Review Course Content Flashcards
Fever in returning traveler is ____ until proven otherwise?
Malaria - falciparum malaria can kill you in 24-48 hours!!
Pre-travel history?
When, where, how long are you going and why are you going there? ie. food tourism = high risk for cholera, GI illness, typhoid fever, parasites SE Asia (Bankok, Thailand for business meetings) - lower risk profile. PHx, PMHx, Family Hx
Management of traveler with fever?
More than meds!
Twinrix and ciprofloxacin
When is typhoid vaccine indicated in Canadian guidelines?
Southeast Asia & surrounding region
Biggest risk type of travel for fever in traveler?
Visiting relatives!
Antimalarials and comparison as per PHAC 2014?
- Atovaquone - proguanil - daily x 7 days post exposure. Daily dosing and $$$$
- Doxycycline - cheap, daily, photosensitivity rash and need it 30 days post exposure
- Mefloquine - once weekly dosing, frequent side effects including wild dreams!! And psychiatric sx. THUS not first line anymore!
- Primoquine - need blood test before medication taken -G6PD deficiency test. ONLY 7 days after exposure.
- Chloroquine - cheap and long term safety data
* **WIDESPREAD RESISTANCE (Check before prescribing) also has skin and corneal side effects.
Non-pharmacological management and recommendations for pre-travel counseling
- PREVENT - Limit high risk activity - night driving (don’t do it), sex tourism (use PREP or condoms)
- QUIT - smoking, don’t check meds in luggage!!, risky activity
- REFER -travel clinic
- Travelers diarrhea
BIGGEST M&M In patients who are travelers?
MVA’s!!!!
How to prep for travelers diarrhea?
- Pack: Oral rehydration solution, loperamide*, azithromycin, bismuth subsalicylate** (can take QID for prevention)
- Take loperamide for mild diarrhea if no dysentry or blood.
- *Pepto bismol - can take QID for prevention
2. Boil it, peel it, cook it, or forget it
3. Ice cubes, salads, uncooked veg
4. Use bottled water
5. Wash and sanitize hands often
How to manage altitude sickness?
Acetazolamide 125 mg BID Dexamethasone 4 mg BID** Nifedipine Sildenafil/Tadalafil Prophylactic salmeterol
**Also treats high altitude cerebral edema AND get em off the mountain!
NOT recommended: ginko biloba
Aspirin a day?
Primary prevention for CV disease? DON’T START IT!
If already taking? Evidence to discontinue less clear. Do risk assessment
Studies: ASPREE, ARRIVE, ASCEND, ACCEPT-D
HCV Screening? Who are the higher risk patients?
NOPE.
Unless higher risk:
Hx incarceration, blood products/organ transplant before 1992, recent immigrants, IVDU
AAA Screening?
Men 65-80 yo - one time abdo ultrasound
Women - NOPE
CFPC Preventive Health Checklist?
Learn it. CFP 2020. Get it off bit.ly/vitalfm-checklist
CFPC Preventive Health Checklist?
Learn it. CFP 2020. Get it off bit.ly/vitalfm-checklist
FALL in PM? How can we prevent the hip fractures?
Best question: How many falls in the last one year?
FALL: review active health status, screen for FALLS yearly
P: Review pain control
M: Medications?
Immigrants and Refugees Guidelines?
Check out Ottawa guidelines from CMAJ 2011 or CPS have good one: caringforkids.ca new to Canada
Immigrants & Refugee Canadian Practice Recommendations?
- Infectious Disease - OFFER testing and vaccines, INTERPRETER, Consider RISK LEVEL for country (ex. HIV, TB, HCV
- Chronic Disease
- Mental Health
- Women’s Health
Recommends for Interpreter?
- Not a family member
- Don’t pull someone from waiting room
- LOTS of access for interpreters!
- Don’t use google translate as not standard of care
How do we test for TB?
