illicit drugs/caffeine
Pain
Restless Legs Syndrome
Obstructive sleep apnea
Hyperthyroidism
What advice about sleep hygiene do you discuss with Michelle. Name SIX.
Keep a sleep diary
Regular exercise: 150 mins/wk of moderate intensity cardiovascular exercise + resistance training 2 days per week
Avoid large meals close to bedtime
Develop/Engage in a wind-down routine
Turn off electronics 1/2 hour before bedtime
Do not watch the clock
Ensure comfortable temperature
Sleep in a dark room
Minimize alcohol use
Use bedroom only for sleep and intimacy
Keep regular sleep-wake schedule 7 days per week
Avoid caffeine later in the day
Name ONE non-pharmacologic therapy that has been shown to be helpful for insomnia.
Cognitive behavioural therapy
Name THREE prescription medications, each from a different class, that could be used to treat insomnia?
Trazodone (FYI: Serotonin antagonist and reuptake inhibitor (SARI),
Mirtazepine (FYI: Atypical antidepressants/tetracyclic antidepressants),
triazolam/lorazepam/temazepam/nitrazepam (FYI: Benzodiazepines),
zopiclone/zolpidem (FYI: Benzodiazepine receptor agonists),
amitriptyline/doxepin (FYI: Tricyclic antidepressants),
tryptophan (FYI: Serotonin precursors)
Writing Benzodiazepines (BDZ) as an answer might have made you nervous, and for good reason! These are not good medications, but the way the question is worded (“drugs that could be used to treat her insomnia”) makes them applicable answer. If the question was worded, “what are the preferred mediations to prescribe when someone has exhausted non-pharmacologic approaches?” then BDZs are not on the list.
Also, suggest avoiding meds that are often used for sleep but are off-label, such as quetiapine (atypical anti-psychotics). In this case you also might have wondered about using hormone replacement therapy or oral contraceptive pills to normalize hormonal patterns. Those medications did not make the answer key because there is not enough information to know if they are appropriate. Melatonin is not on the answer key because it is over-the-counter.
What ocular symptoms are important to inquire about? List FOUR.
Blurred vision/visual acuity
Photophobia
Exudate/Discharge
Itching
Coloured halos in the visual field
Sensation of a foreign body
Double vision/Diplopia
eye pain
redness
name 8 ddx of red eye
Autoimmune: Iritis
Keratitis
Acute angle-closure glaucoma
Foreign body
Blepharitis
Subconjunctival hemorrhage
Pterygium
Abrasion/trauma
Chalazion/Hordeolum/Stye
Chemical burn/irritant
Allergic
3 potentially serious ocular side effects of prolonged use of topical corticosteroid drops
Cataracts
Elevated intraocular pressure
Optic nerve damage
if a patient were elderly, were complaining of acute pain in the eye, and had visual acuity of 20/200, what ophthalmic diagnosis would you be MOST concerned about? Be specific.
Acute angle-closure glaucoma
What technique is the “gold standard” for diagnosing glaucoma
Measurement of intraocular pressure/Tonometry
What is the DEFINITIVE treatment for acute angle-closure glaucoma
Surgical peripheral iridectomy/ Laser peripheral iridectomy/Iridectomy
You diagnose viral conjunctivitis. How do you educate her about her request for antibiotic eye drops?
Describe TWO points of discussion
Since there is no evidence of a bacterial infection, and that viral conjunctivitis is far more common, there is no indication for antibiotic drops.
She will likely get better at the same rate with or without drops
Even if it was bacterial, it is usually a self-limiting condition
Bacterial super-infection in viral conjunctivitis is uncommon
How do you counsel about return to work, preventing transmission to her other eye, and preventing transmission to others in terms of viral conjunctivitis? Name THREE.
Return To Work: Do not return to work until symptoms have resolved.
Prevention of transmission to her other eye: Recommend do not touch her eyes.
Prevention of transmission to others: Recommend frequent hand washing
otalgia DDx
AOM, acute mastoiditis, acute facial nerve palsy, labyrinthitis, venous sinus thrombosis, meningitis, trauma, cholesteatoma, tumor, otitis externa, r/o necrotizing/malignant otitis externa, Herpes zoster , Secondary otalgia, otitis media with effusion, otitis externa
name 3 patogens of AOM
S pneumoniae , M catarrhalis and H influenzae
name 6 risk factors of AOM
Smoking exposure
Upper respiratory tract infection
Daycare (sick contacts)
Bottlefeed
Pacifier
Personal history, family history of AOM
name 3 alternative antibiotics to amoxicilline for tx of AOM in case of allergy
Non-anaphylactic: Cefuroxime 30 mg/kg/day ÷ BID-TID
Anaphylactic: Clarithromycin 15mg/kg/day PO ÷ BID x5-10d or Azithromycin 10mg/kg PO day 1, then 5mg/kg PO x 4d
criterias for ENT referral for ear problems
recurrent AOM 3x/6 months or 4x/1 year
Chronic OME >3 months
With risk of speech/learning problems
Bilateral OME with Hearing loss
Symptoms attributable with OME (vestibular problems, poor school performance, behavioural problems, ear discomfort)
AOM resistant to second-line antibiotics
Perforated TM non-resolved after 6w
T or F: Water precautions should not be encouraged routinely in patients with tympanostomy tubes
T
Topical antibiotic eardrops (Eg. Ciprofloxacin (Ciprodex) = 4 drops BID x 5 days) without oral antibiotics should be prescribed for children with uncomplicated acute tympanostomy tube otorrhea
True
name 6 cognitive domainsLearning/memory
Language
Executive function
Complex attention
Perceptual-motor
Social cognition
name examples of Activities of Daily Living (ADL)
dressing, eating/self-feeding, ambulating/transferring, toileting, hygiene/grooming, bath/shower)
name exemples of Instrumental Activities of Daily Living (IADLs)
shopping, housework, accounting/finances, food prep, telephone, transportation, taking meds
name 6 MNCDs
Alzheimer (most common 50%)
Gradual onset, normal CNS, initial and most prominent deficit = amnestic (associated with impairment in learning and recall of recently learned information)
Mixed Alzheimer and vascular (20%)
Vascular (15%)
Abrupt, stepwise, cardiovascular risks (HTN, DLP), dysexecutive syndrome, focal neurological features
Lewy Body (5%)
Core features: Fluctuating cognition, detailed visual hallucinations, REM sleep behaviour disorder, Parkinsonism (bradykinesia, rest tremor, rigidity)
Other suggestive: Severe neuroleptic sensitivity (irreversible parkinsonism, impaired consciousness), postural instability, falls, syncope, autonomic dysfunction, hypersomnia, hyposmia, delusions, apathy, anxiety, depression
Frontotemporal (1%)
Behavioural problems (disinhibition, loss of social awareness), language impairment
Parkinson disease with dementia
Impaired executive dysfunction and visuospatial function
Differentiate from Lewy Body as parkinsonism is present >1y prior to dementia (whereas in DLB dementia occurs before or at the same time as the parkinsonian signs)
Other: Progressive supranuclear palsy (vertical supranuclear gaze palsy and postural instability), Huntington disease
Other ddx; delirium, depression, neuro: seizures, stroke/TIA
MNCD labs investigations
Labs (low yield <1%)
CBC, TSH, electrolytes (Glucose, Cr, Ca), B12, Lipids
Neurosyphilis screen only if high clinical suspicion
Consider EKG prior to treatment
Avoid AchEI if LBBB, 2nd/3rd degree block, sick sinus, HR<50
when to do CT head for MNCD
<60yo
Abrupt, rapid decline
Focal neurological symptoms (headache, seizure, hemiparesis, babinski reflex)
Urinary incontinence, gait disorder (r/o normal pressurehydrocephalus)
Previous malignancy, trauma
Anticoagulants/Bleeding disorder or history of bleeding disorder
If presence of cerebrovascular disease would change management
name 4 tools to dx MNCD
Highly educated
-Hopkins Verbal Learning test
-Word List Acquisition test
MMSE <24 suggests dementia/delirium (1 in 10 false positive)
MoCA <26 (MCI 78%, AD 100%,1 in 4 false positive)
Clinical Dementia Rating (Lengthy)
Mini-Cog (Brief)
-Clock drawing task and uncued recall of three unrelated words
non pharmalogical treatment/management of MNCD- name 8
Refer to Alzheimer society
Discuss will, power of attorney, personal directives
Safety issues (driving, stove, smoke detector, microwave)
Occupational Therapy
Hearing and vision screen
Social work / Homecare services
Healthy diet, smoking cessation
Exercise program
Eliminate medication (narcotics, anticholinergics, benzodiazepines)
Alternative therapy:
Aromatherapy
Multisensory stimulation
Music/dance therapy
Animal‑assisted therapy
Massage/touch therapy
Outdoor activities
pharmacotherapy for mild cognitive disorder
No pharmacotherapy for mild cognitive disorder
Acetylcholinesterase inhibitors may be considered only in mild to moderate Alzheimer’s Disease (lower quality evidence in Lewy bodies, vascular, Parkinson), where
Healthcare professional has expertise in diagnosing and treating Alzheimer’s Disease
Adequate support and supervision
Adequate adherence and monitoring of adverse effects, which generally requires the availability of a carer
Baseline structured cognitive and functional assessment
Follow up should be carried out on regular basis at least every 3 months
Taper slowly before stopping
May restart if decline shortly after stopping
May reduce all-cause mortality in patient with dementia
Pharmacotherapy for
Alzheimer’s: name 2 classes and exemples
AchEI, eg. Donepezil (Aricept) 5mg-10mg PO daily, Rivastigmine, Galantamine
Consider in mild to moderate (eg. MMSE 10-26)
Titrate q4 weeks
Discontinue when risks outweigh benefits (taper, and monitor 1-3 months, if declines can restart)
2-NMDA receptor antagonists (Memantine) in severe AD
side effects of AchEI
GI (nausea, diarrhea, vomiting)
Bradycardia, hypotension, dizziness, syncope
Insomnia / sleep disturbances
QT prolongation and torsades de pointes (EKG prior to treatment as above)
Frontotemporal mncd tx
SSRI (paroxetine) or trazodone
No evidence for AchEI
Vascular dementia tx
Manage HTN, DM, smoking
No evidence for AchEI
Lewy Bodies pharm tx
Can consider AchEI (eg. Rivastigmine (Exelon) 1.5-6mg BID)
Avoid antipsychotics
Risk of NMS
Atypical depression in elderly tx
Trial of antidepressant, consider Citalopram (max 40mg po daily)
Parkinson’s/Cerebrovascular disease pharmacological tx
Can consider AchEI
levodopa
tx of Behavioral and psychological symptoms of dementia (BPSD)
1-r/o medication side effects or interactions, treatable medical conditions such as sepsis or depression
2-Severe agitation/Violent behaviour
Correct underlying
Physical (pain, constipation, infection)
Environmental (set routines, sound/lights, position, daytime activity)
Psychiatric conditions (depression)
Review medications
3-Intervention
Relaxation, social contact, sensory (eg. music/aromatherapy)
Increased services/care
4-Consider newer antipsychotics (less EPS), eg. Risperidone, Olanzapine, Seroquel
Caution as increased risk of death, CVA, EPS, falls, somnolence, weight gain, diabetes
elements to look for in p/e of dementia
Gait
Neurological signs
Extra pyramidal symptoms
Parkinson (cogwheel rigidity, tremors)
4 ddx of dyspepsia
Functional/IBS (no organic cause) - 60%
PUD - 25%
-Upper abdominal pain prominent, back pain atypical
-Gastric worse with food, Duodenal better with food
-Postprandial belching, epigastric fullness, early satiation, N/V
GERD
-Retrosternal pain/regurgitation
GI Malignancy
Age
Dysphagia, odynophagia
Systemic signs (anemia, fatigue, weight loss)
Drug-induced dyspepsia (NSAIDs and COX-2 inhibitors)
Other: Celiac, chronic pancreatitis, gastritis, Crohn’s, cardiac
name 6 red flags of dyspepsia
Vomiting
Weight Loss (Involuntary)
Blood loss (melena, hematemesis, anemia)
Age >50
Anemia
Abdominal mass or lymphadenopathy
Dysphagia, odynophagia, early satiety
Family history of upper GI cancer
Jaundice
when to do endoscopy for dyspepsia
> 50yo with new-onset dyspepsia
Atypical features or red flags
No response (or limited) after 4-8w of adequate PPI
Consider in chronic GERD with 3 risk factors for Barrett’s esophagus (male > 50 years old, Caucasian, central obesity, smokers and family history of BE)
5 lifestyle modifications for GERD
Weight loss if overweight
Stop smoking, excessive alcohol
Stop NSAID/ASA
Avoid food/drinks that trigger (Alcohol, fried foods, spicy foods, garlic/onion, orange/citrus, chocolate/peppermint, coffee/caffeine, tomatoes)
Eat smaller meals
Elevate head of bed, avoid meal 2-3h before bedtime if nocturnal GERD
when to consider urea breath test
<50yo with dyspepsia but no red flags (especially if family history of peptic ulcer or cancer)
-Active PUD (gastric or duodenal).
-Confirmed history of PUD (not previously treated for H. pylori).
-Gastric MALT lymphoma (low grade).
-After endoscopic resection of EGC
-functional dyspepsia
-low dose ASA
-idiopathic thrombocytopenic purpura (ITP)
-Long term NSAIDS use
-Iron deficiency anemia
> no indication to test a pt with typical GERD
Medication that can cause or worsen dyspepsia, name 8
bisphosphonate, iron, prednisone, potassium suppl, NSAIDS, ASA, MTF, opiates, antibiotics (erythro, metronidazole)
investigations for dyspepsia
- H. Pylori
- Hb
- Iron studies
- ALT, ALP, AST, GGT (possibly add liver function)
- Calcium
- Possibly Gluc AC/screen for diabetes
- Possibly anti-TTG if suspect Celiac
3 Risk factors for being infected with H.pylori
Immigration from a developing country
* Poor socioeconomic conditions
* Family overcrowding
H. Pylori is a risk factor for what conditions?* (4)
Gastritis
* Peptic ulcers
* Gastric cancers
* Gastric MALT (mucosa-associated lymphoid tissue) lymphoma
how to treat for H pylori
Quadruple therapy: bismuth, clarythromycin or tetracycline, metronidazole, PPI x 14 days
how to test for cure of H pylori
test at least 4 weeks after completion of antibiotics, with PPI withheld for 1-2 weeks
4 treatments of functional dyspepsia
The rate of response to placebo in trials 30% to 40%
* A meta-analysis showed that PPIs were effective in reflux-like or ulcer- like FD but not with
dysmotility-like FD
* Prokinetic agents, including cisapride, domperidone, and itopride, have been shown to be more
effective than placebo in a meta-analysis of 24 RCT (**but adverse effects) (lacking high quality
studies for metoclopramide)
* No benefit of venlaxafine or sertraline but some data suggest benefit of amitriptyline
* Mirtazapine showed significant improvements compared to placebo in early satiety (not
correlated to changes in anxiety/depression) but not in epigastric pain.
* Possible benefits of psychological therapy
* Attention to stress reduction is important, and dietary advice should be provided (e.g.,
ingestion of small, regular, low-fat meals and avoidance of foods that precipitate symptoms
factors that may reduce efficacy of contraception
delayed initiation of method, illness,
medications,
specific lubricants
how to manage side effects appropriately of hormonal contraceptived
recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo–Provera
barrier methods or when efficacy of hormonal methods is decreased, advise about post-coital contraception
in a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in post-coital contraception .
emergency contraceptive pill, intrauterine device time limits
side effects of progestin only pills
Irregular bleeding
9% pregnancy risk
Side effects of transdermal patch (Evra 1 patch per week x 3 weeks, one week off)
9% pregnancy risk
17% skin reaction
side effects of Combined vaginal ring (NuvaRing x 3 weeks, one week off)
9% pregnancy with regular use
perfect use 0.3%
May remove for 3h (eg. during coitus)
5% vaginitis, leukorrhea
Side effects of Injectable progestins (DMPA- Depo–Provera 150mg IM q12w
6% pregnancy risks
Irregular bleeding, weight gain, decrease bone density
Consider supplemental low-dose estrogen to reduce irregular bleeding if persists past 3 cycles
Side effects of Intrauterine devices (LNG-IUD Mirena q7y, CU-IUD q10y)
<0.1% pregnancy
44% amenorrhea at 6 months
Risk of expulsion/perforation postpartum until 6 weeks
side effects of subdermal implants (Nexplanon - Etonogestrel)
very effective likely <0.1%
Very rare risk of implant migration
15% bleeding irregularities
Not studied in overweight >130% IBW
Permanent contraception riks of pregnancy
Tubal Ligation - 0.15%
Vasectomy - 0.15%
(how to be certain she is not pregnant) when prescribing contraception
Pregnancy test >2w after last episode of unprotected intercourse
≤7d after start of normal menses or spontaneous/induced abortion
No sex since start of last normal menses
Correctly, consistently using reliable contraception
4w postpartum
Fully breastfeeding and <6 months postpartum
Back-up contraception for 7d if >7d after menses started
name 4 emergency contraceptions and when they are effective
1-Copper IUD - failure rate of <1% (>95% effective)
Effective up to 5 days (limited evidence up to 7 days) after unprotected intercourse, provided pregnancy ruled out
Hormonal/oral (less effective if BMI>30 or weight ≥80kg), side effects include headache, irregular bleeding , N/V
2-Ulipristal acetate 30mg PO x1 - failure rate of 1.4% (~75% effective)
Effective up to 5 days
Hormonal contraception can be initiated up to 5 days after unprotected sex with backup for first 14d
3-Levonorgestrel 1.5 mg PO x1 (or 0.75mg q12h x2) - failure rate of 2.2% (~50% effective)
Effective up to 72h (proven efficacy up to 96h, limited efficacy up to 120h)
Hormonal contraception can be initiated the day of (or after) with backup for first 7d
4-Combined OCP (Yuzpe) 100-120mcg ethinyl estradiol plus 500-600 mcg levonorgestrel (5 pills of Alesse) q12h x2 - least effective
Effective up to 72h
___________
Note: Approx. 5% risk of pregnancy if unprotected sex, but up to 30% if 1-2d prior to ovulation
Only contraindications are pregnancy (and active pelvic infection/cervicitis for IUD)
Name 3 OCP and their levels of estrogen
Standard 30mcg (Marvelon, Yasmin), 35mcg (Ortho 1/35)
Low 25mcg (Tri-Cyclen Lo), 20mcg (Alesse)
Very Low 10mcg (Lo Loestrin Fe)
name 8 Contraindications to Estrogen
Migraine with aura (≥5 min reversible visual/sensory/speech/motor symptom that is accompanied within 60 mins by a headache)
Smoker age ≥35 years and smoking ≥15 cigarettes per day
Uncontrolled hypertension (>160/100)
Acute DVT/PE
History of DVT/PE, not on anticogulation, with risk factor (history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome/SLE, active cancer with the exception of non-melanoma skin cancer, history of recurrent DVT/PE)
Current or history of vascular disease, ischemic heart disease, stroke, complicated valvular disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)
Liver disease (severe cirrhosis, hepatocellular adenoma, malignant hepatoma)
<4 weeks postpartum or peripartum cardiomyopathy
Major surgery with prolonged immobilization
Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy)
Active breast cancer
1contraindication to progestin-only pills and 1 relative C-I
current breast cancer, relative contraindications include liver disease
name 3 meds that decrease effectiveness of OCP
Decreased effectiveness with anticonvulsants (phenytoin, phenobarbitol), antiretrovirals, rifampin (not other antibiotics)
4 side effects of OCP
Nausea - Take pill at bedtime or with meal (consider lower estrogen)
Breast tenderness (consider lower estrogen)
Headache
Breakthrough bleeding (r/o smoking, noncompliance, cervical/uterine disease, pregnancy, consider increase estrogen)
No evidence of weight gain
6 Non-Contraceptive Benefits/Risks
Cycle regulation, predictable bleeds
Decreased menstrual flow, anemia
Decreased acne, hirsutism
Decreased dysmenorrhea, premenstrual symptoms
Decreased perimenopausal symptoms
Decreased risk of fibroids, ovarian cyst
3 Risks of OCP
VTE RR 2-3 (compared to pregnancy RR 6 and postpartum RR 115)
10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users)
UNCLEAR risk of gallbladder disease, possible increase in symptomatic gallstones when used for 15 years
NOT associated with increased risk of MI or CVA if no risk factors
NOT associated with increased risk of major birth defects if taken before/during pregnancy
counsel on risk of cancer with OCP
Decreased ovarian, endometrial, colorectal cancer
Possible association with cervical cancer (causation not demonstrated)
Decreased risk of benign breast disease
Possible increase in breast cancer in current/recent COC users
5 / 1000 COC-users vs. 4 / 1000 non-users will be diagnosed with breast cancer before 39 years-old
Counsel on missed pills ( within 24h, in first week, after 2-3 weeks)
-If missed pill <24h in any week
Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack
-If missed pills in first week
Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack
Back up x 7d*
-If missed pills during second or third week
Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack and start new cycle of OCP without a hormone-free interval
Back-up contraception if 3 or more consecutive doses/days of OCP missed
*if unprotected intercourse in last 5 days and not on active hormone x 7 consecutive days, there is a risk of ovulation and unintended pregnancy consider emergency contraception
what to do if missed pill
Missed Progestin only pills
>3h delay
Take most recent pill ASAP and continue taking remaining pills until end of pack
Back-up x 48h
If unprotected intercourse in last 5 days, Emergency contraception recommended
name 4 management points for idiopathic, refractory cough
-Speech pathology treatment
-Neuromodulating medication
Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w
-CT scan if suspect lung cancer, bronchiectasis or ILD
-Referral to specialty
persistent (or recurrent) cough DDX (5)
., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis
name 5 stages of readiness to change and definition
1 Precontemplation (Not ready)
Highlight advantages for change and problems with current behaviour,
Harm reduction
2 Contemplation (Getting ready)
Weigh pros and cons, explore ambilance/alternatives, identify reasons for change/challenges, increase confidence
3 Preparation - Action (Ready)
Goal setting, start date and strategy for change, as well as address challenges
Support and praise, stress that episodes of relapse are normal
4 Maintenance (Sticking to it)
Help identify and use strategies to prevent relapse
5 Relapse (Learning)
Help renew process of contemplation and action without becoming demoralized
Five A’s (Health risk behaviour)
Ask “Would you mind if I talked to you about your smoking? How often do you smoke/exercise/wear a seatbelt?”