Intradermal (IGRA)-interferon gamma release assay
>95% Specificity for latent TB only
-Don’t use to dx ACTIVE TB
4 meds to tx TB?
Rifampin
Isoniazid
P
E
4 meds to tx TB?
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Painless hematuria is
CANCER until proven otherwise
ALSO a sx. of schistosomias and consider this for
If fever and travel test for malaria. If asymptomatic?
asyx: DON’T Test
Test via: Thick & thin smear
Test for malaria antigen
If patient has no vaccine record and is immigrant?
GIVE THESE!!! (50% don’t have them on avg.)
TDAP-IPV
MMR
TEST first:
HBV
Varicella (if over 13 years old)
Immigrants Screening?
Dentist
Diabetes (use HgbA1C)
Vision - optometrist
Lead poisoning
What mental health like conditions should you NOT screen for in immigrants? What should you screen for?
Don’t screen for maltreatment of children, domestic violence or PTSD unless presenting complaints.
- Are you down, depressed or hopeless? Little interest in doing things? (anhedonia)
- This is the PHQ-2 and first 2 questions of PHQ-9.
Women’s Health in immigrants?
OFFER screening: serum iron or ferritin
women and Children FERST
TRAVEL HISTORY?
Years later…patient has a cough?
Vague GI sx?
TB risk region?
Test for strongyloides if walking barefoot!
TRAVEL HISTORY?
Years later…patient has a cough?
Vague GI sx?
TB risk region?
Test for strongyloides if walking barefoot!
SCZ Guidelines - Initial Workup?
Full history
FUNCTION (sexual function - pregnant????)
SCZ Guidelines Top 5 Recs?
1st episode: antipsychotic How long? 18 months 1st vs. 2nd gen are equal Oral = Depot (patient preference) -NNT = 7 to avoid patient admission Treat Comorbid depression
NMS symptoms and treatment?
FARM: Fever Autonomic dysregulation Rigidity Mental status changes
-Even low dose, any stage of treatment, can be if escalating doses or dose changes.
Tx: Stop medication IVNS Ice packs Dantrolene Bromocriptine
Management of SCZ?
Meds Safety first!! -SI and HI Family counseling Vocational rehab Finances? Day hospital? Admission? Detox? Adherence? Pregnant? SUD?
Adult non resolving pneumonia?
Is it the wrong bug, drug, or diagnosis!?
Typical?
Atypical?
Mycobacterium? Pneumocystis?
Non- abx treatment for abscess, sepsis, appendicitis, laceration and nec fasc?
Abscess - drain it, and de-capsulate
Sepsis - supportive (fluids, pressors, blood cx)
Appendicitis - conservative therapy treatment emerging
Laceration - TETANUS BRO
Nec Fasc - EMERGENTLY DEBRIDE!
Abx Trends?
ORAL after IV? May be non-inferior to prolonged IV
Pneumonia Guidelines (2019)
DON'T -use term healthcare associated PNA term -DON't use CURB-65 score. -procalcitocin -order sputum C&S or blood culture unless patient is sick! Sick = severe CAP as per PSI score. -prescribe steroids -XRAY not required
DO:
- use PSI score
- Test for influenza (at risk for MRSA PNA)
- Treat with antiviral if influenza positive AND abx if PNA expected
Non-resolving PNA: 37 M non smoker, low grade fever, SOBOE and occasional cough. Pulse 102 / 22/ 106/68, afebrile
Generalized lymphadenopathy
Prev got mixofloxacin and hasn’t improved
WBS of 3.6 and low lymphocytes
CXR is normal.
TROC history
Vitals
Treating the wrong bug? drug? or diagnosis?
Repeat CXR: Diffuse interstitial infiltrates, CD4 110, bronchoscopy was PJP!
Weird and Wonderful ddx of PNA?
PJP - pneumocystis Jirovecii pneumonia Mycobacterium Avium Complex (MAC) TB Influenza Toxoplasmosis
CXR normal! Clinical picture unclear?
Get SERIAL dude!!!