Advise “As your doctor, I strongly recommend that you ____. It is one of the most important things you can do for your health.”
Assess “Are you ready to quit smoking in the next 30 days?”
Assist “Quitting smoking can be a real challenge. I can help you with this change, as well as pharmacotherapy/community resources/spousal support may help.”
Arrange ‘I’d like to see you again/call you next week to see how the plan is going.”
5 ways to manage a crisis
Reassure
Relaxation techniques (deep breathing)
Focus on coping mechanisms that were successful in past
Resources: Support system (friends/family) and Community resources
Consider short-term anxiolytics/hypnotics
Discourage inappropriate coping mechanisms (denial, withdrawal, harmful behaviours/substances)
T or F: In patients with high probability for thrombotic disease (e.g., extensive leg clot, suspected pulmonary embolism) start anticoagulant therapy if tests will be delayed
T
name 8 acquired risk factors for DVT
Prior thromboembolism
Recent major surgery
Trauma
Immobilization
Antiphospholipid antibodies
Malignancy
Pregnancy
Oral contraceptives
Myeloproliferative disorders
name 4 hereditary risk factors for DVT
Factor V Leiden
Prothrombin gene mutations
Protein S or C deficiency
Antithrombin deficiency
name the wells criteria for DVT (10)
Paralysis, paresis or recent orthopedic casting of lower extremity
Bedridden >3 days recently or major surgery within 4 weeks
Localized tenderness of the deep veins
Swelling of entire leg
Calf swelling 3 cm greater than other leg (measured 10 cm below the tibial tuberosity)
Pitting edema greater in the symptomatic leg
Non-varicose collateral superficial veins
Active cancer or cancer treated within 6 months
Previously documented DVT
-2 points for 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)
name 3 upper extremity DVT causes
Central venous catheter, recent pacemaker, malignancy
Note distal thrombosis may extend proximally in 20% (repeat in 7 days if suspect DVT)
duration for anticoagulation of DVT and which Rx to use
Anticoagulate for initial 3 months, consider indefinite in unprovoked and cancer (and low risk bleeding)
LMWH or IV heparin (5000 units bolus then 20 units/kg/hr target aPTT 2-3x control aPTT) overlap with warfarin for minimum 5 days and INR >2 for minimum 2 days
Subcutaneous LMWH (eg. Dalteparin 100 U/kg SC daily or Enoxaparin 1.5mg/kg SC daily) or IV heparin x 5-10 days, then dabigatran 150mg PO BID
LMWH x 1 month then DOAC or warfarin
DOAC
when to consider warfarine more than DOAC for anticoagulation
Consider Warfarin in valvular A Fib, CrCl<30, Antiphospholipid syndrome, Weight >120kg, Gastric bypass, Liver failure
name 4 doacs for the tx of DVT
Apixaban 10mg PO BID x 1 week, then 5mg PO BID (can decrease to 2.5mg PO BID after 6 months)
Rivaroxaban 15mg PO BID x 3 weeks then 20mg PO daily (can decrease to 10mg PO daily after 6 months)
Note: Dabigatran and Edoxaban require 5-10 day initial treatment bridge with LMWH
which anticoagulant is better in pregnancy and cancer
LMWH preferred in Cancer and in Pregnancy, advantages include fixed/simple-dosing and lower HIT
There is some evidence that apixaban can be used as an alternative for patient with cancer who do not want injections (but avoid in upper GI malignancy due to increased rate of bleeding)
can you use asa for anticoagulation, DVT
Only consider Aspirin in those who are adverse to long-term anticoagulation (32% reduction of recurrent VTE vs 82% when on oral anticoagulants)
Isolated distal DVT anticoagulation reasons to treat
if symptomatic and risk factors for extension (severe symptoms, >5cm in length, multiple deep veins, close to popliteal veins, no reversible risk factor, previous VTE, in-patient, positive D-dimer) or progression on imaging
treatment of superficial vein thrombosis
topical/oral NSAIDs for symptoms, if >5cm consider low-intermediate dose LMWH
when to do surgical intervention in thrombosis
Urgent surgical intervention for phlegmasia cerulea dolens (extensive thrombosis which can cause irreversible ischemia, necrosis, gangrene)
When to use anticoagulants as prophylaxis and for how long
Hip/knee arthroplasty, hip fracture = 14-35 days
Major orthopedic trauma, Complicated Spine Surgery, Isolated below-knee fracture, L/E amputation, bedrest = until discharge
what are the sx of post-thrombotic syndrome
Signs of chronic venous insufficiency (usually 6 months) after a DVT (extremity pain, heaviness, cramps, paresthesias, pruritus, venous dilation, edema, pigmentation, skin changes, and venous ulcers)
Occurs in 50% of patients within one year of thrombosis, 5-10% severe PTS
risk factors of post thrombotic syndrome
Elderly, obesity
Smoking
Primary venous insufficiency, varicose veins
Proximal DVT, residual thrombus after treatment, recurrent DVT, inadequate anticoagulation
treatment of post thrombotic syndrome
(similar to chronic venous disease)
Smoking cessation, weight loss if obesity
Elevation
Exercise training
Compression stockings/bandages (30-40mmHg) or Compression device
prevention of post thrombotic syndrome
If at risk of PTS, consider compression stockings (start within two weeks of diagnosis, after anticoagulation started, and continue for two years)
sx of dehydration
Increased thirst
Decrease urine/sweating/tears
Weight loss
Altered mental status, lethargy, irritability
P/E findings of dehydration
Vital signs
Orthostatic vitals (HR↑ >30bpm, sBP ↓> 20 or dBP ↓> 10mmHg)
Tachycardia, tachypnea
Hypotension in severe hypovolemia
Altered mental status
Dry mucosa
Sunken eyes
Skin turgor
Capillary refill >3s
Decreased urine output
degrees of dehydration and treatment of each
Mild (3-5% volume lose) - Absent clinical signs
Home-based treatment
Moderate (6-9% volume loss) - Tachycardia, orthostatic hypotension, decreased skin turgor, dry mucous membranes, irritability, delayed capillary refill, deep respirations, possible decreased urine output/tearing and sunken fontanelle
ORT (eg. Pedialyte, Enfalyte, breastmilk) x 1 hour, re-assess
If concerned, see treatment for severe
Severe (≥10% volume loss) - “Near-shock” hypotension, lethargy, altered mental status, delayed capillary refill, cool/mottled extremities, tachypnea
Requires aggressive isotonic fluid resuscitation to prevent tissue injury
20-40mL/kg IV NS over one hour
Consider labs (concern if pH < 7.32, bicarb ≤ 17 mEq/L)
indication for IV hydration in dehydration
Inability for oral intake (mental status, ileus)
Inability to administer ORT (eg. no caregiver)
Persistent vomiting
Electrolyte abnormalities where ORT cannot be monitored
Medications
Can consider one dose of oral ondansetron to reduce vomiting and facilitate ORT
labs for dehydration
Venous or Capillary Blood Gas (pH, electrolytes) +/- serum electrolytes
fluid maintenance 4-2-1- rule
Maintenance in Children (4-2-1 rule)
1-10kg = 4 x Wt (kg) mL/hr
>10-20kg = 40 + 2 x (Wt over 10kg) mL/hr
>20kg = 60 + 1 x (Wt over 20kg) mL/hr
Max of 100mL/hr
Can use D5NS
causes of dehydration
Acute illness
GI (N/V/D)
Skin (Fever/burns)
New medications (diuretics)
when to screen for DB2
Screen with FPG and/or A1C q3 years if ≥40 years old or high risk (33% chance of DM2 within 10y)
Consider screening more frequently (q6-12 months) if very high risk (50% chance of DM2 in 10y)
A1C not recommended for diagnosis in children, pregnant women or suspected DM1
Risk factor for DB2
≥40 years old
First degree relative with DM2
High risk population (eg. Aboriginal, African, Asian, Hispanic, or South Asian descent)
Prediabetes (IGT, IFG, A1C 6-6.4%)
Gestational diabetes mellitus (GDM) or delivery of a macrosomic infant
Presence of end organ damage associated with DM
Microvascular – retinopathy, neuropathy, nephropathy
Macrovascular – coronary, cerebrovascular, peripheral vascular disease
Presence of vascular risk factors
HDL cholesterol level <1.0 mmol/L in males, <1.3 mmol/L in females
Triglycerides 1.7 mmol/L
Hypertension, Overweight, Abdominal obesity
Presence of associated diseases
PCOS, Acanthosis nigricans, OSA
Psychiatric disorders (bipolar, depression, schizophrenia), HIV
Use of drugs associated with DM
Glucocorticoids, atypical antipsychotics, HAART
Other secondary causes
how to dx DB2
Diagnose Diabetes if two tests confirm (may do same test twice on different days)
FPG ≥7.0 mmol/L (8h fasting)
A1C ≥6.5% (falsely ↑ in anemia; ↓ in pregnancy and renal disease; ↕ in hemoglobinopathy)
2hPG in 75g OGTT ≥11.1 mmol/L or random PG ≥11.1 mmol/L
Consider 2hPG in 75g OGTT to identify IGT (2hPG 7.8-11) vs. diabetes (2hPG ≥11.1)
If FPG 6.1-6.9 or A1c 6-6.4%
If FPG 5.6-6 or A1c 5.5-5.9% and ≥1 risk factor
Diagnose Prediabetes if
A1c 6–6.4%
IFG (FPG 6.1-6.9)
IGT (2hPG 7.8-11)
Dx of metabolic syndrome
Elevated waist circumference
Elevated TG
Reduced HDL-C
Elevated BP
Elevated FPG
name classes of antidiabetics
If A1c <1.5% above target, consider 3-6mo lifestyle
Biguanide - Metformin
Sulfonylurea (avoid with short-acting insulin)
Gliclazide (Diamicron) -Least hypoglycemias out of sulfonylureas
DPP4i (rare risk of pancreatitis)
Sitagliptin (Januvia) 100mg PO daily / Janumet (Combo with metformin)
Linagliptin (Trajenta) 5mg PO daily / Jentadueto (Combo with metformin)
Saxagliptin (Onglyza) caution in heart failure / Komboglyze (Combo with metformin)
GLP1R agonists (weight loss, contraindicated in thyroid cancer, rare risk of pancreatitis)
Liraglutide (Victoza) 0.6mg SC daily x 1 week then 1.2mg SC daily (max 1.8mg SC daily)
Dulaglutide (Trulicity) 0.75mg SC weekly (max 1.5 mg SC weekly)
Semaglutide (Ozempic) 0.25mg SC weekly x 4 weeks then 0.5mg SC weekly (max 1mg SC weekly)
SGLT2i (risk of genital infections/UTI, hypotension, caution with loop diuretics)
Empagliflozin (Jardiance) 10mg PO daily x 1 week then 25mg PO daily / Synjardy (Combo with metformin)
Canagliflozin (Invokana)
Dapagliflozin (Forxiga)
If clinical CVD consider empagliflozin (or canagliflozin) and liraglutide
If comorbid NAFLD consider semaglutide, liraglutide, thiazolidinones
If symptomatic hyperglycemia or DKA/HHS
Consider starting insulin +/- metformin
Long-acting: Glargine (Lantus) or Detemir (Levemir)
Intermediate-acting: Humulin N, NPH
Short-acting: Novorapid, Humalog, Apidra
target hba1c for DB2 patients
Diabetes Canada recommends
6.5 in healthy
A1c ≤7.0 in most patients
7-8.5 in elderly, limited life expectancy, or recurrent severe hypoglycemia
target glycemia lebels when self-monitoring
Target preprandial 4-7 mmol/L, 2hr postprandial 5-10 mmol/L (or 5-8 if A1C not at target)
4 causes of glucose not at target
Missed dose, wrong dose (fear of hypoglycemia)
Injection Technique, Lipodystrophy
Insulin conservation (temperature exposure, expired)
Infection/inflammation
complications of DM
Macrovascular: CVD, CVA, PAD
Microvascular: Retinopathy, nephropathy, neuropathy
Other:
Erectile dysfunction (macro/microvascular)
Foot complications (ulceration, Charcot arthropathy)
Infection
How to FU DB2 and what to check for at follow ups
A1c q3 months (until stable)
Each visit
BMI (18.5-24.9)/waist circumference
BP<130/80
Depression screening (PHQ-9)
Erectile dysfunction (Consider PDE-5 inhibitor if no contraindications)
name 4 counselling points for DM patients
Nutrition (Mediterranean diet, low glycemic index)
Physical activity (aerobic >150mins/week, resistance 3 sessions/week)
Smoking cessation
Pre-conception counselling
Enquire about hypoglycemia
Driving safety
tests to do to monitor for DB2
-Lipid profile q1y (until statin started)
EKG
-Nephropathy q1y (if evidence of nephropathy - follow q6months)
eGFR (creat) and Urine ACR (albumin:creatinine ratio)
At least 2 of 3 random urine ACR abnormal to diagnose nephropathy (2-20 microalbuminuria, >20 overt nephropathy)
-Retinopathy optometry q1-2y
If established retinopathy, refer to ophthalmology and consider fenofibrate/statins to slow progression
-Neuropathy q1y
Monofilament - Score 0, 0.5, 1 point x4 per foot arrhythmically
Score 3/8=likely neuropathy, 3.5-5/8 = high risk in next four years, >5.5/8 = low risk neuropathy in next four years
Vibration perception tests (tuning fork, one point if perceived, one point for when stopped)
Treatment for pain: Consider Nortriptyline as first-line
-Foot Care q1y
Skin changes, structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and PAD, ulcerations and evidence of infection
Foot care education (including counselling to avoid foot trauma), professionally fitted footwear and early referrals to a healthcare professional trained in foot care management if foot complications occur
Treat ulcerations with glycemic control, infection, offloading of high-pressure areas, lower-extremity vascular status and local wound care.
indication to screen resting ECG q 3-5 years in pts with DB2
Age >40 years
Duration of diabetes >15 years and age >30 years
End organ damage (microvascular, macrovascular)
Cardiac risk factors
when to test for EKG stress test as initial test
Typical or atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
Signs or symptoms of associated diseases
Peripheral arterial disease
Carotid bruits
Transient ischemic attack
Stroke
Resting abnormalities on ECG (e.g. Q waves)
hypoglycemia definition
symptoms of hypoglycemia, a low plasma glucose level (<4.0 mmol/L for patients on antihyperglycemic agents), and symptoms responding to the administration of carbohydrate
sx of hypoglycemia, name 2 categories and 5 sx for each category
Neurogenic (autonomic)
Trembling
Palpitations
Sweating
Anxiety
Hunger
Nausea
Paresthesias
-____________
Neuroglycopenic
Difficulty concentrating
Confusion
Weakness
Drowsiness
Vision changes
Difficulty speaking
Headache
Dizziness
when and how to tx for hypoglycemia
Treatment (if glucose if <4.0 mmol/L)
15g carbohydrate (glucose or sucrose tablets/solution), recheck glucose 15 minutes and if <4.0 mmol/L can repeat
If severe (unconscious), Glucagon 1mg SC/IM or D50W 20-50mL IV over 1-3 minutes (Glucose 10–25g)
which medications other than antidiabetics should we consider in DB2 and what are the indications
statin+ACEi/ARB+ ASA: if CAD, PAD, cerebrovasc/carotid disease
statin+ACEi/ARB: if reinopathy, kidney disease, neuropathy, over 55 yo with other CV risk factors
If over 40 yo or if over 30 yo with db over 15 years: statin
T or F: avoid canagliflozin in patients with risk factors for lower limb amputations
T
BP targets in DB
under 130/80
ABCDES of Diabetes Care
A A1C targets
GUIDELINE TARGET (or personalized goal)
A1C ≤7.0%
If on insulin or insulin secretagogue, assess for hypoglycemia and ensure driving safety
B BP targets
BP <130/80 mmHg
If on treatment, assess for risk of falls
Cholesterol targets
LDL-C <2.0 mmol/L
ACEVARB (If CVD, age 255 with isk factors, OR diabetes complications)
Statin (if CVD, age >40 for Type 2, OR diabetes
D
Drugs for CVD risk reduction
complications)
ASA (if CVD)
SLGT2i/GLP1ra with demonstrated CV benefit (if have type 2 DM with CVD and A1 C not at target)
150 minutes of moderate to vigorous aerobic activity/ week and resistance exercises 2-3 times/week
E
Exercise goals and healthy Eating
*Follow healthy dietary pattern (i.e. Mediterranean diet, low glycemic index)
Cardiac: ECG every 3-5 years if age >40 OR diabetes complications
Foot: Monofilament/Vibration yearly or more if
S
Screening for complications
abnormal
Kidney: Test eGFR and ACR yearly, or more if abnormal
Retinopathy: yearly dilated retinal exam
If smoker: Ask permission to give advice, arrange
S
Smoking cessation therapy and provide support
Set personalized goals (see “individualized Goal
S
Self-management, Setting” panel)
stress, other barriers Assess for stress, mental health, and financial or other
concerns that might be barriers to achieving goals
Hyperosmolar Hyperglycemic State (HHS) sx
Polyuria, polyphagia, polydipsia
Headache, fatigue, decreased LOC
Nausea/vomiting
Abdominal pain
If abdominal pain does not improve as ketoacidosis improves, consider other pathologies for abdominal pain
Physical Examination findings of hhs
Dehydration, postural hypotension, tachycardia, tachypnea
Resp: Kussmaul respiration, acetone-odoured (fruity) breath
Abdo: Diffuse abdominal tenderness
Neuro: LOC, pupils
dx of HHS and lab values
Develops over days
Plasma glucose >33
pH >7.3, Bicarb >15, no ketones
Serum osmolality >320mOsm/kg
dx of DKA and associated lab values
Develops over hours
Typically, anion gap metabolic acidosis (although vomiting may cause a normal pH and normal bicarb)
-Arterial/venous pH ≤7.3
-serum bicarbonate ≤15 mmol/L
-anion gap >12 mmol/L
Positive ketones in serum and/or urine (acetoacetate)
-β-hydroxybutyrate level >1.5 mmol/L has a sensitivity of 98-100% and specificity of 78.6-93.3%
Ketosis differential:
-DKA
-Alcoholic ketoacidosis
-Starvation ketoacidosis
-Isopropyl alcohol ingestion
Plasma glucose usually ≥14.0 mmol/L
-Can be euglycemic DKA (eg. SGLT2, pregnancy, chronic pancreatitis, bariatric surgery), will need immediate dextrose infusion
Triggers of hyperglycemia
Infection (30%)
New diagnosis of diabetes (25%)
Insulin non-adherence (20%)
Infarction (ACS, CVA, mesenteric ischemia)
Alcohol
Trauma
Medications (eg. glucocorticoids, diuretics, atypical antipsychotics)
Abdominal pathology
Pregnancy
investigation to ask in context of HHS or DKA
Blood gas, including lactate
Anion gap = [Na+] – [Cl−] – [HCO3−], if >10-12mEq/L consider elevated anion gap differential
Serum osmolality (HHS)
CBC, Chem-10 (Ca, Mg, Phos)
LFTs, albumin, CK
bhCG
Capillary Ketones
Serum ketones +/- serum beta-hydroxybutyrate level
Urinary ketones (more false negatives and false positives)
Consider
Lipase (note can be increased by DKA)
Infectious work-up
UA
Blood/urine cultures
CXR
EKG
Troponin (only if EKG suggests ischemia)
Serum ketons (β-hydroxybutyrate) if diagnosis unclear
Treatment of HHS or DKA
ABC, vitals
Fluid resuscitation
Bolus
NS 10mL/kg (or 1L) bolus IV
If persistent tachycardia or hypoperfusion, repeat until euvolemic (HR<100)
Maintenance
See table below for rates in pediatrics
In adults, eg. 0.9% NS 250mL/h x 4-6h then 0.45% NS 250mL/h (to avoid hyperchloremic metabolic acidosis
Add IV dextrose when serum glucose <14.0 mmol/L (maintain glucose 12-14)
eg. D5W 0.5%NS or D5W 0.45%NS
If glucose <4, provide 1 amp of D50 and increase dextrose infusion
Avoidance of hypokalemia
Add KCl 40 mmol/L when serum K<5.0 mmol/L and patient has urinated (cardiac monitoring needed, caution in renal failure- ensure urine output)
Consider oral potassium
Magnesium/phosphate replacement as needed
Insulin administration (avoid initially in HHS)
Hold insulin if K<3.3
If mild-moderate DKA (pH 7.1-7.29, HCO3 5-14.9)
After one hour of fluids, Humalog 0.15 Units/kg/dose (or 10 units) q2h
If severe (pH<7.1, HCO3<5)
After one hour of fluids, Humulin R infusion of 0.1 units/kg/h (0.05 units/kg/h for HHS)
If glucose does not fall by 3mmol/L in first hour, check IV access and if normal consider doubling insulin
Bolus may increase hypoglycemic events without clinical benefits
If hypoglycemia give more glucose, do not stop insulin (to avoid more ketoacidosis)
Avoidance of rapidly falling serum osmolality (risk of cerebral edema)
Suspect cerebral edema if sudden headache, altered LOC and lethargy, irritability in young children, Cushing’s triad (high BP, low HR, low RR)
Manage ABC, raise head of bed 30 degrees, restrict fluid
Consider mannitol 0.25-0.5g/kg IV over 30 mins OR hypertonic 3% NS 5-10mL/kg over 30 mins
Search for precipitating cause (infection, drugs, thyrotoxicosis, adherence to medication, new diabetes, MI, stroke)
how to monitor a patient with HHS/ DKA
Repeat serum glucose q1h
Repeat VBG (pH, electrolytes), plasma osmolality (for HHS) q2-4h until stable
Anion gap = [Na+] – [Cl−] – [HCO3−] (may consider adjust for albumin with other more complicated formulas)
Monitor for Osmolality
Calculating osmolality
Measure or calculate osmolality (2 [Na+] + [glucose] + [urea] in mmol/L)
Aim for gradual decline, especially in patients under 40 years old (eg. 3 mmmol/kg/hr or 20mOsm/kg/day)
If osmolality increase
Fluid balance inadequate, increase rate of 0.9%NS
Fluid balance adequate, consider switch to 0.45%NS
If osmolality decreasing >8mosmol/kg/h, consider reducing IV fluids
Name goals of tx of DKA and HHS
Avoid overly aggressive therapy which will cause complications (hypokalemia, cerebral edema)
Most patients with DKA (especially those with HHS) probably need admission and observation,
DKA:
Normalization of the plasma anion gap <12 mEq/L
Ketoacidosis resolved
Normalization of bicarbonate
Glucose controlled <14 mmol/L
HHS: Mentally alert, and osmolality <315 mOsmol/kg
Patient eating and ideally hungry
-Received full daily dose of long-acting insulin >2 hours (Consider SC insulin regimen once glucose <11.1)
DDX of acute diarrhea
Acute: 2-14 days of looser and more frequent stools (>3 stools/day or >200g stool/d)
Parasitic - Giardia, cryptosporidia, cyclospora, isospora, amoebiasis
Bacteria - Campylobacter, salmonella, shigella, listeria, C diff, S Aureus, Clostridium perfrigens
Symptoms suggestive of invasive bacterial diarrhea include fever, tenesmus, gross bloody stool
Viral - Hep A, rotavirus, norovirus
Travel - ETEC, norovirus, shigella, salmonella, campylobacter, giardia
Daycare - Campylobacter, cryptosporidia, parvum
Hospital - C Diff, norovirus, rotavirus (children)
DDX of chronic diarrhea
Chronic: >4 weeks
Function - IBS (10-20%), overflow constipation, incontinence
Osmotic - Lactose, sugars (sorbitol, mannitol), laxatives
Inflammatory - IBD, microscopic/collagenous colitis
Metabolic - Addison’s, hyperthyroid, uremia, cystic fibrosis
Malabsorption - Pancreatitis, celiac, short bowel syndrome, bacterial overgrowth
Neoplastic - Colorectal cancer, carcinoid, gastrinoma, medullary thyroid
Iatrogenic - Drugs, alcohol, caffeine, surgery, radiation, laxatives
definitions/differences between secretory, osmotic, large bowel and small bowel diarrhea
Secretory: Continues despite fasting
Osmotic: Decreases with fasting (malabsorption, drugs)
Large Bowel: Small volume, frequent, pus, blood
Small Bowel: Large volume, infrequent, watery
6 risks factors of diarrhea
Travel
Immunocompromised
Food outbreaks
Antibiotics
Family History
Laxatives
7 red flags in hx of diarrhea
Age >50 (think of acute mesenteric ischemia, obstruction, diverticulitis, malignancy)
Immunocompromised (HIV, steroid)
Inflammatory features (fever, bloody, mucoid stool)
N/V, fever, arthritis, skin rash, anorexia
Night sweats, weight loss
Nocturnal (pathologic)
Recent antibiotics (C-diff)
targeted hx of diarrhea
Diarrhea onset, duration, severity, frequency, quality (watery, bloody, mucus, purulent, bilious)
Signs of dehydration (decreased urine output, altered mental status)
Vomiting (viral or toxin)
Fever, tenesmus, bloody (invasive bacterial)
Food/Travel
Pregnant (12x risk of listeriosis - cold meats, soft cheeses, raw milk)
Recent sick contacts, antibiotics, medications
Immunosupression
Exposures (daycare, fecal-oral sexual contact, hospital admission)
which investigations to ask in diarrhea
Usually not indicated unless severe illness or red flags
Consider
CBC, CRP, TSH, Celiac (IgA, anti-TTG)
FOBT or FIT
Stool leukocytes/lactoferrin/calprotectin (r/o IBD)
Stool cultures if leukocytes positive or risk factor/red flag (eg. symptomatic bloody diarrhea)
C-diff toxins A/B done if unexplained diarrhea after 3d of hospitalization or high risk (eg. antibiotic use)
Ova and parasites if high-risk (travel to high-risk area, infants in day care, immunosuppresssed, MSM, waterborne outbreak, bloody diarrhea with few fecal leukocytes)
If available, consider Giardia antigen test or PCR
C-scope if altered bowel habit +/- rectal bleeding
Treatment of diarrhea
Rehydration (oral if possible)
Consider reduced oral rehydration solution (ORS): water with salt and glucose
Early refeeding
No clear evidence for BRAT diet (banana, rice, applesauce, toast) and avoidance of dairy
Loperamide/simethicone in non-bloody stool and afebrile
Consider empiric antibiotics in severe symptomatic bloody diarrhea or immunocompromised
Fluoroquinolone or Azithromycin (if resistance, eg. from South East Asia)
Antibiotics effective in shigella, campylobacter, C diff, traveler’s diarrhea, protozoal
Avoid use in toxin (bloody, history of eating seed sprouts, rare beef, outbreak) risk Hemolytic uremic syndrome
2 tips for prevention of diarrhea
Hygiene (handwashing, diaper changing, water purification), safe food preparation, clean water
Vaccine (rotavirus, typhoid fever, cholera)
No clear evidence for probiotics, zinc supplementation
Return to school ≥48h last diarrhea/vomiting (NICE)
classify the different types of dizziness
Vertigo: Sustained (r/o stroke) vs. Episodic
Non-vertigo:
Syncope (r/o CVS, seizure, hypoglycemia)
Pre-syncope (r/o CVS)
Disequilibrium (r/o neuromuscular)
Lightheadedness
DDx of vertigo (10)/ dizziness
Acute prolonged severe vertigo (Stroke, demyelinating disease, vestibular neuronitis)
Recurrent spontaneous attacks, minutes-hours (Meniere, Vestibular Migraine)
Recurrent positional, seconds-minutes (BPPV)
Chronic persistent dizziness (Psychogenic, cerebellar ataxia)
arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis
measure postural vital signs to r/o orthostatism
Exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding)
prescription and over-the-counter medications
name 10 red flags in hx of vertigo
Diplopia, Dysarthria, Dysphonia, Dysphagia, Dysmetria
Multiple transient prodromal episodes of dizziness over weeks/months
Headache, neck pain, recent trauma (vertebral artery dissection/aneurysm)
Auditory symptoms (despite mimicking benign peripheral causes, hearing loss in acute vestibular syndrome is frequently associated with stroke)
Neuro signs: Facial palsy, sensory loss, limb ataxia, hemiparesis, oculomotor (Internuclear ophthalmoplegia, gaze palsy, vertical nystagmus)
Gait unsteadiness
Difference in nystagmus to differentiate neuro vs peripheral vertigo
Peripheral: Unidirectional, Horizontal nystagmus, Suppressible with visual fixation, Positional
Central: Uni or Bi-directional, Purely vertical/horizontal/torsional nystagmus, Not suppressible, Not positional (ie. Central is usually Spontaneous)
explain the HINTs exam
HINTS+ only in Acute Vestibular Syndrome (to differentiate stroke from vestibular neuritis) in patients with current nystagmus
Head Impulse - Rapid head rotation towards mid-line with eyes fixed on object (normal suggests central cause)
Nystagmus - Vertical/bidirectional/torsional (note torsional is expected in episodic BPPV, but not in acute vestibular syndrome due to peripheral cause)
Test of Skew - Skew deviation or misalignment on cover-uncover test
Presence of one INFARCT (impulse normal or fast-phase alternating or refixation on cover test) may be more accurate to diagnose stroke than urgent MRI
Negative INFARCT (abnormal head impulse, horizontal unidirectional nystagmus, no skew deviation), but may not be enough to rule out stroke in the emergency room
+ Hearing loss, rule-out AICA infarct
If no nystagmus, will need to rely on detailed neurological exam (CN, hearing, anisocoria, phonation, facial sensation, cerebellar ataxia, gait)
investigations to do in context of dizziness
EKG (r/o Arrhythmia, MI)
CBC, Lytes, TSH (Low yield)
MRI (83% sensitive), CT (16% sensitive)
MRI can miss stroke (20% false negative) until 48h after symptom
Treatment of vertigo (BPPV, meniere, vestibular neuritis)
General acute symptomatic management of vertigo: Antihistamines, Benzodiazepines, Antiemetics
Peripheral (early ENT referral as needed, and vestibular rehab)
BPPV (episodic seconds, head position)
Epley maneuver
Sermont maneuver
Gufoni maneuver in horizontal canal BPPV
Betahistine 24mg PO BID limited evidence
Meniere’s (episodic minutes-hours, hearing loss, tinnitus/ear fullness)
Limit salt, caffeine, nicotine, alcohol
Betahistine, Diuretic
Vestibular neuritis and Labyrinthitis (single acute onset, lasts days, possible viral syndrome)
Methylprednisone 22-day tapering dose schedule
Supportive
Central
Vestibular migraine (episodic minutes-hours with migraine headache)
Brainstem or cerebellar infarct (persistent over days-weeks, vascular risk factors, prominent gait impairment) or TIA (episodic minutes-hours, vascular risk factors)
MRI
Evaluation for Thrombolysis/Thrombectomy
Secondary risk management
Antihypertensives if BP >140/90
Aspirin or clopidogrel
Atorvastatin 80mg/day (SPARCL trial)
Carotid endarterectomy for recent symptom
Holter-24-48h r/o Afib
Echocardiography
Lifestyle
Glucose control if diabetic
Eliminate alcohol, smoking
Exercise
Referral
ENT, Neurology, Psychiatry
Vestibular rehab
PT/OT
Risk factors of domestic abuse (4)
Young female (<24yo)
Low SES
Pregnancy
Disability
Unemployment
Witnessing or experiencing violence as a child
Substance abuse (alcohol/drug use)
History of mental illness
Risk factors for perpetration of domestic abuse
Unemployment
Witnessing or experiencing violence as a child
Substance abuse (alcohol/drug use)
History of mental illness
Woman Abuse Screening Tool (WAST), 90% sensitivity with first two questions
name questions and how to communicate with patient if abuse is detected
In general, how would you describe your relationship? No tension, some tension, a lot of tension?
Do you and your partner work out arguments with no difficulty, some difficulty, or great difficulty?
Do arguments ever result in you feeling down or bad about yourself?
Do arguments ever result in hitting, kicking, or pushing?
Do you ever feel frightened about what your partner says or does?
Does your partner ever abuse you physically?
Does your partner ever abuse you emotionally?
Does your partner ever abuse you sexually?
Listen
Acknowledge the injustice
“This is abuse”
“I am very sorry this is happening to you”
Frame the violence due to perpetrator’s behaviour and not the survivor’s
“You do not deserve this, and it is not your fault”
Respect autonomy and patient’s decisions
“I want to help you through this in any way I can.”
questions to assess for safety in domestic abuse
Violent outside the home
Violent to children
Threatening to kill
Escalating threats
Drugs, alcohol
Abusive during pregnancy
Obsessive, controlling relationships
Serious prior injury
Owns weapons, especially handguns
Threatened others (family/friends)
management of domestic abuse
Safety planning, resources, community services including local shelters
Emergency kit with important documents, keys, money, essential items - stored outside the home
Place to go (friend, family shelter)
Signal to alert others (children/neighbours) to call 911
Document findings
Quotes from patient
Physical exam findings and photographs
Labs/radiology
Mandatory reporting may be required in the following instances:
Abuse involving children
Contact Youth Protection
Abuse of elderly (in retirement home)
Abuse of disabled persons
Weapon use
Frequent follow-up
Counsel on possible escalation/cycles of violence (tension build up, violent outburst, honeymoon phase)
Update safety plan
anorexia nervosa definition
Restriction of energy intake relative to requirements, leading to a significantly low body weight (BMI<18.5 or <5th percentile in children, or rate of weight loss) in the context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
2 types of anorexia nervose
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Bulimia nervosa definition
Recurrent episodes of binge eating, characterized by both of the following:
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa.
Avoidant/Restrictive Food Intake Disorder (ARFID)
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional supplements.
Marked interference with psychosocial functioning.
The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
screening questions for eating disorders
Does your weight/body shape cause you stress?
Recent weight changes?
Dieted in the last year?
SCOFF
Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
Do you worry that you have lost Control over how much you eat?
Have you recently lost more than One stone (14 lb {6.4 kg}) in a three-month period?
Do you think you are too Fat, even though others say you are too thin?
Would you say that Food dominates your life?
8 risk factors of eating disorders
Early puberty
Poor or abnormal growth curves in children and adolescents
Low or high body mass index, or weight fluctuations
Weight concerns among normal weight individuals
Activities and occupations that emphasize body, shape, and weight (e.g. ballet, gymnastics, modeling)
Amenorrhea (primary or secondary)
Type 1 diabetes
Family history of ED
10 associated physical symptoms of eating disorders
Exertional or chronic fatigue, weakness, dizziness, pre/syncope, hot flashes, cold intolerance, depression
Cardio: Palpitations, CP, SOB, peripheral edema
Dental: Tooth pain (decay/cavities), mucosal bleeding/trauma and parotid gland enlargement
GI: Abdominal pain, early satiety, bloating, constipation
Endo: Amenorrhea, decreased libido, infertility
Derm: Hair loss, brittle nail and skin changes, poor healing
(other questions to ask: Rate/amount of weight loss
Dietary intake (quantity, restriction)
Compensatory behaviour (vomiting, laxatives, diuretics, exercise)
Attitudes about weight / Body image
Mood symptoms, suicidality
Menstrual history)
10 physical exam of Eating disorder
Vital Signs (eg. HR<60, BP<90/60, Temp<36)
Orthostatic vitals (supine, standing)
General Appearance
Height/Weight and BMI; weight in kilograms divided by height in meters squared
Hydration status
HEENT
Enlargement of parotid or submandibular salivary glands in BN
Dental erosion due to frequent vomiting
Cardiac, r/o murmur
Skin
Brittle hair and fingernails
Lanugo hair
Dry skin
Pretibial edema
Russell sign (callous on MCP from teeth abrasion during self-induced emesis)
MSK
Muscle strength
Sit-up Squat Stand test (muscle weakness)
10 Investigations of eating disorder
Determine level of medical acuity
EKG
Bradycardia, non-specific ST-T wave changes including ST segment depression, U waves in the presence of hypokalemia and hypomagnesemia
CBC (hemoglobin, leukocytes, platelets)
Serum electrolytes (Na, K, Glucose, Blood urea nitrogen, Creatinine, Calcium, Magnesium, Phosphate)
TSH, T4, T3
Liver function tests (AST, ALT, bilirubin)
Amylase/lipase
Albumin, transferrin
UA
BhCG r/o pregnancy
Consider celiac screen
If underweight > 6 months
Bone densitometry to assess for osteopenia and osteoporosis
Abdominal ultrasound to assess maturity of ovaries and uterus
FSH, LH, and estradiol levels in females
Testosterone levels in males
10 non-negotiable physical and nutritional indicators for hospitalization
Suicide risk, food refusal
Vitals unstable
Core temperature < 35.5°C or 95.5°F
Heart rate < 40 beats per minute or severe bradycardia
Blood pressure < 90/60 mm Hg or orthostatic hypotension
ECG arrhythmia
Electrolyte abnormalities
Sodium < 127 mmol/l
Potassium < 2.3 mmol/l
Hypoglycaemia; blood glucose < 2.5 mmol/l
Hypophosphataemia; phosphorous below normal on fasting
Magnesium < 0.6 mmol/l (normal above 0.7 mmol/l)
Rapid and progressive weight loss
Acute medical complications of malnutrition
Signs of inadequate cerebral perfusion (confusion, syncope, loss or decreased level of consciousness, organic brain syndrome, ophthalmoplegia, seizure, ataxia)
Seizure
Heart failure
Pancreatitis
Severe acrocyanosis
Dehydration that does not reverse within 48 hrs
Muscular weakness
Comorbid psychiatric or medical (poorly controlled diabetes type 1)
Pregnancy with an at risk foetus
Inadequate weight gain, failure of outpatient treatment
3 pharmacology tx to consider in eatign disorder
SSRI / Fluoxetine at higher doses (60mg/d) in BN
Multivitamins with iron and Vitamin D
Consider Zinc 50mg PO daily (aids in weight gain)
Treat acne (as patient re-experience puberty as they gain weight)
3 pharmacology tx to consider in eatign disorder
SSRI / Fluoxetine at higher doses (60mg/d) in BN
Multivitamins with iron and Vitamin D
Consider Zinc 50mg PO daily (aids in weight gain)
Treat acne (as patient re-experience puberty as they gain weight)
5 non pharmalogical managements of eating disorder
Medical stabilization
Assess outpatient vs. admission if needed for safety
Assess and treat coexisting psychiatric conditions (MDE, anxiety, substance use)
Nutritional rehabilitation with multidisciplinary approach
Family-based treatment
Individual Psychotherapy, FBT/CBT (TRY THIS FISRT)
Psychiatry
Dietician / nutritional rehab
School
Support groups / resources
Consider referral to specialiset child and adolescent eating disorder team
Target weight range in AN (90% of expected weight)
Gradual weight gain in AN (1lb/week)
Limit exercise
Regular appointments with vitals, weight/BMI, and blood tests repeated
Complications (tooth decay, amenorrhea, electrolyte)
Disease activity (eating patterns, exercise, laxative)
questions to ask in motivational interviewing of eating disorder
Establishing rapport:
Open-ended questions such as, “How have things been going with your eating?” or “Do you have concerns about your eating?” or “What is most important to you about your eating and health?”
Assessing Readiness:
“How do you feel about making changes to your eating?” or “How do you feel about making changes to improve your physical health?”
Provide Feedback:
“What is your reaction to these test results?” or “Would more information be helpful?”
Offer further support targeted to level of readiness for change:
For clients who are not “ready” to make change: “What would it take for you to consider thinking about change?”
For clients who are unsure about change: “What are the things you like and don’t like about your eating disorder?”
For clients who are ready to make change: “What would you like to work on changing?”
refeeding syndrome definition and name 3 risks/complications
Metabolic changes during refeeding of a malnourished patient
Risk of hypophosphatemia leading to heart failure, arrhythmia, respiratory failure
Prevent with careful slow refeeding/monitoring and phosphate supplementation
6 ddx of eating disorder/weight loss
anorexia nervosa, bulimia,Avoidant/Restrictive Food Intake Disorder (ARFID)
diabetes, coeliac disease, hyperthyroidism, malignancies, depression, anxiety, OCD< alcohol misuse/depensdance
important questions to include in a hx for eating disorder
Eating patterns, relationship with food, body image, distress
Underlying mental health, alcohol, and substance use problems, including previous psychological trauma
Use of prescribed and over-the-counter medications, tobacco, caffeine, laxatives, and supplements
When assessing a patient presenting with a problem that has defied diagnosis (e.g., arrhythmias without cardiac disease, an electrolyte imbalance without drug use or renal impairment, amenorrhea without pregnancy) include “complication of an eating disorder” in the differential diagnosis.
10 complications of eating disorder
amenorrhea,
electrolite imbalance, muscle weakness, spinal compression/osteoporotic fractures, decreased height/weight, slow pulse, depreased core temperature, postural hypotension, gastric dilation, pressure sores, depression/SI, cardiac arrythmia, prolonged QTc, sinus bradycardia, signs of electrolyte disturbance on EKG
malnutrition:
-anemia, thrombocytopenia, neutropenia, hypophosphataemia, low ca/mg/po4, hypoglycemia,
You are seeing 3 year-old son Jaxson who is noted to have intermittent rashes over the face and extremities. You suspect atopic dermatitis. He is otherwise healthy. They have no pets at home.
What are the historical/physical exam features of this condition that will support your diagnosis? List 4.