Serial exams, serial ECG’s, Serial Imaging
*Also relevant for chest pain etc. Imaging evolves over time!
What 3 infectious diagnoses should you think about testing together?
HIV-TB-HCV
4 factors affect antibiotic choice in pneumonia (and one bonus)?
- Allergies
- Drug drug Interactions (ex. warfarin)
- COPD co-treatment needed?
- Are we covering for aspiration PNA? (anaerobes!)
- Outbreak!? (Think legionaires, COVID-19)
When do you use antibiotics in COPD?
In exacerbations!
COVID-19 CXR imaging?
Interstitial PNA
Most common cause for PNA in ALL people?
Strep Pneumoniae!!!!
In kids…uncomplicated PNA recommendations?
Amoxicillin - banana flavoured!! is still first-line
Routine X-ray post treatment is NOT recommended unless clinically indicated.
Hypertension screening best practice?
Automated> manual
Gold standard 24 h ambulatory
If chubby or muscly arm? Use wrist device (sit at level of heart)
-Take BP when patient relaxed, no coffee, no smoking, feet flat, no gum
Out of office measurements of BP recommendations?
- CRITICAL!!
- White coat HTN effect is real!
- BP cuffs aren’t that expensive anymore
Diagnosis of HTN?
Automated office BP mean >135/85
Office BP >140/90
Diabetes >130/80 if 3 office measurements on different days
If any above: get outpatient BP
Amb >135/85
Diabetic 130/80
Workup for HTN?
Do a lipid panel
Non fasting OK
Also K, Na, Creatinine, urinalysis, HbA1c, diabetic patients (urinary albumin), ECG
-MAKE SURE NOT PREGO!!
% of cases are essential HTN?
90%
Secondary HTN?
Atherosclerosis Big belly, bruits, bad kidneys Catecholamines (pheo) Drug, diet Endocrine sleep apnea and stress
CPAP does NOT?
Decrease cardiovascular events
or decrease mortality
First line for eHTN?
- Diet
2. Lifestyle
When do you start treatment for eHTN?
Based on RF’s:
Low
High
Diabetes
All others
HCTZ and skin cancer?
- uncertain and not proven
- Possible 4x incr risk after 3 years of:
- Non melanoma skin CA
- Inform patients and
-consider switch if higher risk:
light skin
personal or fam hx
Immunosuppressed
HTN ABC’s to avoid!?
AVOID:
Alpha blocker alone
Beta blocker if older than 60 yo
ACE or chlorthalidone if black
Chlorthalidone in HTN?
Incr risk diabetes, renal, e’lyte abnormalities VS HCTZ (similar CV benefit for both)
Prefer LONG acting diuretics (chlorthalidone or indapamide)
What does taking antiHTN at bedtime do?
Reduce CV disease risk by nearly half (hazard ratio is ~0.55?)
HTN urgency vs. Emergency?
Urgent: Rapid treatment is NOT successful or necessary
Emergency: Asymptomatic DBP >130
Acute heart, brain, aorta or kidney damage
Pre-eclampsia or PHEO
Treat with: Nifedipine Labetolol Captopril Clonidine Nitrates
Resistant HTN definition? #1 reason?
if on 3 meds REFER! This = resistant
4th agent: Spironolactone has BEST effect to lower BP (monitor kidney fcn)
Reason: NOT TAKING THE MEDICATION!
Other: not appropriately prescribed?
Lifestyle: salt, tobacco, sedentary, obesity, alcohol
Other meds: naproxen, NSAID’s, contraception, steroids, licorice, OTC medications
HTN in kids?
> 3yo then measure
Check in RIGHT arm because if coarctation of aorta then falsely low BP in LEFT arm
Workup = ECHO and CVD risk assessment
HTN in pregnancy?
AVOID/CONTRAINDICATED: ACE and ARB pre-conception and in pregnancy
BREASTFEEDING: Choose labetalol, methyldopa, nifedipine
COUNSELING PRE-CONCEPTION: Look at BMI!