Chronic, relapsing dermatitis
Typical morphology of the lesion: erythematous, rough/scaly, patchy
Pattern of distribution: facial and extensor involvement, joint surfaces
Pruritus/ Intense itching
Personal history of asthma
Personal history allergic rhinitis
Family history of atopy
Hyperactivity to environmental triggers
Age of onset (most common age 2-4)
4 ddx of atopic dermatitis
Psoriasis
Seborrheic dermatitis
Contact/irritant dermatitis
Impetigo
Systemic viral illness
Neurodermatitis
Dermatitis herpetiformis
Dermatophytic infection
Immunodeficiency disorder
4 treatment options of atopic dermatitis
Avoid dry skin / Optimal use of emollients/moisturizer
Topical corticosteroid cream/ointment
Avoidance of known triggers: soaps, fabrics, cleansers, metals, sweat/heat, sunscreens, stress
Topical calcineurin inhibitors/protopic/tacrolimus
Antimicrobial if infected
Oral anti-histamine for pruritus
Other than viral hepatitis, name FIVE causes of elevated hepatocellular-pattern liver enzymes.
Non-alcoholic fatty liver disease/steatohepatitis (NASH) - recommend do not abbreviate this
Chronic alcohol use/alcoholic liver disease
medication toxicity/prolonged acetaminophen use
hemochromatosis
autoimmune hepatitis
Wilson’s disease
Alpha-1-anti-trypsin deficiency
Primary biliary cirrhosis
Hepatitis B can be transmitted by various mechanisms. Name FOUR.
- Blood exposure/blood transfusion/direct contact with infected blood/Sharing personal hygiene products (razors, nail clippers, toothbrushes, jewelry)/Intravenous drug use/needle sharing/needlestick injuries
- Sexual/unprotected sex/semen/vaginal secretions
- Perinatal/vertical transmission/trans-placental
- Exposure to open sores of an infected person
Name THREE chronic complications of hepatitis B.
cirrhosis
end-stage liver disease/liver failure
hepatocellular carcinoma
If we assume a patient is chronically infected with hepatitis B, name FIVE tests or investigations that can determination the stage of his chronic infection.
HBeAg
ALT
AST
Hepatitis B DNA
abdominal ultrasound
Fibroscan
Biopsy
This is a tough one. The question states there is no doubt about the diagnosis and wants to know how we assess the phase of chronic infection. That is why Hep B core antibody, Hep B IgG and Hep B IgM are not on the answer key.
Mrs. Elouise Santos, age 54, presents at the emergency department (ED) complaining of severe right upper quadrant abdominal pain, which at times radiates to the right shoulder. She feels nauseated and has vomited twice without relief of the pain. She has been in good health in the past. Her vital signs are as follows:
Blood pressure: 142/90 mm Hg; Pulse rate: 90 bpm; Temperature: 38.2 degrees Celsius; Respiration rate: 17 bpm
What is the MOST likely diagnosis?
Acute Cholecystitis /Cholecystitis /Biliary colic
What are the possible complications of cholecystitis? List five.
Choledocholithiasis/Jaundice/Biliary obstruction
Hydrops
Empyema
Emphysematous cholecystitis
Duodenal perforation
Gallstone ileus
Pancreatitis
Hepatitis
Ascending cholangitis
Peritonitis/Perforation of the gallbladder/Necrosis/Gangrene
Sepsis
This question only asks for three answers. The exam could ask for more. Use this answer key as a study guide
Which imaging test would be BEST to confirm the diagnosis of choledocholithiasis ? Name ONE.
Endoscopic retrograde cholangiopancreatography (ERCP)
Hate to say this, but better to write out “Endoscopic retrograde cholangiopancreatography” than to rely on “ERCP” alone as your answer. It is possible that ERCP is acceptable, but since answers keys are not released, it’s hard to know for sure.
What blood tests would you consider ordering for cholecystitis (name 4)
White blood cell count (WBC)
Total Bilirubin
Alkaline phosphatase
Lipase
International Normalized Ratio (INR)/ Prothrombin time (PT) measurement
Partial thromboplastin time (PTT)
GGT
Alanine transaminase (ALT)
A 49 year-old man presents to your office with a two-week history of paraspinal lumbar pain. It started during a family vacation after a long drive. He was more active than usual while on vacation. There was no trauma. He has a desk job, and is generally sedentary. He had a knee injury playing baseball in the past, but otherwise has not had any musculo-skeletal complaints over the years. There is no significant past medical history. He denies alcohol, smoking, and IV drug use. His energy is good, and he denies night sweats, fever, and weight loss. His body mass index (BMI) is 28.
What other items on history of present illness are relevant to the presenting case? List EIGHT.
bladder changes/retention
bowel changes/incontinence
saddle anesthesia
radiation pattern
severity
quality of pain
timing of pain/is it worse at night
aggravating factors: for example, is it worse with certain movements
alleviating factors: for example, positional changes
associated features: rashes
associated features: eye/vision changes
is he taking pain killers?/need for analgesics
radicular symptoms: leg weakness
radicular symptoms: sensory changes
morning stiffness
changes in sexual function/erectile dysfunction
One buzzword in this question is “other”. It is subtle, but it means you cannot use historical items from the preamble as answers.
For history questions, most of them will relate to the history of present illness (HPI), which means that past medical history, surgical history, allergies etc are not what the question is looking for. Read the question carefully. Using a mneumonic to help you remember an approach to HPI questions can be helpful, such as OD PQRST AA.
O - onset; D- duration; P - pain, Q - quality, R - radiation, S - severity, T - timing; A - associated features (rash/GI/eye etc), A - aggravating and alleviating factors. Or use another system if you have one.
What non-pharmacologic recommendations would you offer for lumbar hernia? Name FOUR.
recommend physical activity/exercise/core strengthening
encourage walking
education about self-limiting nature of most cases of back pain
education: avoidance of bed rest
symptomatic strategies: heat/cold
encourage weight loss (goal of 10% of body weight)
ergonomic assessment at work
As per guidelines, most causes of low back pain are self-limiting. The guideline in the links document suggests not referring for physiotherapy or chiropractic right away, but rather waiting for natural resolution of symptoms before embarking on formal therapy. Since there are no red flags identified in this case, expectant management as above is indicated.
Name THREE medications in three different classes that you would consider recommending for back hernia without radicular pain
Tylenol/acetaminophen
ibuprofen/Advil
cyclobenzaprine/Flexeril
Pt returns after 12 weeks of back pain, having followed your conservative management. He continues to work. His pain is now worse. It has localized somewhat to the left side. The physical exam is unchanged.
what investigation do you want to do
Acceptable answers: lumbar x-ray AP and lateral (oblique not required given no pain with extension so you are not worried about a pars interarticularis fracture)
Imaging may be considered now because his symptoms have become chronic.
You are seeing a 2 year 6 month old Ava in your clinic for a well child check. Along with her parents, Ava has two step-siblings who live with her: a 5 year old girl, and 7 year old boy. Mom reports noticing that Ava isn’t as affectionate as the other children. She also wonders if Ava should have more language skills at her age.
Name TWO conditions on your differential that must be addressed at this visit.
Autism spectrum disorder
Child abuse
Rett’s syndrome
Hearing problems
Name FOUR domains that are assessed when determining if a child has developmental delay.
Gross Motor
Fine Motor
Speech/language
Social/emotional
Cognitive/problem solving
What TWO developmental domains are most impacted in a child with autism spectrum disorder (ASD)?
Social/emotional
speech/language
Name FIVE diagnostic features of a child with autism spectrum disorder.
inability to participate in social/emotional interactions
deficits in nonverbal communication: no/limited understanding of gestures/body language
poor eye contact
difficulties in developing relationships
evidence of repetitive movements
evidence of repetitive speech
inflexibility/adherence to routines
restricted/fixated interests
Altered/Hyper-/hypo-reactivity to sensory input
Before what age must these features be present in order to make a diagnosis of Autism Spectrum Disorder?
3 years
Name TWO classes of medications that may be used in patients with ASD to treat their co-morbid conditions.
selective serotonin re-uptake inhibitors (SSRI)
atypical anti-psychotics
anticonvulsant mood stabilizers
stimulants
alpha 2 antagonist (mirtazapine)
melatonin
Name TWO classes of medications that may be used in patients with ASD to treat their co-morbid conditions.
selective serotonin re-uptake inhibitors (SSRI)
atypical anti-psychotics
anticonvulsant mood stabilizers
stimulants
alpha 2 antagonist (mirtazapine)
melatonin
Nineteen year-old Tucker presents to your emergency department with a nosebleed which was severe three days ago and has trickled ever since. Today, he was dizzy when getting out of bed, so a friend brought him to hospital. He has never had a serious nosebleed before, but he gives a history of easy bruising. Once, after a dental extraction, he bled continuously, and was eventually given plasma and an intravenous medication which his doctor explained could also be given “up the nose”. Later he was told that he had a clotting problem, but he can’t recall the exact diagnosis. He was adopted as an infant. No medical records are available. He takes no regular medication.
On examination: HR 105 supine, 130 sitting, BP 98/60, RR 24, afebrile
Skin pale, slightly clammy
HEENT: active bleeding from L nare; controlled with pressure; gag reflex intact, airway patent
Assuming the bleeding is currently well controlled with pressure, list the THREE most important interventional steps at this point. Be specific.
- type and crossmatch for 2-4U of packed red blood cells
- Two large bore IVs with 1L normal saline running in each
- 100% oxygen by rebreather mask
List THREE laboratory investigations which will be most helpful in managing severe epistaxis
Hemoglobin
Hematocrit
Platelet count
PT/INR
PTT
Bleeding time
Where do you expect to find the source of the bleeding for epistaxis?
Little’s area/anterior inferior nasal septum/Kisselbach’s plexus
19 yo patient in ER for epistaxis was told in the past that he has a bleeding diasthesis. Name the THREE most likely diagnoses.
Hemophilia A, Hemophilia B, Von Willebrand’s disease
Pt’s previous test results become available. They are:
Prothombin time (PT): normal
Partial thromboplastin time (PTT): prolonged
Von Willebrand’s Factor Activity: pending
Factor VIII-C: decreased
Bleeding Time: prolonged
Factor IX: normal
Given these results, what is the MOST likely diagnosis?
Answer: liver disease
von Willebrand disease
Other than silver nitrate, name TWO oral or IV medications that can be used to help control the bleeding.
fresh frozen plasma/cryoprecipitate,
tranexamic acid,
DDAVP
Your nasal examination confirms active bleeding from the expected site. Cautery with silver nitrate is unsuccessful. List THREE other local interventions which might now be employed to control haemorrhage.
packing with petrolatum gauze
packing with lidocaine soaked in epinephrine
packing with cocaine
packing with sponge/merocel/nasaspore
packing with hemostatic balloon
List TWO important infectious complications from the treatment of packing nose in epistaxis
toxic shock syndrome
acute sinusitis
bacterial rhinitis
putrefication of packing
Maria is a 29 year-old female who ingested an unknown quantity of acetaminophen 12 hours ago in a suicide attempt and is brought to the ED by her mother. Her mother found no other pill bottles nearby.
What is the toxic dose of acetaminophen in mg/kg?
Acceptable answer: 150-200mg/kg (anywhere within this range)
You will not be asked many numbers on this exam, and usually the answer will only be worth 1 point, so not enough to make you fail the case if you get it wrong. Most number-related answers will accept a range. If one of your two numbers is outside the range, you risk being marked wrong, so the safest approach is to give a specific number rather than a range.
At what time point after ingestion can activated charcoal be used for decontamination?
Acceptable answer: 1-2 hours (anywhere in this range)
Name FIVE drugs or compounds that do not bind to charcoal.
Lithium, lead, solvents, iron, alcohols, hydrocarbons, potassium, pesticides, alkali, acids
There are mnemonics to help remember this list. It is unlikely that any question will ask you for the whole list.
Other than nausea, what are the TWO most likely symptoms that a patient with acetaminophen intox?
diaphoresis, vomiting
Poisoning pearls: Know indications for dialysis (AEIOU), causes of anion gap (MUDPILES)
Other poisonings/toxidromes to review: alcohol, opioids, TCAs, anti-cholinergics, cholinergics, ASA, hallucinogens (unlikely to show up on the exam), sedatives, sympathomimetics (ie cocaine: more likely to show up on the exam), salicylates, serotonin syndrome, benzodiazepines, dilantin, carbamazepine
Some years there are a couple of poisoning questions, and other years none. Best to prepare to that you will get at least one.
Other than an acetaminophen level, and levels for any other toxin, what bloodwork would you order in a case of acetaminophen intox? Name SIX.
aspartate aminotransferase (AST)
alanine aminotransferase (ALT)
international normalized ratio (INR)
partial thromboplastin time (PTT)
Alkaline phosphatase
gamma glutamyltransferase (GGT)
total bilirubin
direct bilirubin
serum albumin
serum creatinine
serum sodium
serum bicarbonate
serum phosphate
serum glucose
serum lactate (via arterial blood gas)
serum/arterial pH (via arterial blood gas)
Arterial blood gas is considered a grouped test and is never an answer on this exam. Choose the part of the ABG that you want, and use that as your answer.
In this question, I recommend not populating all six of your answers with liver tests. Choose the most important two or three.
Mr. Koph, a 59 year-old businessman, presents to your local emergency room with a three-day history of fever, productive cough, fatigue and dyspnea. He denies infectious contacts, recent travel, or recent illness. He had his second Covid-19 vaccination three months ago. He denies rhinorrhea and sore throat. He is a current smoker and has a 25 pack-year smoking history. He denies other significant past medical history apart from mild hyperlipidemia. He has no allergies.
Name FOUR items on your differential diagnosis.
Bacterial pneumonia
Viral pneumonia
Influenza
COPD exacerbation
Acute bronchitis
The reference to Covid-19 vaccination status is meant to communicate that this is most likely NOT Covid-19 infection.
Users have asked whether “asthma exacerbation” could be an answer, but this is less likely as he has no history of asthma, and this diagnosis doesn’t explain his fever.
The way the question is worded, it is pointing to an infectious cause. It is hard to know whether each answer should be a different type of infection (ie mycoplasma pneumonia, streptococcal pneumonia etc) or whether the answers should be more broad. Specific types of pneumonia could populate all four answers, but you don’t want to exclude reasonable options such as COPD and acute bronchitis. Therefore, in this case, the recommendation is to stay broad and use categories of viral vs bacterial pneumonia only.
You have a pt suspected to have pneumonia. On examination, his blood pressure is 120/80, heart rate is 96 and regular, respiratory rate is 24, O2 saturation is 93% on room air, and temperature is 38.2 degrees celcius.
What investigations do you order? Name FOUR.
serum white blood cell count and differential
chest x-ray, PA and lateral
serum hemoglobin
serum creatinine
serum sodium
Sputum cultures are rarely helpful and therefore are rarely collected in pneumonia. The culture takes at least a week and sometimes two to come back, by which time the information is usually irrelevant. Additionally, the patient is not sick enough for blood cultures (usually the patient would be admitted and septic). See the links document for exam 2 for more information.
Other than vital signs, name SIX signs on respiratory examination that would support a diagnosis of pneumonia.
diminished chest expansion
increased tactile fremitus
increased vocal fremitus/vocal resonance
dullness on percussion
diminished air entry on auscultation
bronchial breath sounds
whispering pectoriloquy
crackles
pleural rub
egophony
bronchophony
Name THREE first line antibiotics, each from a different class, that you could use to treat pneumonia in a healthy patient.
doxycycline
amoxicillin or amoxicillin/clavulanate (clavulin for comorbidities - smoking could be considered a comorbidity)
azithromycin/clarithromycin/erythromycin
Note: 1st line use of fluoroquinolone not recommended
Canadian guidelines in this area are old. In general, newer resources (such as Bugs and Drugs) are steering away from macrolides as a first-line choice due to mounting resistance. Having said that, macrolides still make the list as a first-line option with a caveat to avoid in areas where there is evidence of mounting macrolide resistance. Macrolides are still recommended for inpatient or severe pneumonia.
Here is a link to an American guideline (which I usually do not prefer to recommend) which is far newer than anything we have in Canada.
See table 3. Let’s hope the exam only asks for TWO answers. In that case, it’s easy: amoxil and doxy in healthy patients; clavulin + doxy or clavulin + azithro in patients with co-morbidities.
Explain why you would or would not admit this patient. 59 yo with 25 pack year smoking hx, otherwise healthy, LLL PNA on CXR. On examination, his blood pressure is 120/80, heart rate is 96 and regular, respiratory rate is 24, O2 saturation is 93% on room air, and temperature is 38.2 degrees celcius.
NO side: You would not admit him because he doesn’t meet criteria as per the PSI /Curb-65 score. Not hemodynamically compromised. Other than smoking no active significant co-morbid conditions. No hypoxemia (considered to be 02 sat <90%).
You may also explain answer using Curb-65, but PSI has been validated whereas Curb-65 has not been. However, PSI has higher specificity than Curb-65
YES side: You may get points as long as you explain your rationale: ie he appears septic. Then support why you feel that he is septic.
You will not be asked to regurgitate the Curb 65 or PSI criteria on the exam, but you may be asked to make a decision that utilizes the scores so you should memorize one of them (Curb 65 much easier to memorize than PSI).
On this question, most previous exam writers have answered NO.
You order a follow-up chest x-ray to ensure the absence of malignancy after you diagnose pneumonia. When would you ask the pt to do this follow-up x-ray?
6-8 weeks (any answer in this range is acceptable)
You counsel patient about preventing future episodes of pneumonia. Identify FOUR items that you would include in your discussion.
smoking cessation
avoidance of 2nd hand smoke
limit the spread of viral infections/handwashing/hand hygiene
annual flu shot
pneumococcal vaccine
Thirty year-old Brittany sees you in the office about headaches. Her headaches have been more frequent over the past six months. They are characterized by episodes of throbbing, unilateral head pain, and are associated with nausea, vomiting, and sensitivity to sound. Initially, they lasted only a few hours and occurred less than once a month. Now they are more severe and more frequent. She experienced similar headaches as a teenager.
What is the most likely diagnosis?
migraine, migraine headache, migraine without aura, classic migraine
List THREE broad non-pharmacologic approaches that may help to prevent migraines
regular sleep/optimize sleep
regular meals
regular exercise: 30 mins/day 5d/wk to goal of 150mins/wk aerobic activity
stress management
avoid dietary triggers (ie. caffeine, MSG, chocolate, alcohol)
stay well hydrated
avoid analgesic overuse (>9d/month)
Other than narcotics, list FOUR agents, all from different classes, that could be used in the management of acute migraine attack in ER
aspirin, ibuprofen, naproxen (or any other NSAID)
metoclopramide
sumatriptan (or any other listed triptan)
acetaminophen
intravenous fluids/normal saline
List FOUR oral medications, all in different classes, that you can prescribe for migraine prophylaxis (not acute treatment)
amitriptyline/nortriptyline
divalproex/valproic acid
propranolol/metoprolol/nadolol
topiramate
gabapentin
candesartan
lisinopril
verapamil/flunarizine
pizotifen
venlafaxine
B-blockers and TCAs are considered first line. Some resources indicate that anti-convulsants are also first line, but there is not general consensus on this, so if they ask for classes of meds, stick with TCAs and B-blockers as preferred classes, and anti-convulsants next, followed by CCB/ACEI.
Botox is recommend for prophylaxis when there are over 15 headache days per month, as per Headache Society of Canada. Since botox is not an oral medication, it is not an answer for this question. If the question reads, “What pharmacologic agents could you use for prevention?” then botox is an answer.
There are newer injectable immunologic agents (Aimovig) that are also gaining popularity. Again, these are injectable agents so not on this answer key
over-the-counter preventative products for migraines. Which over-the-counter agents can be recommended? List THREE.
Butterbur
Magnesium
Vitamin B2/riboflavin
Coenzyme Q10
Red flags in a patient with migraines, that would require imaging
Red flags include recent onset, rapidly increasing frequency and severity of headache; headache causing the patient to wake from sleep; associated dizziness, lack of coordination, tingling or numbness, new neurologic deficit; new onset of a headache in a patient with a history of cancer or immunodeficiency; new headache disorder in patient over 50.
“The yield of neuroimaging in patients with typical recurrent migraine attacks is very low. Any imaging study, particularly MRI, can identify incidental findings of no clinical significance which may lead to patient anxiety and further unnecessary investigation. For patients with typical migraine and a normal clinical examination who desire reassurance, careful explanation of the diagnosis and patient education may be more advisable.” - Choosing Wisely
Physical Exam of wellbaby and normal weight gain pattern
Height, weight, head circumference (WHO Canadian Growth Chart)
Correct percentiles if born <37w until 2-3yo
Max 10% weight loss by 4-5d, regain birthweight by 2w
30g/d until 3 mo, 20g/day until 6 mo, 10g/day until 12 mo
Double BW by 4mo, triple BW by 1y
when to do wellbaby visits
Recommended at 1 week, 2 months, 4 months, 6 months, 12 months, 18 months, 4-5 years
when should fontanelles be closed
Posterior closed by 2mo, anterior closed by 18mo
which hip exam to do in children depending on age
Hip exam until walking
0-3 months: Ortolani, Barlow
> 3 months: Limited hip abduction, Galeazzi
when to refer for undescended testes
6 months (4-12 months)
Refer if undescended (palpable, ectopic, nonpalpable) at 6 months
Consider earlier if ascended testis, bilateral nonpalpable, or associated hypospadias/ambiguous genitalia
Ultrasound not recommended as unhelpful
Retractile testis can be followed until puberty
benefits of circumcision
Decrease
Penile cancer (NNT 900-322,000)
Phimosis (NNT 67)
UTI (NNT 111)
HPV (NNT 5), HIV (NNT 298), HSV (NNT 16)
Decrease cervical cancer and STI in partner
3 cons of circumcision
and name a contraindication
Surgery risks: Infection (NNH 67), bleeding (NNH 67)
Meatal stenosis (NNH 10-50)
Ethical concerns
Contraindicated: Hypospadias
until when should a women breastfeed and which supplement to give? when to start regular milk
Exclusive breastfeeding recommended for first 6 months and continued into second year of life
Breastfed babies should receive Vitamin D 400 units PO daily
Vitamin D 800 units daily if high risk (limited sun exposure, darker skin, obesity)
Express breast milk can refrigerate up to 3d and freeze up to 6mo
Warm milk by placing in warm water
Switch from formula to homogenized milk at 500-750 mL/day at 12 months
Discontinue bottle by 18 months
Transition to 1-2% milk (500mL/day) at 2-3 years
6 tips for introduction of solids in baby
No evidence to delay food beyond 6-12 months
Introduce foods one at a time q3d (monitor for reactions)
Avoid solid round smooth dry/sticky foods risk of choking
Avoid sugary food/drinks
No beets, carrots, spinach, turnips before 6 months (nitrates)
No honey in first year
Inquire about vegetarian diets
Iron-containing foods should be encouraged when introducing solids
Iron-fortified cereals and grain products
Consider screen at 6-12mo for anemia in at-risk (eg. low SES)
5 tips for safe sleep
Safe crib (no soft objects/loose items, firm mattress)
On Back
Room sharing for <6 months
Pacifier if <6 months
Avoid bed sharing (consider bed box)
3 advice on car seats and children
Rear-facing car seat
-Infant must use rear-facing car seat
-Use a larger seat once baby outgrows infant seat, and keep rear facing until at least 2 years of age or reaches the maximum weight or height limit of the rear-facing seat, as stated by the manufacturer
Forward-facing car seat with a 5-point harness
-Once child outgrows larger rear-facing seat and is at least 2 years old, use 5-point harness seat until at least 18kg (40lbs) and can sit straight/tall without moving out of position or unbuckling (this may be 4-6 years old)
Booster seats with belt-positioning
-When child has outgrown forward-facing car seat with a 5-point harness, use a booster seat until 145cm (4’9”) tall and they safely fit in adult seat belt without slouching (for most children this is 9-12 years old)
Rear seat with adult seatbelt until 13 years old
counsel on use of acetaminophen and ibuprofen with correct dosing in pers
Acetaminophen 10-15mg/kg/dose q4-6h
Ibuprofen 4-10mg/kg/dose q6-8h in >6mo
Avoid OTC medication (especially if using acetaminophen/ibuprofen)
at which frequency should mothers breastfeed
Mothers should breastfeed when infant shows signs of hunger or q4 hours (8-12 feeds in first 24h, which decreases slowly to seven feeds per day by 1-2 months)
Infant should urinate one void per number of days of life until 6-8 times daily by day 5
Suspect inadeqaute milk intake if >7% weight loss or if the infant does not regain their weight by 2w
cause leading to breastfeeding issues
Inadequate milk production
-Breast development (previous surgery, radiation, endocrine -prolactinoma)
-Delay in lactogenesis within first 5d
-Usually due to obesity, hypertension, PCOS
-Medications (oxytocin, SSRI, estrogen)
-Offering only one side per feeding
Poor milk extraction
-Infrequent feeding
-inadequate latch-on
-Maternal-infant separation
-Use of supplemental formula
differential diagnosis of nipple pain
Trauma
Vasoconstriction
Engorgement/Excessive milk supply
Plugged ducts
Infection
Dermatitis/psoriasis
non pharmalogical tips for helping to breastfeed better
Proper positioning and latch
Support breast with hand in shape of “C” (fingers under breast, thumb on top)
Place baby’s chin below areola
Top and bottom lips wide open
Lower lip turned outward against breast
Chin touching breast, nose close to breast
Full cheeks
Re-try latch if discomfort, noisy sucking, does not swallow rhythmically
If unable to get proper latch, consider pumping with expressed breastmilk until problem is addressed
Lactation consultant
No data for galactogogues (domperidone, metoclopramide, fenugreek) over breastfeeding technique interventions
Cool or warm compresses, breastmilk to nipple
pharmalogical treatment of cracked nipples in breastfeeding
Antibiotic ointment (bacitracin or mupirocin) on cracked nipples to prevent infection and form a barrier
All Purpose Nipple Ointment (APNO)
Mupirocin ointment 2%: 15 grams
Betamethasone ointment 0.1%: 15 grams
Miconazole powder added to a concentration of 2% miconazole
Total ~30g, Apply sparingly after each feeding. Do not wash or wipe off.
when should a mother wean from breastfeeding
Natural weaning or “child-led weaning” happens when your baby starts to accept more—and different types—of solid foods while still breastfeeding on demand. With this type of weaning, you watch your baby’s cues and wean at their pace. Babies who are weaned naturally usually stop breastfeeding completely sometime between 2 and 4 years of age.
Planned weaning or “mother-led weaning” happens when mothers decide to start the weaning process.
A “partial wean” means substituting one or more feedings with a cup or bottle and breastfeeding at other times. This can work well if you are going back to work or school, but still want to breastfeed. Early morning, evening and night feedings can continue even if you are separated from your baby during the day.
how to wean breastfeeding
follow baby cues
do it gradually
start by substituting one feed and continue this way
hold and cuddle your baby: never prop a bottle
watch the cues you give to your baby
how to counsel parents who do not want to vaccinate their child
-explain that Vaccines are made with a tiny amount of dead or weakened germs.
They help the immune system learn how to protect itself against
disease. Vaccines are a safe and effective way to keep your
child from getting very sick from the real disease.
-consequences of not vaccinating: congenital rubella, death, possible complications of preventable disease
-no third world country travel
vaccination schedule
depends on each province.
6 risk factors of violent patient
Young Male
Low SES
History of violence
Legal history
History of physical abuse
Substance use disorder
Mental illness
Victimization
8 causes to rule out in violent patient
hypoxemia/hypoxia, hypoglycemia, neurologic disorder (injury, hemorrhage, cva, seizure), schizophrenia, infection (meningitis, encephalitis, sepsis), metabolic (hyponatremia, hypoglycemia, thiamine deficiency, hypercalcemia), hyper/hypothermia, liver/renal failure, withdrawal (alcohol, benzodiazepine), medication/substance (amphetamine, steroids, alcohol), psychiatric
8 labs to consider ordering in suddenly violent patient
CBC, electrolytes (glucose), LFT, renal function
Blood alcohol level, urine drug screen
UA, urine culture
CT head +/- LP
how to manage a violent patient
Consider personal safety at all times
Never turn back to individual (don’t walk ahead of patient)
Ensure adequate personal space
Ensure access to personal duress alarm
Ensure you have a safe escape route
Remove dangerour objects
Consider safety of other patients and visitors
Place patient in quiet secure area, inform other staff
de escaladation tricks to deal with violent patient
Empathic nonconfrontational approach, but set boundaries
Address agitation directly (name the emotion)
Listen to the patient, avoid excessive stimulation
Recruit family, friends, case managers to help
Address medical issues (pain, discomfort)
Ascertain the patient’s wishes and the level of urgency
indications to restrain and sedate agressive patient
Prevent harm to patient/other patients/caregiver/staff
Prevent serious damage to the environment
Assist in assessment and management of patient
Never use restraints for convenience
pharmalogical management of violent behaviour
Benzodiazepines (avoid in elderly)
Diazepam 5-10mg PO/IV (max 30mg per event)
Lorazepam 2mg (max 10mg in 24h)
Midazolam 5-10mg IM (max 20mg per event)
Short-acting, rapid sedation (peak in 10mins, lasts up to 2h)
Antipsychotics
Olanzapine 5-10mg oral (max 30mg per event)
Quetiapine 25-200mg PO
Risperidone 0.25-2mg PO/SL
Haloperidol 5-10mg IM (max 20mg per event)
Risk of dystonia
Acute dystonia - Benztropine 2mg PO or IM or IV
conditions that increase risk of depression (5)
Comorbid medical disorders (CAD, Hypothyroidism)
Comorbid psychiatric disorders (anxiety, substance use)
Chronic pain
Low SES
Postpartum
management of Suicidal ideas
Hospitalization vs. close outpatient follow-up
Emergency psychiatric consultation and in-patient treatment if unsafe to self/others
If low risk of suicide, consider safety plan***
-Keep home environment safe (remove access to weapons)
-Recognize early warning signs
-Coming up with ways to cope personally with suicidal thoughts
-Identify people to contact for help/distraction
-Identify place to go to for safety (eg. hospital)
**provide specific instructions for follow up
Consider psychiatric referral for substance use disorder or psychiatric comorbidity (bipolar, anxiety, personality)
Persistent subthreshold depressive symptoms or mild-moderate depression
-CBT, CCBT (computerized), structured group physical activity program
Drug treatment if
-Past history of moderate/severe depression
-Long period (>2y) of subthreshold depressive symptoms
-Persistent symptoms after other interventions
-Moderate/severe depression in combination with CBT or IPT
8 symptoms of depression
≥ 5 (with depressed or decreased interest) for >2w with change in functioning
Depressed mood most of the day
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor agitation/retardation
Suicidal ideation
psychiatric DDx (6) of depression
Bipolar (≥1w of energy/activity with ≥3 GST PAID)
Depressive disorder due to another medical condition
Persistent Depressive Disorder (>2y of 2SIGECAPS, with no MDE)
Adjustment disorder with depressed mood (stressor <3mo, resolves in <6mo)
Grief reaction (loss, usually <3mo)
Schizoaffective
Anxiety
ADHD
Medical DDx of depression
Adrenal insufficiency, hypercortisolism, hypothyroidism,
Mononucleosis,
Multiple sclerosis, Huntington disease, Parkinson disease, systemic lupus erythematosus
Obstructive sleep apnea
Stroke, traumatic brain injury
Vitamin B12 insufficiency
Medication: Corticosteroids, interferon, antiretrovirals
Substance-induced
investigation for depression
CBC (anemia), electrolytes (creat), TSH, B12/folate, LFTs
B-hCG
UA, urine toxicology
EKG (QT)
Neuroimaging if focal neurological sign or elderly
elements that increase suicide risk
SADIPERSONS
Sex (male)
Age>60yo
Depression
Previous attempts
Ethanol abuse
Rational thinking loss (psychosis)
Suicide in family
Organize plan
No spouse/support
Serious illness/pain
name 5 questions to assess suicide ideation
Passive vs. Active ideation
Plan (time/place), Intent (would you actually carry out this plan)
Past Attempts (Practiced/Aborted)
Access to means
Provocative/Protective factors
lifestyle modification for depression (3
Regular exercise, adequate food, housing, sleep
Stress management (mindfulness-based stress reduction, engaging in ≥1 pleasurable activity per day)
Avoiding substance abuse
4 types of therapies to help with depression
Cognitive behavioural therapy
Interpersonal psychotherapy
Behavioural activation
Group (less effective than individual but lower costs)
name 5 common side effects of SSRI
Side effects: Nausea (21%), xerostomia (20%), diaphoresis (20%), drowsiness (18%), insomnia (15%), sexual dysfunction (up to 50%), weight gain, headache
name 5 dangerous complications of SSRIs
Serotonin syndrome, suicidality, upper GI bleed, osteoporosis, hyponatremia, prolonged QT
2 most common drugs to screen in patients who present in ER with suicide attemps
Acetaminophen and ASA
also consider attempted suicide in patients with trauma
How to know if someone is responding well to antidepressants
Use objective scales (eg. PHQ-9) to monitor improvement
-If >20% improvement at 2-4w continue treatment and reassess at 6-8w
-If <20% improvement at 2-4w
—Increase dose
—Switch to another medication: Consider Escitalopram, Mirtazapine, Sertraline, Venlafaxine
—Adjunct/Augment (if ≥ 2 antidepressant trials, well tolerated, partial response, specific symptoms to target, less time to wait (severe, functional impairment), patient preference)
-Consider Aripripazole, Quetiapine, Risperidone
-Other options may include lithium, thyroid hormone
name 4 adjuncts in antidepressors in treating depression
Consider Aripripazole, Quetiapine, Risperidone
Other options may include lithium, thyroid hormone
for how long do you keep the prescription of antidepressor
Maintenance until 6-9 months minimum after remission
-Consider 2y minimum especially if high risk (frequent/recurrent episodes, severe, chronic, comorbid, residual symptoms, difficult to treat)
Discontinuation by slow taper over weeks
sx of SSRI withdrawal 5
-Symptoms include FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal)
-Typically resolves in 1-2 weeks
other non pharmalogical treatments of depression
Neurostimulation
-Repetitive transcranial magnetic stimulation (rTMS) if failed ≥1 antidepressant
ECT if severe (active suicidal ideation), psychotic, treatment-resistant
-Consider in medication intolerance, catatonic features, rapidly deteriorating physical status (eg. malnutrition due to food refusal)
Complementary:
Light therapy (phototherapy)
-10,000 lux for 30 minutes per day during early morning up to 6 weeks (response usually within 3 weeks)
-Consider especially in seasonal, shift work, sleep dysregulation
Acupuncture
Sleep deprivation (total for 40h or partial allowing 3-4h of sleep per night, employed 2-4 times over one week)
Natural health products
St John’s Wort (care for medication interactions)
Omega-3 fatty acids (3-9g/day) or 1-2g of EPA + 1-2g of DHA per day
SAM-e
Zinc
Social skills training, vocational rehabilitation
first line of tx for under 18 yo in depression
First line
CBT/IPT or internet-based psychotherapy
Second line
Level 1 evidence: Fluoxetine
Level 2 evidence: Escitalopram, sertraline, citalopram
treatement of depression in pregnancy
Pregnancy/Breastfeeding
First line
CBT/IPT
Second line
Citalopram, escitalopram, sertraline
counsel on the risk of malformations when taking antidepressants in pregnancy
Most antidepressants not linked to major congenital malformations
Paroxetine: CV malformations (OR 1.5)
Fluoxetine: Small increase in congenital malformations
Very modest link for spontaneous abortion (OR 1.5) , 4-day shortened gestational duration and reduced birth weight (74g)
Exposure to antidepressants in breastfed infant is 5-10 times lower than in utero
Sertraline has lowest relative infant dose (milk-to plasma ratio)
perimenopausal first line antidepressant
First line
Desvenlafaxine
CBT
first line of antidepressant for patients over 60 yo
Level 1 evidence: Duloxetine, mirtazapine, nortriptyline
Level 2 evidence: Buproprion, citalopram/escitalopram, desvenlafaxine, sertraline, venlafaxine, vortioxetine
Forty-four year old Susan presents with a 4 month history of fatigue and weight gain in spite of not changing eating habits and maintaining regular exercise. She is otherwise healthy and not on any medications. On further questioning, Susan mentions that she had a painful neck swelling for a few weeks about 6 months ago following a cold.
What is your most probable diagnosis?
hypothyroidism/thyroiditis
What are SIX signs or symptoms of hypothyroidism
weight gain
fatigue
Hypoventilation
Intolerance to cold
Slow HR
tongue swelling
Infertility
Menorrhagia
memory impairment
Mood change: (depression)
Constipation
dry, thickened skin (previously, this answer said cold, clammy skin, which is more likely for hyperthyroid rather than hypo)
course hair
brittle nail
Paresthesia
periorbital edema
goitre
myalgias
delayed reaction phase of deep tendon reflexes
which labs to ask for if there is fatigue, weight gain, tender neck/suspicion of hypothyroidism
TSH
Free T4
Hemoglobin
Mean corpuscular volume
low density lipo-protein (because a high TSH can cause high LDL)
serum creatinine
ferritin
what is the starting dose of synthroid in healthy patient
0.05 - 2.0 ug/kg (FYI: standard starting dose is 1.6ug/kg - this is the safest option for the exam, unless your patient is old with co-morbidities, then you would start lower. Also, a question asking for this dose would be unusual on the exam.)
If the patient is > 80 years old or with cardiac disease, what will you choose for a starting synthroid dose in ug/dose?
25ug
In an asymptomatic 60 year old patient with a slightly elevated TSH, at what TSH level would you consider treatment?
TSH>10
name 10 signs and sx of hypothyroidism
Depression
Decreased mental function
Physical tiredness
Paresthesia
Hypokinesis
Hyporeflexia
Weight gainA
Coarse, dry skin
Periorbital edema
Hoarseness
Bradycardia
Isolated diastolic hypertension
Goitre
Diminished sweating
Cold intolerance
Constipation
Menorrhagia
Hyperthyroidism:signs and sx (10)
Anxiety, irritability, restlessness
Fatigue, restless sleep
Increased appetite
Decreased attention span
Tremors
Proximal muscle weakness
Hyperreflexia
Weight loss
Hair loss
Palpitations, tachycardia
Atrial fibrillation
Isolated systolic hypertension
Goitre
Increased sweating
Heat intolerance
Blurred or double vision
Dry eyes, conjunctivitis, proptosis or dysconjugate gaze
Increased frequency of stools
Amenorrhea/oligomenorrhea
6 risk factors of thyroid disease
Risk factors for thyroid disease include1:
men: age ≥ 60 years2
women: age ≥ 50 years2
personal history or strong family history of thyroid disease
diagnosis of other autoimmune diseases
past history of neck irradiation
previous thyroidectomy or radioactive iodine ablation
drug therapies such as lithium and amiodarone
dietary factors (iodine excess and iodine deficiency in patients from developing countries); or
certain chromosomal or genetic disorders (e.g., Turner syndrome3, Down syndrome4 and mitochondrial disease5)
which test to ask in suspicion of thyroid disease
thyroid stimulating hormone
free T4
free T3 rarely indicated, only relevent if thyroid disease is suspected clinically and TSH is abnormal, but fT4 is inappropriately normal.
anti-thyroide peroxidase (TPO): not routinely indicated
-can be used in goitre or mildly elevated TSH to see if cause is autoimmune thyroiditis
-TPO antibody positivity increases the risk of developing hypothyroidism in patients with subclinical hypothyroidism, autoimmune diseases (e.g., type 1 diabetes), chromosomal disorders (e.g., Turner syndrome and Down syndrome) or patients who are on certain drug therapies (e.g., lithium, amiodarone) or are pregnant or postpartum (see Thyroid Disease in Pregnancy section below)13, 14. Once a patient is known to be TPO antibody positive, repeat analysis is not indicated.
thyroid ultrasound scan is not routinely recommended in patients with abnormal thyroid function tests, unless there is a palpable abnormality of the thyroid gland
when to retest TSH in patient with confirmed thyroid disease
6 weeks after start or change in treatment
if there is a change in patient’s clinical status
annually once TSH is stabilized
q 6 months if patient is taking lithium and amiodarone(3-6m)
q 6-12 months in subclinical hypothyroidism
when to treat subclinical hypothyroidism
A decision to treat is often made if the TSH is >10 mU/L even if the fT4 is within the reference range.
Treatment can be considered when TSH is between the upper limit of the reference interval but ≤10 mU/L and any of the following are present13:
symptoms suggestive of hypothyroidism
elevated TPO antibodies
evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases; or
pregnancy (see Thyroid Disease in Pregnancy section below)
name 4 causes of high TSH
autoimmune hypothyroidism
subclinical hypothyroidism
recovery from non-thyroidal illbess (sick euthyroid syndrome)
rare: pituitary disease, resistance to thyroide hormone
4 causes of low TSH
Hyperthyroidism or other causes of thyrotoxicosis
Excessive thyroid hormone replacement (levothyroxine)
Graves’ disease
Subacute thyroiditis (viral)
Painless/postpartum thyroiditis (autoimmune)
Toxic (multinodular) goitre
Hyperthyroidism or other causes of thyrotoxicosis
T3 thyrotoxicosis (e.g., autonomous nodule)
Excessive thyroid hormone replacement (liothyronine or desiccated thyroid)
Subclinical hyperthyroidism
Recovery of hyperthyroidism
Pregnancy related14, 20
Assay artefactB
Sick Euthyroid Syndrome
Hospitalized patients, recovery from severe illness
Very rare causes
Central hypothyroidism (hypopituitarism)
Assay artefactB
4 causes of low TSH
Hyperthyroidism or other causes of thyrotoxicosis
Excessive thyroid hormone replacement (levothyroxine)
Graves’ disease
Subacute thyroiditis (viral)
Painless/postpartum thyroiditis (autoimmune)
Toxic (multinodular) goitre
Hyperthyroidism or other causes of thyrotoxicosis
T3 thyrotoxicosis (e.g., autonomous nodule)
Excessive thyroid hormone replacement (liothyronine or desiccated thyroid)
Subclinical hyperthyroidism
Recovery of hyperthyroidism
Pregnancy related14, 20
Assay artefactB
Sick Euthyroid Syndrome
Hospitalized patients, recovery from severe illness
Very rare causes
Central hypothyroidism (hypopituitarism)
Assay artefactB
risks of taking synthroid
hyperthyroidism
bone loss in post menopausal women
atrial fibrillation (in elderly)
which population to screen for hyperthyroidism
atrial fibrillation
osteoporosis
other endrocrine disorders
when to test pregnant women for TSH/risk factors of thyroid disease
age > 30 years
more than 2 prior pregnancies
history of pregnancy loss, preterm delivery, or infertility
type 1 diabetes or other autoimmune disorders
morbid obesity (BMI ≥ 40 kg/m2)
history of hypothyroidism/hyperthyroidism or current symptoms or signs of thyroid dysfunction
family history of autoimmune thyroid disease or thyroid dysfunction (1st degree relative32)
history of head or neck radiation or prior thyroid surgery
known TPO antibody positivity or presence of a goitre
currently receiving levothyroxine replacement33
use of amiodarone or lithium, or recent administration of iodinated radiologic contrast
residing (or recently resided) in an area of known moderate to severe iodine insufficiency
when to treat pregnant women for thyroid disease and what is the target TSH
connection between untreated overt maternal hypothyroidism and neuropsychological impairment in the offspring3
A preconception TSH between the lower reference limit and 2.5 mU/L is recommended in women being actively treated for hypothyroidism
If hypothyroidism has been diagnosed before or during pregnancy, treatment should be adjusted to achieve a TSH level within the normal trimester specific reference interval.