Lifestyle treatments of HTN?
Sodium <2000 mg/day (drop 5mmHg)
Weight decrease 4.5 kg (drop 7 mmHg)
Alcohol -decrease by 2.7 drinks/day (drop 4 mmHg)
Exercise Rx - 30-45 mins 3x/week (10 mmHg)
Diet - DASH (10 mmHg)
Relaxation - CBT (10 mmHg)
When do you start treatment for HTN?
START treatment if? Low risk: >160/100 (goal: <140/90) High risk: >130 (<120 sys) Diabetes: >130/80 (<130/80) All others: >140/90 (<140/90)
Febrile neutropenia?
- Recognize early!!!
- Stabilize (fluids and ABX)
- Avoid rectal temp, look in mouth (mucositis), look for source (consider fungal)
Fever without cause -when to do tissue biopsy? What other tests?
Full workup previously normal….
Tissue biopsy? Liver Node Temporal artery Bone marrow
SPEP Vasculitis/autoimmune ECHO HIV, TB test Dental assessment Viral cultures
No idea wtf going on with this weird AF PNA?
Serial exams
Serial ECG’s
Serial imaging
Serotonin Syndrome
- GI symptoms and NMS does not
- myoclonus
Kid prevents with 5 days of fever and he is 5yo?
KAWASAKI’s
CRASH
Conjunctivitis Rash Adenopathy Strawberry tongue Hands and feet
Bad bad bad -CAA: Coronary artery aneurysm
ASA and IVIG in KAWASAKI
Don’t forget about MIS-C!!
-Children 0-19 with fever >3 days and COVID 19 positive or close contact, and unexplained ESR/CRP elevation
Kid presents with 5 days of fever and he is 5yo?
KAWASAKI’s
CRASH
Conjunctivitis Rash Adenopathy Strawberry tongue Hands and feet
Bad bad bad -CAA: Coronary artery aneurysm
ASA and IVIG in KAWASAKI
Don’t forget about MIS-C!!
-Children 0-19 with fever >3 days and COVID 19 positive or close contact, and unexplained ESR/CRP elevation
Issues with Framingham?
OVER ESTIMATES RISK
Screen who for hyper
Men >40yo
Women >50 (or post menopauisal)
EARLIER:
Smoker
Screen who for hyperlipidemia? (incomplete)
Men >40yo
Women >50 (or post menopauisal)
EARLIER:
Smoker
DO NOT in hyperlipidemia
Treat LDL target (CCS disagrees rx. to <2 or 50% reduction or <1.8 if ACS) Use framingham in renal dz make patients fast Order Apo-B, CRP Use ezetimibe for primary prevention
DO NOTs in hyperlipidemia
DO NOT in HYPERLIPIDEMIA: Treat LDL target (CCS disagrees rx. to <2 or 50% reduction reduction or <1.8 if ACS) Use framingham in renal dz make patients fast Order Apo-B, CRP Use ezetimibe for primary prevention
CAM for high lipids?
O3FA FIRST LINE FOR HYPERTRIGLYCERIDEMIA
25% risk reductions
Effective and safe except poor GI sx
CAM for high lipids?
O3FA FIRST LINE FOR HYPERTRIGLYCERIDEMIA
25% risk reductions
Effective and safe except poor GI sx
Dumb Mnemonic for Dizziness that is validated?
TiTrATE (validated tool):
Timing
a. How long does it last? seconds, minutes, days. When feel dizziness how long does it last? Does it go away?
Triggers
A thorough exam
Don’t need to ask med school questions for lightheaded or room spinning? Get a double yes that is UNHELPFUL
Dizziness timeline clues?
In shower, look up, and dizzy but resolves in 30 seconds?
20-30 mins long ladsting?
Constant/days?
BPPV
Orthostatic Hypotension
Meniere’s last longer
Migraine, neuritis, stroke
Triggers of dizziness?