If the TSH value is above 2.5 mU/L but within the reference interval, some practitioners would consider treating if the TPO antibody is positive.
normal range of TSH
TSH high (>4-5mU/L)
TSH low (<0.2mU/L)
additional tests to do in patients with hyperthyrodism without obvious cause
Thyrotropin receptor antibodies (TRAb)
Radioactive iodine uptake (contraindicated in pregnant/breastfeeding)
Ultrasound with thyroidal blood flow
Thyroid ultrasound (if abnormal thyroid size, nodules)
FNA for nodules >1cm or 5mm and suspicious features (r/o cancer)
drugs causing hypothyroidism (name3)
thionamides, lithium, amiodarone, interferon-alfa, interleukin-2, perchlorate, tyrosine kinase inhibitors
when to treat for subclinical hyperthyroidism
Consider treatment if TSH <0.1 mIU/L and
Symptomatic (palpitations, tremor, nervousness)
>65yo
Comorbidities such as heart disease or osteoporosis
Postmenopausal (<65yo) and not taking estrogen/bisphosphonates
treatment of Subacute granulomatous thyroiditis (viral infection, painful thyroid)
NSAIDs, steroids, beta blockers for sx treatment
sx of myxedema coma
Altered mental status, hypoventilation, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia
tx of myxedema
Levothyroxine (T4) loading dose 200-400mcg IV, then 1.6mcg/kg/day IV
Liothyronine (T3) 5-20mcg followed by 2.5-10mcg q8h given with T4
Glucocorticoids (hydrocortisone 100mg IV q8-12h x2d) until coexisting adrenal insufficiency can be excluded
Supportive measures (ventilation, fluids, correction of hyponatremia and hypothermia)
graves disease lab and treatment
(TSH receptor antibodies=TRAb)
Thionamides (Methimazole - MMI or Propylthiouracil - PTU)
If persistently high TRAb, consider continuing MMI or radioiodine/sugery
beta blockers for sx control
Toxic adenoma/multinodular goiter treatment
First-line: Radioiodine or surgery
May consider thionamide initially for short-term
Beta-blockers for symptomatic treatment
thyroid storm sx and treatment
Hyperthermia, tachycardia, N/V/D, dehydration, delirium, coma
Causes: Trauma, surgery, RAI
Treatment
B-Blockers (Propranolol 60-80mg q4-6h)
PTU 200mg PO q4h
Iodine solution (delayed 1h after PTU)
Iodinated radiocontrast
High-dose IV hydrocortisone 100mg IV q8h
ample history
Allergies, Meds, PMH, Last meal, Events
normal urine output/goal
Urine output goal of 0.5mL/kg/h in adults (1mL/kg/h in pediatric, 2mL/kg/h in <1yo)
name 5 life threatning thoracic trauma conditions
Tension pneumothorax
Needle thoracostomy at 2nd ICS mid-clavicular line or 5th ICS anterior/mid axillary line, do not wait for X-ray (can do bedside ultrasound)
Chest tube at fifth intercostal space at anterior axillary line
Cardiac tamponade
-Penetrating chest wound,
—-Beck triad (hypotension, distended neck veins, muffled heart sounds), pulsus paradoxus, Kussmaul sign (rise in JVP on inspiration)
-Confirm with echochardiogram, guide pericardiocentesis
Hemothorax
Flail chest
Upper airway obstruction
Aorta lesion
name the types of choc and one example for each
hypovolemic
-hemorrhagic
-Non-hemorrhagic (GI, skin-burns, renal, third space, pancreatitis)
distributive
-Sepsis
-Neurogenic (TBI, spinal cord injury)
-Anaphylactic
-Inflammatory
obstructive
-Pulmonary vascular (PE)
-Mechanical (Tension pneumothroax, pericardial tamponade)
cardiogenic
-Cardiomyopathic (MI)
-Arrhythmogenic (tachy/bradyarrhythmia)
Mechanical (valvular)
neurogenic:
-trauma to spinal cord
endocrine
-adrenal insufficiency, thyrotoxicosis, myxedema coma
metabolic:
-acidosis, hypothermia
Drugs:
-CCB, BB, Digoxin
In trauma what is in the primary survey?
Danger: check if it is safe
Response: chceck response to stimulus to determine level of consciousness
Circulation: pulse
-Consider defibrillation, hemorrhage control, leg elevation, IV access, fluid therapy
Airway: check if patent
consider C spine immobilisation, simple airway maoeuvers, suctionning, basic and advanced airway adjuncts
Breathing: consider Oxygen and IPPV
secondary survey in trauma
obtain Hx using OPQRST and SAMPLE
vital signs, EKG, GCS
PE from head to toe and fast echo
signs of difficult intubation
previous hx of difficult intubation
trauma on face, upper airway or C spine
early difficulty to ventilate with face mask
severe aspiration risk
small mouth, short mandibule, large tongue, short neck, prominent central incisors
limited mouth opening
C spine decrased ROM, trauma, degenerative changes
obesity,
Mallampati score
thyromental distance
laryngeal oedema (infection, inhalation thermal injury)
indication for intubation
unprotected airways, trauma to the airway, a Glascow Coma Scale (GCS) less than eight, a rapid decline or loss of consciousness, and procedural sedation and paralysis
absolute contraindication to direct laryngoscopy
facial trauma
name 4 precipitants of trauma
seizure, drug intox, hypoglycemia, attempted suivide
who to treat in mass casualties
ff. In such cases, patients having
the greatest chance of survival and requiring the
least expenditure of time, equipment, supplies, and
when to transfer a patient in trauma
Use ABCDE for transfer consideration:
-airway compromise, high risk for airway loss, tension PTx, hemothorax, open PTX, hypoxia, hypoventilation, hypotension, pelvic fx, vascular injury, open fx, abdo distension or peritonitis, GCS under 13, secvere hypotermia, depressed skull fx or penetrating injury, eye injury, complex lacerations, complex traumas
is important not to delay transfer to perform an indepth diagnostic evaluation. Only undertake testing
that enhances the ability to resuscitate, stabilize, and
ensure the patient’s safe transfer
e. Patients who exhibit evidence of shock, significant physiologic deterioration, or progressive deterioration in
neurologic status require the highest level of care and
will likely benefit from timely transfer
Stable patients with blunt abdominal trauma and
documented liver or spleen injuries may be candidates
for nonoperative management, requiring the immediate
availability of an operating room and a qualified surgical
team.
r.
Patients with specific injuries, combinations of injuries (particularly those involving the brain), and/or a
history indicating high-energy-transfer injury may be
at risk for death and are candidates for early transfer
to a trauma center. Elderly patients should be considered for transfer for less severe injuries (e.g.,
multiple rib fractures and patients on anticoagula
tips to minimize trauma
do no drive drunk, use seatbelts, helmetsfhypo
definition and 3 classes of hypothermia
Hypothermia is defined as a core body temperature
below 35°C (95°F). In the absence of concomitant
traumatic injury, hypothermia may be classified as
mild (35°C to 32°C, or 95°F to 89.6°F), moderate (32°C to
30°C, or 89.6°F to 86°F), or severe (below 30°C, or 86°F).
in the presence
of injury, different thresholds for classification are
recommended: mild hypothermia is 36° C (96.8° F),
moderate hypothermia is <36° C to 32° C (< 96.8° F
to 89.6° F), and severe hypothermia is < 32° C (89.6°
or stage 135°C to 32°C
stage 2 32-28
stage 3 24-28
stage 4 below 24
rewarming techniques in Mild (HTI) hypothermia
35°C to 32° C (95-89.6 F)
- Dry patient
- Warm environment
- Shivering
- Blankets or clothing
- Cover head
External
* Heating pad
* Warm water, blankets,
and warm water bottles
* Warm water immersion
* External convection
heaters (lamps and
radiant warmers)
rewarming technique in moderate
(HT II) hypothermia < 32°C
to 28° C (< 89.6-82.4 F)
External
* Heating pad
* Warm water, blankets,
and warm water bottles
* Warm water immersion
* External convection
heaters (lamps and
radiant warmers)
Internal
* Heated intravenous
fluids
* Gastric or colonic lavage
* Peritoneal lavage
* Mediastinal lavage
* Warmed inhalational air
or oxygen
severe hypothermia rewarming technique
Extracorporeal
Rewarming
* Hemodialysis
* Continuous arteriovenous rewarming (CAVR)
* Continuous venovenous
rewarming (CVVR)
* Cardiopulmonary
bypass
physical exam findings suspicious of child abuse
General assessment of alertness, eye
opening, and responsiveness
Intracranial hemorrhage, head injury
Height, weight, head circumference
(compared with past
measurements, if possible)
Failure to thrive, neglect, or growth
failure with concurrent physical
abuse
Mouth and teeth examination Dental caries suggestive of neglect
Scalp examination Patchy hair loss caused by traumatic
alopecia or severe malnutrition
Funduscopic examination of the eyes
Retinal hemorrhages
Skin examination for bruising or
burns
Multiple patterns of bruising
suggestive of abuse: bruise in child
younger than four months; bruise
in torso, ear, and neck areas; ear
bruising (suggests “boxing ears”);
buttocks bruising; patterned
bruises (hand, cord, belt, object);
bruises at different stages of
resolution; burn injuries
Palpation for tenderness, especially
of the neck, torso, and extremities
Occult fracture
Deep tendon reflexes, muscle tone,
or responsiveness to tactile stimuli
Spinal cord injury
suspicious xr findings of child abuse
Highly specific injuries*
Classic metaphyseal lesions
Rib fractures, especially posteromedial
Sternal, scapular, and spinous process fractures
Moderately specific injuries*
Multiple fractures
Fractures in different stages of healing
Epiphyseal separations
Vertebral body fractures and subluxations
Digital fractures
Complex skull fractures
Common but low specificity
Clavicular fractures
labs to ask in suspected child abuse
cbc, fibrinogen, von willebrand factor, platelet aggregation studies, clotting factor assyas, ALt, AST, amylase, lipase, tox screen, UA, renal and lytes, ca, alk phosp, phosphorus, albumin, PTH for malnutrition, rickets
5 general advice to give to people travelling
get up to date information from reliable travel website
discuss prevention of accidents, safer sex, alcohol, safe travel for women
provide prevention and treatment advice and prescribe meds for common conditions (traveler’s diarrhea, altitude sickness)
ensure pts know how to manage their chronic disease
update routine vaccinations
check insurance coverage
have adequate medical supply, put in carry on bags
list common infections patients can get from travelling and their sources
Sick contact (TB)
Fresh water (shistosomiasis, leptospirosis)
Unclean water, unpasteurized milk, raw food (Traveler’s diarrhea, giardiasis, nontyphoidal salmonellosis, enteric fever, shigellosis, campylobacter, hepatitis A and E, brucellosis, listeriosis)
Skin contact with soil - walking barefoot (Strongyloidiasis, melioidosis)
Farm animals
Sexual contact (Herpes virus, HIV, Hep A/B/C, syphilis, gonorrhea, Zika, viral hemorrhagic)
IVDU, tattoo, piercing (Hep B/C, HIV, CMV, malaria, babesiosis)
Insect bites/Animal bites
malaria prevention
Clothing, DEET, bed nets with permethrin
when does malaria (plasmodium) sx appear
7 days to months after anopheles mosquito bite
malaria treatment, prophylaxis
atovaquone, proguanil (malarone) daily (start 1 day prior and 7 days after), avoid in children under 5 kg
Mefloquine (Lariam) weekly
-Start 3w prior, continue 4w after
-AE: Severe intolerance in some patients
Chloroquine weekly
-Start 1-2w prior, continue 4w after
-Resistance
Doxycycline also option for prophylaxis (risk of sun sensitivity, and avoid in children <8yo due to teeth staining)
treatment: IV antimalarials (Quinidine with doxycycline or Artesunate)
Consider outpatient treatment if <4% parasitemia and no severe features as above
Chloroquine (if sensitive) 600mg base orally immediately, then 300mg base orally 6, 24, 48h (total of 1500mg base)
Artemisinin combintation therapy if Chlororoquine-resistant region (eg. Artemether-lumefantrine)
Monitor parasitemia with daily blood smears until no parasitemia
name 5 germs causing traveller’s diarrhea
Escherichia Coli
Campylobacter jejuni
Salmonella
Shigella
Yersinia
Norovirus
Rotavirus
Giardia
Entamoeba histolytica
Bacterial causes: 50-80% of travel-related diarrheal illness
Viral causes: 5-25%
Protozoal causes: <10%
for how long should patients avoid pregnancy after travelling to areas with zika
Avoid pregnancy after return from Zika area (2 months for women, 6 months for men)
non pharmacologic measures to prevent traveller’s diarrhea
Wash hands with soap and water before eating/frequent hand hygiene
Only eat fruit that they can peel themselves
Avoid uncooked vegetables (FYI: because these have likely been exposed to local tap water)
Avoid salads (FYI: because these have likely been exposed to local tap water)
Heat food to piping hot
Eat only thoroughly- and recently-cooked meats and fish
Drink only boiled or bottled beverages
Purify drinking water/Boil drinking water for 1 minute
Only eat pasteurized dairy products
Avoid food from street vendors/unknown sources
Avoid ice cubes
Only use purified/bottled water for brushing teeth and washing face
is vaccine against cholera useful
No, the vaccine (dukoral) is not recommended.
It is no more effective than placebo for prevention of diarrhea.
It is no more effective than placebo for prevention of enterotoxigenic E. Coli (ETEC)
t treatments she can utilize right away if she develops diarrhea abroad.
use oral rehydration solution or salts/ensure adequate hydration
loperamide/Imodium
bismuth subsalicylate/Peptobismal
2 bismuth subsalicylate tablets 4 times daily (prevents up to 60%)
which antibiotics to treat traveller’s diarrhea
Consider antibiotics if severe (> four unformed stools daily, fever, or blood, pus, or mucus in the stool) or high risk (child, pregnant, elderly)
Ciprofloxacin 500mg PO BID x 3 days
Azithromycin 1000mg PO x 1 in children, pregnant women, or travellers to Asia (resistance to fluoroquinolones)
labs for traveller’s diarrhea or fever
CBC (anemia, lymphopenia, thrombocytopenia, eosinophilia)
Thick and thin blood smear r/o Malaria (consider repeat q12h until three negative smears as parasitemia is cyclical)
Liver/Renal studies
Electrolytes
Blood culture x2
Urinalysis/Urine culture
CXR
Consider
ESR/CRP
PPD r/o TB
Dengue Serology
Widal test r/o typhoid fever
LP
If >10-14d, stool culture and O+P should be done for targeted therapy
treatment of scrub typhus (or other rickettsial infection)
Doxycycline
complications of malaria
organ dysfunction, anemia, electrolyte abnormalities, altered mental status, seizure, coma
name general travel vaccines and country specific vaccines:
-south asia
-meningitis belt-sub-Saharan Africa, Hajj
-Africa, south american
-rural asia
General travel vaccines
Hepatitis A/B
Rabies vaccine (adventure trips lasting more than 4 weeks)
Country specific vaccines
Typhoid vaccine (South Asia)
Meningitis vaccine (Meningitis belt, Hajj)
Yellow fever vaccine (African, South American countries)
-Must be given at designated clinic for official certificate
Japanese encephalitis vaccine (Rural Asia)
Antimalarials-arge areas of Africa and Asia.
Central and South America.
treatment of altitude sickness
Consider symptomatic treatment (analgesic, antiemetic)
Consider prophylaxis, Acetazolamide 125mg PO q12h
In High Altitude Cerebral Edema (encephalopathy and ataxia, usually above 4000m) consider immediate descent, dexamethasone and oxygen
treatment of motion sickness
Visual cues congruous with vestibular cues (eg. view the horizon from the deck of a ship)
Lying supine
Ginger, acupressure
Anticholinergic medication (care in elderly or risk of angle closure glaucoma)
Dimenhydrinate, diphenhydramine, transdermal scopolamine (patch 72h)
symptoms of malaria
fever (which may be periodic), chills, rigors, sweating, diarrhea, abdominal pain, respiratory distress, confusion, seizures, hemolytic anemia, splenomegaly, and renal abnormalities
symptomatic management of common cold
Analgesics (Acetaminophen/NSAIDs)
Combination products (Antihistamine, decongestant, analgesics)
Consider Zinc lozenges 75mg PO daily, Pleragonium sidoides, Andrographis paniculata
Risk of irreversible anosmia in intranasal zinc preparations
Nasal symptoms
Nasal saline irrigation (poor evidence)
Intranasal cromolyn sodium 1 spray (5.2mg) in each nostril q2h PRN x 2 days then 4 times daily x 5 days
Intranasal ipratropium bromide 0.06% solution two sprays (42mcg/spray) in each nostril 3-4 times daily PRN x 4 days
Cough suppressant
Brompheniramine plus sustained-release pseudoephedrine
Ipratropium bromide inhaled
Dextromethorphan 30mg PO q6-8h PRN
prevention of common cold
Handwashing
Flu vaccine (6mo-5yo, ≥65yo, chronic disease, pregnancy/postpartum, healthcare worker, frequent contact with above)
Pneumococcal 23-valent
≥65 years old, or if specific risk factors
treatment of flu (2) and indication
Zanamivir (Relenza) two inhalations (10mg) PO BID x 5d or oseltamivir (Tamiflu) 75mg PO BID x 5d
Amantadine not first-line due to high rates of resistance
May extend therapy in severely ill patients
Treatment with antiviral should be considered for the following patients
Severe disease (requiring hospitalization or evidence of lower respiratory tract infection, eg. dyspnea, tachypnea, oxygen desaturation)
High risk for complications (pregnancy)
Most efficacious within first 48h of illness, but indicated to treat if severe illnessor pregnancy
Indications to consider X-ray
indications to consider XR in URTI sx
Hemoptysis
Pleuritic chest pain
Dyspnea
Systemic symptoms (fever, tachycardia >100, tachypnea>24)
Abnormal physical exam (crackles, decreased breath sounds, bronchial breathing)
how to counsel on someone with viral URTI who wants antibiotics
Compassionate communications
Describe infection as viral illness
Discuss expected course of illness and cough duration (2-3w)
Explain antibiotics do not shorten illness duration, and may cause adverse effects and antibiotic resistance
Treatment plan including symptom management (analgesia, antiinflammatory)
Consider
-Delayed prescription strategies (agree on time frame, eg. 1 week that symptoms should improve - and only to use prescription after the specified time)
-Immediate prescribing if suspect pneumonia or high-risk (immunosuppressed)
who are considered high risk patients in upper respiratory infections:
COPD, cancer, immunodeficiency virus infection
otitis media signs
bulging or distorted light reflex (i.e., not all red eardrums indicate OM).
otalgia DDx
AOM, acute mastoiditis, acute facial nerve palsy, labyrinthitis, venous sinus thrombosis, meningitis, trauma, cholesteatoma, tumor, otitis externa, r/o necrotizing/malignant otitis externa, Herpes zoster , Secondary otalgia, otitis media with effusion, otitis extera
Herpes zoster (Ramsay Hunt syndrome)
Secondary otalgia
Sinusitis / Stomatitis / Parotitis / Pharyngitis
Dental infection / abscess
TMJ dysfunction syndrome
Auricular lymphadenopathy
Facial nerve palsy
Trigeminal neuralgia
Temporal arteritis*
complications of AOM
Acute mastoiditis (pain/swelling over mastoid bone)
Acute facial nerve palsy - associated with temporal bone inflammation
Sixth CN palsy (failure of ipsilateral eye abduction) due to petrous bone inflammation or infection (Gradenigo’s syndrome)
Labyrinthitis
Venous sinus thrombosis
Meningitis
treatment of otitis externa
Keep dry (Avoid water sports x 7-10d)
Clean ear canal
Analgesia
Mild, Buro-Sol 2-3 drops TID-QID
Moderate, Ciprodex 4 drops TID
If perforated consider systemic antibiotics.
which dangerous otitis to rule out in high risk patients
r/o necrotizing/malignant otitis externa (elderly, diabetic, immunocompromised, otalgia despite antibiotics, granulation tissue in ear canal)
ESR, CRP, osteomyelitis on CT/MRI
Ciprofloxacin 750 mg PO BID PLUS Ciprodex 4 drops BID x 4-8w
physical exam findings to diagnose AOM
loss of light reflex
impaired mobility
bulging TM
acute perforation with purulent discharge
when to treat for AOm
Immediate therapy if < 6months of age
-Send to ER if <3 months old with T>38, suspect meningitis or mastoiditis, toxic looking
Healthy children ≥6 months with mild disease, consider:
Watchful waiting, and reassess in 24 to 48h (return if worsens anytime within 48h)
Antimicrobial prescription to start course if child does not improve
Pediatric: Amoxicillin 75 to 90mg/kg/day (max 2000mg) ÷BID
Adults: Amoxicillin 500mg PO TID x 5-10d (can use 1g PO TID if high risk) in adults
Acetaminophen 10-15mg/kg/dose q4-6h (max 75mg/kg/day)
Ibuprofen 5-10mg/kg/dose q6-8h (max 40mg/kg/day)
Bulging TM, febrile (≥39°C), moderately systemically ill, or severe otalgia, or significantly ill for 48h should be treated with antimicrobials
second line treatment of AOM (no response x 2-3d or recent amoxicillin use in 30 days)
Amoxicillin-clavulanate (7:1 formulation, 400 mg/5 mL suspension) 45 to 60 mg/kg/day ÷ TID (max 500mg PO TID) x 10d
Adults: 875/125mg BID or 2000/125mg BID x 10 days
Ceftriaxone 50 mg/kg IM/IV daily (max 1000mg) x 3 days
name 5 pharyngitis redflags
Drooling/Secretions
Dysphonia
Dysphagia
Muffled “hot potato” voice
Neck swelling
dangerous ddx + other ddx to rule out in case of suspected pharyngitis
Submandibular space infections (Ludwig’s angina - woody induration, crepitus)
Primary HIV (mucocutaneous ulcerations)
Peritonsillar abscess (trismus)
Epiglottitis (out of proportion to findings on exam)
Retropharyngeal space infection
infectious mononucleosis (fever, pharyngitis, fatigue, lymphadenopathy, splenomegaly, palatal petechiae)
HIV, Gonorrhea
CMV, toxoplasmosis
Suppurative complication (peritonsillar abscess)
Infectious thrombophlebitis of the internal jugular vein (Lemierre’s)
Fusobacterium necrophorum (in 15-30yo)
labs to test in mono
WBC, AST, ALT, Monospot (or EBV serologies)
diagnosis of pharyngitis
CENTOR: Cough absent Exudate/erythema tonsils, Neck nodes, Temp, Range of age (3-14=+1, 15-45=0, >45=-1)
If CENTOR ≥3 (>30%): Rapid Antigen Detect Test (RADT) and/or culture
Negative RADT consider throat culture back-up in children or immunocompromised (sensitivity 86%)
Positive RADT do not need back-up culture (specificity 96%)
symptomatic treatment of pharyngitis + when to return to school
Acetaminophen/NSAIDs
Topical (Benzocaine 10mg lozenge q2h PRN, Benzydamine 0.15% 15mL gargle q3h PRN)
Consider Dexamethasone 0.6mg/kg (max 10mg) PO x 1 (NNT 12)
After full dose of amoxicillin, 91% of children the next morning had negative RADT/culture
Consider returning to school on Day 2 of antibiotics if improved/afebrile
pharmacologic tx of strep throat + 2 options in case of allergy
Penicillin V (50mg/kg/day ÷ BID) 600mg PO BID x 10d
Can consider Pen V QID x 5d
Pediatrics: Amoxicillin 50 mg/kg PO daily (max 1g) x 10d
if allergy:
Cephalexin (50mg/kg/day ÷ BID) 500mg PO BID x 10 days
If anaphylactic
Clarithromycin (15mg/kg/day ÷ BID) 250mg PO BID x 10d
diagnosis of sinusitis
Diagnosed clinically using symptoms and signs >7d duration
Must have one of “OD” and one other “PODS” symptom
Facial Pain (or pressure), Nasal Obstruction, Discharge, Smell loss
imaging in sinusitis
Radiological imaging usually not required (unless diagnosis unclear)
X-ray (3 views) diagnosis with air/fluid level or complete opacification
CT scan if complication
causes of sinusitis and criteria to treat
Most are viral and resolve spontaneously within 10-14d
Suspect bacterial if
Deterioration of symptoms 5-7d after improvement (biphasic)
Persistent symptoms without improvement >10-14d as per INESSS
>7d without improvement (or >10d persisting symptoms) as per Canadian guidelines
Treat bacterial if severe symptoms impacting function/sleep
when to follow up after treating fo rsinusitis
Lack of response within 72h suggests treatment failure
Referral to ENT if (and consider CT if long waiting time)
Complications
Persists >8w
Recurrent rhinosinusutis >3 episodes per year
Alarm symptoms of sinusitis (4)- Consider urgent referral to ER
toxic, altered mental status
Persistent fever (>38C)
Periorbital erythema/swelling or decreased visual acuity
Meningeal signs/severe headache or neuro signs
Predisposing conditions of sinusitis
Recent viral URTI
History of allergic/nonallergic/medication-induced rhinitis
Concomitant conditions (pregnancy, immunodeficiency, migraine)
Anatomic causes (deviated septum, enlarged tonsils, nasal polyp)
non pharmalogical tx of sinusitis
Prevention: Smoking cessation, hand hygiene
Symptom management:
Analgesics (acetaminophen, NSAIDs)
Saline irrigation BID
treatment of sinusitis and tx in case of PNC allergy
Oral decongestants <10d (when worse congestion, eg. night)
Topical decongestants <3d (risk of rebound congestion)
Consider topical intranasal corticosteroids (eg. nasonex) in mild-moderate ARS (NNT 15)
If no improvement after 72h, consider antibiotics
Consider treatment for suspected acute bacterial rhinosinusitis (as above) with severe symptoms or mild-moderate not responsive to INCS after 72h (NNT 17, NNH 8)
Amoxicillin 500mg PO q8h x 5-10 days
Second-line (or first-line if suspect resistance, immunosuppressed, frontal/sphenoidal sinusitis due to higher rates of complications)
Amoxicillin/Clavulanate 875/125mg PO BID x 7d
Moxifloxacin 400mg PO daily x 5d
Levofloxacin 500mg PO daily x 10d
If non-severe penicillin allergy, consider cefuroxime 250 BID x7d or cefixime 400 daily x10d
If anaphylaxis, consider clarithromycin, doxycycline or TMP-SMX
treatment of chornic sinusitis
Oral glucocorticoids PLUS empiric oral antibiotics x 4w
Prednisone 20mg PO BID x 5d, then 20mg daily x 5 days (total 10 days)
Amoxicillin-clavulanate 875mg PO BID or Clindamycin 450 mg PO TID
Topical glucocorticoid spray and intranasal saline irrigation or sprays
normal menstural bleeding in terms of frequency , days and blood loss
s regularly (every 24–38 days) for 4 to 8 days with
blood loss of 5 to 80 ml
4 types of AUB
Heavy menstrual bleeding (most common AUB complaint)
* Excessive blood loss that interferes with quality of life and daily function.
* Can occur with other symptoms (e.g., menstrual pain).
Prolonged menstrual bleeding * Menses lasts > 8 days.
Frequent menstrual bleeding * Bleeding at intervals < 24 days apart.
Irregular, non-menstrual
bleeding
* Intermenstrual—Bleeding (often light/short) between normal menstrual periods.
* Post-coital—Bleeding after intercourse.
* Premenstrual/postmenstrual spotting—Bleeding on a regular basis (≥ 1 days)
before or after regular menses.
PALM COEIN
Polyps (cervical or endometrial)
-Intermenstrual bleeding
Ademonyosis
-Endometrial glands and stroma present focally or globally
in uterine musculature.
Heavy or prolonged bleeding.
Menstrual pain.
Dense enlarged uterus.
Leiomyoma (myoma or fibroids
-Myomas or fibroids. Heavy or -prolonged bleeding.
-Pelvic pain/pressure.
-Enlarged uterus.
Malignancy
Malignancy of vagina, uterus, cervix. Variable bleeding patterns.
Coagulopathy
Inherited bleeding disorders, including von Willebrand
disease.
* Acquired coagulopathy.
Heavy bleeding
Ovarian dysfunction
Polycystic ovary syndrome.
* Thyroid diseases.
* Ovarian follicle decline (perimenopause).
Irregular bleeding.
Heavy or prolonged bleeding.
Endometrial
-Pelvic inflammatory disease.
* Endometritis.
Iatrogenic
Hormonal contraceptives.
* Anticoagulants.
* Antiepileptics.
* Tricyclic and SSRI/SNRI antidepressants.
* Antipsychotics.
* Corticosteroid-related drugs.
* Tamoxifen.
* Herbs (ginseng, chasteberry, danshen, motherwort).*
Not yet
specified
* Arteriovenous malformations.
* Caesarean scar defects.
difference between anovulatory AUB and ovulatory AUB
Ovulatory AUB is typically regular and often accompanied by premenstrual symptoms and painful periods.
* Anovulatory AUB is common near menopause with irregular, heavy, and/or prolonged bleeding.
* In a cohort of 804 women (42–52 years), anovulation occurred in 20% of cycles, mostly in the early
perimenopause. Anovulation was associated with both shortened and prolonged cycle intervals and bleeding
duration. Short-cycle intervals occurred more frequently in early perimenopause.14 Anovulatory cycles were
less likely to be associated with heavy menstrual bleeding than were ovulatory cycles.
Anovulatory AUB is more likely than
ovulatory AUB to be associated with endometrial hyperplasia and cancer
questions to ask to someone with AUB
bleeding, anemia sx, vaginal discharge, pelvic pain, galctorrhea, sexual and reproductive hx, systemic illness, presence of comorbidities, meds, family history
systemic illness that could cause AUB
hypothyroidism
hyperprolactinemia
coagulation disorders
PCOS
adrenal or hypothalamic disorders
range of thicknes sof normal endometrium in premenopausla woman
4 mm in follicular phase to 16 mm in luteal phase
initial investigation in AUB
Pap smear.
* STI testing if there is a risk.
* CBC for women with a history of heavy or prolonged bleeding .
* Serum BHCG if there is a risk of pregnancy.
* TSH—only if there are symptoms or findings that suggest thyroid disease [Low Evidence].
* Ferritin—there is no evidence that the addition of ferritin changes management if CBC is normal. Test only if there
are symptoms of iron deficiency without anemia.
* Coagulation tests—only for women with a history of heavy menstrual bleeding that began at menarche or a
personal or family history of abnormal bleeding.
· Endometrial biopsy (see Endometrial Biopsy section).
other: blood type and screen if acute blood loss, consider prolactin if sx, vWF, fibrinogen, gono/chlam
name 6 meds causing AUB
Hormonal contraceptives.
* Anticoagulants.
* Antiepileptics.
* Tricyclic and SSRI/SNRI antidepressants.
* Antipsychotics.
* Corticosteroid-related drugs.
* Tamoxifen.
* Herbs (ginseng, chasteberry, danshen, motherwort).*
when to do imaging in AUB and which imaging to choose
when the history or examination suggests structural causes for
bleeding, conservative management has failed, or there is a higher risk of malignancy. TVUS is considered a firstline imaging test for AUB because it has adequate test performance and is relatively noninvasive.3 TVUS can help
diagnose endometrial polyps, adenomyosis, leiomyomas, uterine anomalies, and endometrial thickening associated
with hyperplasia and malignancy (see Box 1)..3
In some cases (particularly the detection of intrauterine pathology such as submucosal fibroids or polyps), saline
infusion sonohysterography and diagnostic hysteroscopy are preferred due to better test performance and can be
used as second-line tests.
when to consider endometrial biopsy
Are > 40 years of age.
* Have high risk or findings suggesting malignancy
-overall risk for endometrial cancer
-risk of progression to cancer in women with hyperplasia (see risk factors)
* Do not respond to medical treatment.
* Have substantial intermenstrual bleeding (
indicators of difficult endometrial biopsy
1) previous Caesarean sections; 2) nulliparity; 3) structural issues (e.g.,
cervical stenosis, pelvic organ prolapse); or 4) anxiety with office procedures
TVUS and/or gynecological referral may be offered in these cases.1
specificity and sensitivity for endometrial cancer
It
has high specificity for endometrial cancer (almost 100%) but sensitivity is lower (~90%)
risk factors of endometrial cancer
obesity, diabetes, nulliparity, history of polycystic ovary syndrome, and family history of hereditary non-polyposis
colorectal cancer
Lynch Syndrome 40-60% endometrial CA
risk of hyperplasia to progress to endometrial cancer
- Atypical hyperplasia is associated with higher risk of progression to endometrial cancer. Up to 60% of patients will
have co-existent endometrial cancer and ideally require definitive surgical management with hysterectomy and
bilateral salpingo-oophorectomy. Medical management can be considered for patients wishing to preserve their
fertility.26 - Hyperplasia without atypia has a much lower rate of progression (1–3%) and can be managed conservatively with
progesterone or with watchful waiting, if the patient chooses, as spontaneous regression rates of over 75% have
been reported.3,27,28 By comparison, progesterone treatment of any type appears to have higher regression rates
(89–96%),28 although this data is derived from small observational studies. If watchful waiting is chosen, the
SOGC recommends reassessment (with biopsy) every 3 to 6 months.26
how to reduce endometrial hyperplasia without atypia
Continuous oral or monthly injectable progestins or the LNG-IUS over a 6-month period.
9 Disease regression rates are the highest with the LNG-IUS (80–95%) and injectable
progestins (> 90%) compared with about 70% for oral therapy.30 Endometrial biopsy (which can be performed with the
IUD in place) should be performed every 3 to 6 months to monitor for disease progression and eventual resolution
Obesity is associated with a lower rate of regression.
* Persistent abnormal bleeding despite therapy, intolerance to therapy, inability to comply with surveillance, or
failure of hyperplasia to regress after 6 to 12 months should prompt referral.
* Following resolution of hyperplasia without atypia, the question of how often and how long to continue performing
endometrial biopsies has not been directly addressed by research. The UK Royal College of Gynaecologists
and Obstetricians guideline recommends performing endometrial biopsies every 6 months until 2 consecutive
negative biopsies occur.28
how to manage uterine bleeding in non-acute/outpatient context, name 4 pharmalogical methods
Regular (cyclic) heavy menstrual bleeding: hormonal and non-hormonal treatments.
* Irregular or prolonged bleeding: hormonal treatments, such as oral contraceptive pills or progestins, can help
regulate cycles, but non-hormonal treatments can help to control any associated heavy bleeding.
Note: Women with anemia should receive iron supplementation
-Levonorgestrel Intrauterine Releasing System (LNG-IUS) (IUD) -> reduces ovarian and endometrial risk of cancer but does not increase risk of breast cancer
e etonogestrel implant
-reduces bleeding days but menstrual bleed can remain unpredictable
-Combined Hormonal Contraception (CHC)
-Oral Progestins: Treatment consists of
medroxyprogesterone acetate, norethindrone, or micronized progesterone,
-Injected Progestin
25. Depot medroxyprogesterone acetate (DMPA) is used to suppress ovulation and ovarian steroidogenesis, eventually
leading to endometrial atrophy
-Danazol
26. Danazol inhibits ovarian steroidogenesis and results in endometrial atrophy
-Gonadotropin-Releasing Hormone (GnRH) Agonists
27. GnRH agonists (leuprolide, goserelin, nafarelin) stop ovarian steroidogenesis and lead to endometrial atrophy and
amenorrhea within 3 to 4 weeks.3 However, long-term use leads to adverse effects associated with a hypoestrogenic
state and should only be considered for women in whom other options are contraindicated
Non-hormonal Medical Treatment
-Nonsteroidal Anti-Inflammatory Steroids (NSAIDs)
-Antifibrinolytics
Tranexamic acid
when to consider surgery in AUB
y may be considered in women in whom 1) medical treatment has failed; 2) medical treatment is contraindicated
or side effects are considered intolerable; 3) significant anemia is present; 4) uterine pathology (e.g., large uterine
fibroids, endometrial hyperplasia with atypia, malignancy) is present; or 5) AUB has a severe impact on quality of life.3
Surgical options include hysteroscopic polypectomy, endometrial ablation, myomectomy, and hysterectomy. Uterine
artery embolization is a radiological intervention that can be used to treat fibroids
when to refer AUB
Investigative tests show:
* Malignancy, or atypical hyperplasia is present.
* Hyperplasia without atypia, if this is the patient’s preference or the clinician is not comfortable managing.
* No primary care practitioner is available to perform a required endometrial biopsy, or technical issues prevent the
ability to perform a satisfactory biopsy.
* AUB (including hyperplasia without atypia) fails to respond to medical treatment options or if GnRH agonists are
being considered.
* Patient wishes to explore surgical options (after being informed about or having trialled available medical
treatments).
when does b HCG start to be positive
Serum positive 9d post-conception
Urine positive 28d after LMP
how to treat acute vaginal bleed in non pregnant patient
Hypovolemia/Hemodynamic instability
-blood type and screen, consider transfusion if necessary
-if pregnant give rH immunoglobulin (winrho or rhogam )
Acute Non pregnant
Conjugated equine estrogen 25mg IV q4-6h x24h
Consider antiemetic due to side effects of nausea/vomiting
Combined OCP TID x7d
Medroxyprogesterone acetate 20mg TID x7d
Tranexamic acid 1g PO/IV TID x5d
Procedure (D&C, endometrial ablation, uterine artery embolization, hysterectomy)
Treat underlying primary pathology
Correct anemia (iron replacement)
Rule out malignancy (if high risk)
First trimester vaginal bleed DDx
implantation bleed
abnormal prenancy (ectopic, molar)
Abortion (threatened, inevitable, incomplete, complete, missed, septic)
Non-Obstetrical (Uterine, Cervical Vaginal Pathology)
P/E vaginal bleed in pregnancy T1
Vitals (r/o hemodynamic instability, fever)
Abdominal exam (r/o surgical abdomen)
Speculum
Source of bleeding (Vagina/Cervical/Uterine)
Cervical os (r/o cervical dilation)
Bedside ultrasound (r/o free fluid, confirm IUP)
investigations vaginal bleed in pregnancy T1
CBC
Blood type
Serial b-hCG
Rising b-hCG >35% over 48h consistent with viable IUP (but ectopic may also display rising hCG)
hCG <35% over 48h suggest ectopic or abnormal IUP
Abdominal Ultrasound
IUP if b-hCG >6000 IU/L
Transvaginal Ultrasound
Gestational sac and yolk sac at 5w gestation
Cardiac activity at 6w gestation
IUP if b-hCG >1500IU/L
Absence of IUP does not always ectopic (eg. early multiple gestation)
treatment of ectopic pregnancy
-3 meds for excessive bleeding
-tranexemic acid1g IV over 10-20 mins
-Misoprostol 800mcg SL/PO/PR/(avoid PV if excessive bleeding), then 400mcg q3h PRN
-vasopressin injected on anterior lip of cervix
treatment of incomplete abortion
dilation and aspiration
-prophylactic antibiotics Azithromycin 500mg PO x1 or Doxycycline 200mg PO x1
2nd and 3rd trimester vaginal bleed ddx
Bloody show (onset 72h prior to labor, PPROM)
Placenta previa (20%)
-Touching/covering internal os (low-lying is within 2cm)
Placental abruption (30%)
-Painful contractions, hypertonus tender uterus, vaginal bleeding may be concealed
Uterine rupture (rare)
-Suspect in shock, acute abdominal pain, change in station, abnormal FHR, vaginal bleeding
Vasa previa (rare)
-Suspect in painless bleeding with change in FHR
6 risk factors of placenta previa
previous placenta previa, previous C/S, uterine surgery, advanced age, multiparity, smoking/cocaine, multiple gestation, in vitro
placental abruption risk factors
Prior abruption, thrombophilia, iron deficiency, PROM, Hypertension, Overdistended uterus, maternal age/parity, smoking/cocaine, abdominal trauma, c/s
diagnosis of placental abruption
Clinical diagnosis, not well diagnosed on ultrasound
Kleihauer-Betke test (fetal cells in maternal blood)
3 risk factors of uterine rupture
Risk: Uterine scar, hyperstimulation (IOL), multiparity
vasaprevia risk factors
Twins, placenta previa (consider TVUS screen at 32w), IVF
diagnosis of vasa previa
transvaginal color doppler ultrasound
Apt test (positive = fetal blood, negative = maternal blood)
- alkali denaturation test, also known as A or Apt test, is a medical test used to differentiate fetal or neonatal blood from maternal blood found in a newborn’s stool or vomit, or from maternal vaginal blood
Wright stain (nucleated RBC on smear)
P/E to do in 2-3rd T vaginal bleed
Vitals (r/o hemodynamic instability)
Abdominal exam (including uterine tone/activity)
Bedside ultrasound (r/o placenta previa)
Sterile speculum
Avoid digital cervical exam until placenta previa ruled out by ultrasound (also if possible prior to speculum)
investigation to do in vaginal bleed in 2-3 trimester + management
Type (Rh) and Crossmatch
CBC
Kleihauer-Betke if abruption
Bedside clot test
INR
Fetal monitor
bedside US
management:
Get help, oxygen, IVF (LOTS!), foley
Massive transfusion protocol
Follow Hb and Coag
ddx vaginitis sx
Infectious vaginal discharge
Bacterial vaginosis (most common cause of vaginal discharge 30%)
Candida vulvovaginitis
Trichomonas vaginalis (STI)
Cervicitis (Gono/Chlam)
Non-infectious vaginal discharge
Physiologic
Atrophic vaginitis (scant discharge)
Foreign body
Non-infectious vulvovaginal pruritus without discharge
Irritant or allergic contact dermatitis (latex, soaps, perfumes)
Lichen planus
Lichen sclerosus
Vulvar cancer
Psoriasis
Colovaginal fistula
bacterial vaginosis dx
Clinical (Amsel’s), require 3 of 4
1-Adherent and homogenous vaginal discharge (smoothly coats vaginal walls)
2-Vaginal pH >4.5
3-Clue cells on saline wet mount
4-Positive whiff-amine test
-Fishy amine odour (before or) after addition of 10% KOH
Other
Gram stain vagina smear with Nugent scoring system (gold standard)
Commercial test DNA probe (eg. Affirm VP III)
Note: Vaginal culture positive for G. vaginalis is not diagnostic due to low specificity (cultured in >50% of healthy asymptomatic women)
treatment of BV
Oral: Metronidazole 500mg PO BID or Clindamycin 300mg PO BID x 7-14d
-Preferred in pregnancy as they have been shown to reduce preterm birth
Topical: Metronidazole gel 0.75% one applicator (5g) PV daily x 5d
Longer courses if multiple recurrences
Consider Metronidazole gel 0.75% one applicator (5g) PV daily x10d then two times per week for 3-6 months
Alternatives:
Vaginal metronidazole gel
Oral or vaginal clindamycin cream
trichomonas vaginalis dx
Malodorous, green/yellow frothy discharge, pruritus, dyspareunia, petechiae - strawberry cervix
Motile trichomonads on wet mount microscopy, NAAT PCR vaginal swabs, culture
trichomonas vaginalis tx
Metronidazole 2g PO x1 or Metronidazole 500mg PO BID x7d
High-dose therapy may be needed for resistance
Partner treatment enhances cure rates
Abstain from intercourse until both patients treated and asymptomatic
candida vulvovaginitis dx
Erythema, edema of vulvovaginal tissues with thick, white clumped vaginal discharge, pH<4.5
Budding yeast and pseudohyphae on wet mount microscopy (negative in 50%)
Consider culture in negative microscopy or persistent/recurrent symptoms after treatment
candida vulvovaginitis tx
Uncomplicated (Sporadic, infrequent ≤3/y, healthy, immunocompetent, nonpregannt)
-Fluconazole 150mg PO x1 or topical intravaginal/suppository (clotrimazole, miconazole)
-Topical antifungal azoles may require longer courses, but are first-line in pregnancy
eg. Clotrimazole Combi Pak (Canesten 500mg vag tab/1% cream) or cream 10% x 1
Complicated
-Fluconazole 150mg PO x3 doses 72h apart (day 1, 4, 7)
-Consider maintenance with Fluconazole 150mg PO weekly x 6 months
-Monitor for hepatotoxicity with long-term use and drug interactions
Non-albicans species may not respond to fluconazole
For C glabrata, consider vaginal boric acid capsules at compounding pharmacist (avoid in pregnancy)
For C krusei, consider topical clotrimazole
prepubescent vaginal discharge ddx
Non-specific (most common)
Causal factors
Thin vaginal mucosa
Moisture (tight clothing)
Irritants (soap, bubble bath, prolonged contact with urine/feces)
Bacterial:
Group A beta-hemolytic strep
H. influenzae
E. coli
Candida (unusual)
Dermatologic:
Lichen sclerosis
Psoriasis
Atopic dermatitis
Foreign body:, usually toilet paper (recurrent symptoms or bloody discharge)
Flush with sterile saline or refer to gyne for vaginoscopy
Pinworms (nocturnal perineal pruritus)
-Treat with mebendazole
Systemic infection (varicella, measles, rubella, diphtheria, shigella)
Rule out STIs and sexual abuse, especially in recurrent cases
investigation for prebubescent vaginal discharge
Introital (not vaginal) swab if profuse discharge
-Bacterial culture (GAS, Haemophilus influenzae, Gardnerella)
-if positive bacterial culture, can treat with antibiotics
Candida unusual, consider if immunosuppression
management of vulvovaginal complaints in prepupertal girls
Treat underlying cause
If non specific,
Reassurance
Hygiene (wipe front to back)
Avoid causal factors (soaps, baby wipes, tight-fitting clothing, wet bathing suits, bubble bath, scented detergents)
Warm soaks, gentle drying
Sleep without underwear
Gentle emollients and barrier creams
management of placenta previa
excessive or continuous vaginal bleeding: cesarean section regardless of gestational age.
If bleeding subsides: expectant management if less than 36 weeks.
-If at or greater than 36 weeks of gestation then cesarean delivery is recommended.
Admission
magnesium sulfate (before 32 weeks) for fetal neuroprotection and steroids for fetal lung maturity if indicated. Bedrest, reduced activity, and avoidance of intercourse are commonly mandated, though there is no clear benefit.
If the vaginal bleeding subsides for more than 48 hours and the fetus is judged to be healthy, then inpatient monitoring is continued, or the patient may be discharged for outpatient management. Inpatient vs. outpatient management depends on the stability of the patient, the number of episodes of bleeding, proximity to the hospital, as well as compliance.
acute cough, within 3 weeks DDX (5)
URTI
post nasal drip
COPD exacerbation
asthma
PNA,
Sinusitis
acute bronchitis
chronic cough ddx
chronic bronchitis
post nasal drip
post nasal drip
post infection cough (hyper responsiveness
gerd
foreign body
primary or secondary tumor
smoker’s cough
meds (ACEI, betablocker (asthma exacerbation)
cough ddx with high mortality
PE
pneumothorax
cancer
TB, HIV
sarcoidosis
pertussis
name 3 RX that are cough suppressant
codeine, diphendydramine
dextromethorphan
chlophedianol
guaifenestin for wet cough (expectorant)
gabapentine can be tried for chronic cough
redflags sx of cough
hemoptysis, dyspnes, weight loss, TB/HIV exposure, decrased SP)2, increased RR, exposure to toxins
asthma PFT diagnosis
FEV/FVC less than 0.8-0.9 and increace of FEV over 12 % or increase of PEF more than 20 % with bronchodilator
Name 4 signs of pna on exam
egophony, dullnes to percussion, decreased air entry, crackles
acute cough in children
URTI
pneumonia
croup
pertussis
foreign object
asthma
gerd
ro bacterial tracheitis, pe, ptx, cancer, TB, pertussis, foreign body, PNA
chronic chough more than 8 weeks ddx in children
chronic bronchitis
post nasal drip
post infection cough
GERD
Bronchiectasis/Cystic fibrosis (wet productive cough, weight loss)
when to give antibiotics for acute bronchitis
cough more than 3 weeks, more than 75 yo,
clarithromycine, azithromycine, doxycycline
post nasal drip/ allergic rhinitis tx
nasal corticosteroids
allergen avoidance
second generation antihistamines
combination corticosteroids/antihistamine inhaler or cromolyn eye drops
if non allergic rhiniris:
-first generation antihistamine plus decongestiant (care in hypertension), glaucoma
-sanal ipratropium bromide
management of cough sensitivity syndrom (idiopathic refractory cough)
Speech pathology treatment
Neuromodulating medication
Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w
CT scan if suspect lung cancer, bronchiectasis or ILD
Referral to specialty
Ayesha, a 9 year old girl, presents in your office with a cold and cough for the last ten days. It started with a runny nose, headache and mild fever for 2 days and has progressed to a dry cough with wheeze over the last four days. The cough is worse at night. She has a history of asthma diagnosed first at age 6. She takes salbutamol by metered dose inhaler intermittently. She has never been hospitalized for asthma. Her father had asthma as a child.
What further history about her asthma should you elicit? Name FOUR items.
Acceptable answers:
Is she symptomatic when she is not sick?
Can she identify triggers?
Compliance: How often does she take her meds?
Inhaler technique/Using a spacer?
Co-morbidity: Does she have allergies?
Co-morbidity: Does she have rash/eczema?
Name FIVE features on history and/or investigations that would indicate a person’s asthma is well controlled? 5 points
Daytime symptoms < 4 days/week
No nighttime symptoms
No limitation to physical activities
Mild infrequent exacerbations
No school absences
No need for beta agonists
FEV1 or PEF > than 90% of personal best
PEF diurnal variation less10-15%
indicators of persistent asthma? Name THREE
Parental history of asthma,
Asthma diagnosed after age 3
Likely allergic rhinitis
Persistence/recurrence of symptoms
what non-pharmacologic management items are indicated in child with asthma? Name SIX items.
Use of aerochamber if metered dose
Education for child/parent
Use of patient symptom diary
Regular assessment of peak expiratory flow (PEF)
Pulmonary function testing
Allergy testing
Environmental allergen/irritant control
Written action plan
A 9 yo patient on ventolin and flovent returns after four weeks of daily medication. Her mother reports that in spite of good compliance and environmental control, she is improved but still having night cough and using salbutamol each night.
What changes or additions to pharmacologic therapy would you consider? Name THREE.
Leukotriene receptor antagonists
Long acting beta agonists
Increasing inhaled corticosteroid dose
Medium-dose inhaled corticosteroid + long-acting beta agonist combination (recommend do not abbreviate)
diagnosis of asthma
typical clinical features:
-wheeze, sob, chest thightness and cough
-variable expiratory airflow limitation
Reduced FEV1/FVC (<0.75-0.8 in adults and <0.9 for children) AND variable expiratory airflow limitation:
Post-bronchodilator reversiblity increase in FEV1 >12% (minimum of 200mL in adults)
Excessive variability in twice-daily (diurnal) PEF over 2 weeks (adults >10%, children >13% daily diurnal variability)
Significant increase in lung function after 4 weeks of anti-inflammatory treatment (adults FEV1 >12% and >200mL increase from baseline)
Positive exercise challenge test (adults decrease FEV1 >10% and >200mL or in children decrease FEV1>12% predicted or PEF >15%)
Positive bronchial challenge test/methacholine (Fall FEV1≥20% or ≥15% with standard hyperventilation, hypertonic saline or mannitol challenge)
Excessive variation in lung function between visits *less reliable (FEV1>12% and 200mL in adults)
triggers of asthma
exercise, laughter, allergens, cold air, viral infection, occupational hazards
asthma ddx
GERD, post nasal drip, chronic sinusitis, ace inhibitor induced cough,eosinophilic bronchitis, CHF in elerly, COPD, TB, aids/HIV, parasitic or fungal lung disease
comorbidities of asthma
rhinitis, chronic rhinosinusitis, GERD, obesity, OSA, depression, anxiety
determinants that asthma is well controlled
in the pst 4 weeks:
-daytime sx less than twice per week
-no night waking due to asthma
-saba reliever needed no more than 2 x per week
-no activity limitation due to asthma
modifiable asthma exacerbation risk factors
-SABA over use
-inadequate ICS
-comorbidities like obesity, chronic rhinosinusitis, GERD, food allergy, anxiety, depression
-smoking, vapijg, air pollution, allergen, major socioeconomic problems, lpw lung function, high blood eosinophils
how often to do PFT for asthma
at diagnosis, 3-6 months after starting tx and periodically q 1-2 years
in adults with asthma, what is the first line of treatment + 5 general management points
GINA recommends adding an ICS-formeterol (eg. Symbicort) even in mild intermittent asthma in 12+ year old, as adding any ICS significantly reduces the risk of severe exacerbations
ICS formoteral as needed (preferred)
-ICS + LABA PRN (reliever) in 12+ years old
Symbicort Turbuhaler
or
regular low dose ICS + as needed SABA
-like Flovent HFA (fluticasone) 50, 125, 250mcg 1 inh BID
-Pulmicort Turbuhaler (budesonide) 100, 200, 400mcg 1 inh BID
-Ciclesonide (Alvesco) 400 mcg once daily
DO not treat with SABA without ICS
management:
decrease allergens and modificable risk factors, comorbidities
asthma information
inhaler skills
adherence
written asthma action plan
self monitoring of sx and or peak flow
regular med review
PFT for dx
asthma second line treatment if ICS and LABA PRN or ICS + SABA PRN not enough
ICS + LABA maintenance and PRN in 12+ years old
Symbicort Turbuhaler (budesonide/formoterol)
Refer for add-on treatment (LAMA Tiotropium, anti-IgE, anti-IL5, oral steroids, Bronchial thermoplasty, SC/SLIT)
LTRA are less effective than ICS
Consider if unable/unwilling to use ICS or in concomitant allergic rhinitis
Singulair (Montelukast) 5, 10mg 1 tab PO PRN
In <5yo, use MDI with spacer and face mask or nebulizer, and dose-adjust
recommendations for initial controller therapy
If symptoms <2/month and no risk factors
-Consider no controller
If symptoms >2/month or risk factors
-Consider Low-dose ICS
If symptoms >2/week
-Low-dose ICS
Asthma most days or waking due to asthma ≥1/week
-Medium/high-dose ICS or Low dose ICS/LABA
Severely uncontrolled asthma or acute exacerbation
-Short course oral corticosteroids AND High-dose ICS or Moderate-dose ICS/LABA
when to FU pts with asthma
Ideally 1-3 months after starting treatment, and q3-12 months after
Step-up vs. Step-down
when to refer patient for asthma
difficult confirming dx
occupational asthma
uncontrolled asthma
risk factors for asthma related death (ICU, anaphylaxis or confirmed food allergy)
give example of asthma action plan
Early intervention in worsening asthma is key
Increase reliever frequency
Increase usual controller
Double ICS or Quadruple maintenance ICS/formoterol (max formoterol 72mcg/day)
Severe exacerbation (PEF <60%) or not improving after 48h
Oral corticosteroids and contact doctor
Prednisolone 1mg/kg/day (40-50mg)/day
asthma exacerbation inER
O2 target 93095%
SABA MDI with spacer 4-8 puffs or 5 mg nebulizer q 20 min x 3
early oral corticosteroids
ipratropium bromide (atrovent)
consider MgSO4 2 g IV over 20 min
transfer to acute care facility
asthma patient in acute setting severity level
Mild-moderate
Talks in phrases, not agitated, Pulse 100-120, O2>90%
Severe
Talks in words, agitated, RR>30/min, Accessory muscle use, Pulse >120bpm, O2 <90%
asthma patient in acute setting DDX / comorbidities to not miss
CHF, COPD
general skin care for eczema
Eliminate exacerbating factors
Excessive bathing (without subsequent moisturization)
Low humidity environment
Overheating/hot water exposure
Avoid potential allergens and irritants
Exposure to solvents/detergents
Avoid fragrant/perfumed topic agent
Avoid coarse fiber clothing (wool/synthetic)
Emotional stress/anxiety
Xerosis (dry skin)
Treat skin infections (S. aureus, herpes simplex)
Sunscreen/protection
Hydration/Emollients multiple times per day
💡 Occlusiveness of topical preparations (from most to least): ointments (use for dry lesions) > creams (use for wet lesions) > lotions (use for weeping/intertriginous lesions)
Stevens-Johnson syndrome (<10% skin involved) / Toxic epidermal necrolysis (>30% skin involved) symptoms
Prodromal flu-like illness: Fever >39C, sore throat, rhinorrhea, cough, aches
Sudden onset tender/painful skin rash on face/limbs, 90% with involvement of mucous membranes (mouth, eyes, genital)
Tender red/purple macules, diffuse erythema, targetoid lesions, bullae and/or vesicles (may have positive Nikolsky)
treatment of stevens johnson or toxic epidermal necrolysis
stop causative drug (Sulfas, Alloprurinol, Tetracyclines, anticonvultivants, NSAIds
Treat infections (eg. Mycoplasma pneumoniae)
Admission to ICU
IV fluid resuscitation and wound management
Necrotizing soft tissue infections (cellulitis, fasciitis, myositis, gas gangrene) presentation
Diffuse erythema, swelling, warmth, shiny, exquisite tenderness
Late findings include crepitus, bullae, skin necrosis, loss of sensation
Necrotizing soft tissue infections (cellulitis, fasciitis, myositis, gas gangrene) labs
↑ WBC, ↑ CRP/ESR, ↑ CK, subcutaneous air on XR/CT/MRI
Necrotizing soft tissue infections (cellulitis, fasciitis, myositis, gas gangrene) treatment
ICU admission plus aggressive surgical exploration and debridement and broad-spectrum antibiotics: e.g., Tazo/Clinda/Vanco IV
Meningococcal infection rash presentation
Can present with abnormal skin color pallor, mottling
Petechial rash involving trunk, lower body, mucous membranes (oral and ocular), may have purpura, ecchymotic lesions
chemical and non chemical burns management
When in doubt, consult Poison Control for additional guidance
Fluid Resuscitation for burns >15% BSA in children and >20% BSA in adults
Modified Brooke/Parkland Formula 2-4mL x %BSA x kg Ringer’s Lactate, 1/2 in first 8 hours, 1/2 in next 16 hours
Wound management
Keep moist
Apply antibiotic ointment to non-adherent dressing (Adaptic) then apply to wound
Pain control
Ensure tetanus vaccine status up-to-date
Follow-up at <72h, to re-assess burn to better characterize partial vs. full thickness
Refer to burn center PRN
Diagnosis and treatment melanoma
Diagnosis and treatment: full-thickness excisional biopsy with 0.5-2cm safety margin (according to Breslow thickness)
Prognosis highly dependent on Breslow thickness, 5-year survival drops with depth > 1-2 mm
squamous cell carcinoma treatment
Treatment: Surgical excision + biopsy (e.g., punch biopsy, Mohs micrographic)
actinic keratosis treatment
Treat local AK with cryotherapy (eg. two freeze thaw cycles of 5s)
Treat widespread AK with fluorouracil 5% cream BID x 2-6 weeks
types of pemphigus and compications
Refers to a group of life-threatening autoimmune blistering and erosive diseases affecting the skin and mucosa (
Complications include infection, fluid loss, electrolyte disturbances
Types: Vulgaris (most common; 70% of all pemphigus), Foliaceus, IgA, Paraneoplastic
treatment of phemphigus
Systemic steroids (1-2mg/kg prednisone daily or 0.5-1mg/kg in combination with rituximab)
Azathioprine or mycophenolate mofetil are often used to attempt to reduce steroids
Consider adjunctive high potency topical steroid (e.g., clobetasol propionate) for larger erosions
Cover erosions with antibiotic ointment or a bland emollient (eg, petroleum jelly) +/- non-adhesive wound dressings
systemic skin disease ddx
granulomatosis with polyangiitis (wegener’s)
systemic lupus erythematosus
dermatitis herpetiformis
psoriasis
kaposi’s sarcoma in HIV
treatment of scabies
Treatment: Topical permethrin 5% cream applied to the whole body from the neck to the soles of the feet, including areas under the fingernails and toenails (plus scalp in infants & young children) and washed off after eight hours. Can be repeated 1 week later if necessary.
Can manage pruritus with oral antihistamines or topical corticosteroids if severe
All textiles, bedding, clothing should be washed and dried at hottest temperature
Strongly consider prophylactic treatment for close contacts (even if asymptomatic as incubation period can be ~1 month)
Watch for superficial bacterial infection and treat accordingly with oral antibiotics
impetigo treatment
Topical mupirocin 2% ointment (Bactroban) TID x 5 days
Can consider topical fusidic acid (although some resistance)
acne DDx
Drug-induced acne
Tropical acne - Extreme heat
Acne aestivalis (Mallorca acne) - Sun exposure
Rosacea - Late age onset, erythema, talengiectasia, papules, pustules, no comedones
Periorificial dermatitis - Around mouth, nose or eyes sparing vermilion border
Pseudo/Folliculitis, no comedones
Keratosis pilaris - Follicular prominence and roughness (usually on arms, but may resemble acne on cheeks)
Favre-Racouchot syndrome - Comedones on cheek due to sun damage
treatment of acne depending on severity (comedomal, mild-moderate papulopustular, severe_
Comedonal
Topical retinoids gel/cream (Tretinoin 0.025%, Adapalene 0.1%, Tazarotene 0.1%)
Benzoyl peroxide (BPO) 2.5% or 5% gel or Azelaic acid (AA) 20% cream (possible better tolerability than BPO)
Mild-moderate papulopustular
Topical Retinoid + BPO or Topical Abx + BPO
Adapalene 0.1% and BPO 2.5% (Tactupump)
Clindamycin 1% and BPO 5%
Treat with all three topicals (Retinoid, BPO, Abx) if no response x 3 months
Combined OCP or systemic antibiotics
High estrogen (ethinyl estradiol) concentration associated with decrease in inflammatory lesions
Tetracycline (eg. doxycycline 100mg PO BID or daily x 3-4 months)
Risk in pregnancy or <9yo (teeth discoloration/bone growth)
Side effects: GI, photosensitivity
Severe papulopustular
Oral isotretinoin (pregnancy-prevention measures due to teratogenicity)
0.5-1mg/kg daily divided BID for 15-20 weeks or
0.5mg/kg daily divided BID for 1 month, then 1mg/kg/day divided BID, until a cumulative dose of 120-150 mg/kg
Consider lower dose 20mg every alternate day or 0.25-0.4mg/kg/day for moderate
Consider monitoring labs
Fasting lipid and LFTs at 4 weeks and 8 weeks, and then stop if normal
Other
Oral zinc has been shown to have effect against inflammatory lesions
Diet: Some evidence for low glycemic index diet, lack of evidence concerning dairy consumption
Chemical peels have minimal evidence but are safe and inexpensive
what to monitor when giving oral isotretinoin
fasting lipid
LFTs
A 17 year-old male comes to the office complaining of moderate amount of papules and pustules on the face and the upper back, ongoing for the last two years and getting worse. You diagnose him with acne. He would like his acne to improve in time for his high school graduation.
Name FOUR different classes of medications that can be used for the treatment of acne in this patient.
antibiotics
benzoyl peroxides
retinoids
salicylates
intralesional steroids
Name ONE combination topical medication that you could prescribe for mild-mod papulopustular acne
clindamycin/benzoyl peroxide
erythromycin/benzoyl peroxide
erythromycin/Vitamin A
adapalene/benzoyl peroxide
Name ONE oral antibiotic for acne
minocycline, doxycycline, tetracycline, erythromycin, trimethoprim
duration of therapy: 6-12 weeks