Medication start or change
Trauma (barotrauma)
BPPV or orthostatic hypotension
Associated symptoms of dizziness?
Migraine aura - think migraine
Blood, Blisters, Back of neck pain -Ramsay hunt, trauma, vertebral artery dissection
Chest pain - aortic dissection
Deafness (1 side) -Meniere’s (tinnitus, fullness, dizziness)
Vertigo exam includes?
Orthostatic BP
GAIT (stroke?)
HINTS + loss of hearing exam - head impulse, nystagmus, test of skew
Dix-Hallpike
Where to REFER for dizziness?
ENT Neurology Vestibular rehab Physiotherapy OT Psychiatric comorbidity with vertigo: 37-50%
Tdap in pregnancy?
EVERY pregnancy at 28-32 weeks to prevent pertussis in the lil infant even if the mom got it recently.
YEARS criteria?
Look it up RIGHT NOW!
PNA and steroids?
NO (IDSA guidelines)
Red or black stool ddx?
IF not blood:
beets
iron
bismuth subsalicylate
Deprescribe PPI?
Stop or taper slowly
Step down (H2 antagonist)
Reduce: on demand, EOD
Ddx of Lower GI bleed?
ROYAL Family: Kate is always pregnant = Hemorrhoids (statistically) Queen Elisabeth (old AF) = Probably your aspirin (RULE OUT BAD THINGS)
Treatment for EVERY Acute Situation?
ABC MOVIES
Airway
Breathing
Circulation
Monitor Oxygen Vitals IV ECG Sugar check
SERIAL ABC’s, VITALS, ECGs
Acute GI bleed myths and facts?
Increase hemoglobin? Transfuse ONLY if fluids not working and Hb <70
Decrease stomach contents? Decrease acid! PPI bolus (non variceal), Decrease blood/clots? Erythromycin
Scope Urgently? Scope by 6 hours does NOT reduce mortality compared to 24 hours.
Ceftriaxone? IF cirrhosis or varices? Ceftriaxone and somatostatin
NO varices? NO other drugs - don’t give transexamic acid as NO benefit and doubles risk of VTE
Prevent GI bleed?
PPI and H2RA
Anxiety RFs? Don’t miss!?!?
Family history PHx of mood or anxiety ACEs Female Chronic medical illness Behavioural inhibition
Don’t MISS: SUICIDE Assessment!
-Anxiety is INDEPENDENT RF for suicide completion (controlling for mood disorders)
PTSD treatment?
VPS + F: Venlafaxine Paroxetine Sertraline Fluoxetine
CBT (trauma focused)
Group Therapy
Debrief all trauma victims?
NO WAY!
OCD
- Obsessions and/OR compulsions
- time consuming or distressing
- Significant impairment in social or occupational functioning
OCD: O’s are ego dystonic
OCD treatment?
SSRI’s except citalopram
First line augmentation: aripiprazole, risperidone
Exposure response prevention (ERP) (Gold standard type of CBT)
Generalized anxiety disorder meds? Most effective for GAD?
VPS PEAD: Venlafaxine Paroxetine Sertraline Pregabalin Escitalopram Agomelatine Duloxetine
MOST effective: Pregabalin, duloxetine, venlafaxine, escitalopram,
Also (but smaller): Mirtazapine, sertraline, buspirone, agomelatine AND quetiapine, paroxetine and BZD’s.
A word on BZD’s for anxiety…
- NOT monotherapy
- Avoid if on opioids
- Consider risk and discuss dependence
- Avoid high doses or large quantities
- Avoid in elderly!! Increases all cause mortality.
Social anxiety treatment?
VPS PEF: Venlafaxine, paroxetine, sertraline, pregabalin, escitalopram, fluvoxamine
New SADPERSONS?
Precipitating factors: Drugs/alcohol (50% of SA's involve EtOH) Access to means Life events New terminal/chronic dz diagnosis Media effects
Predisposing factors: Neuropsychiatric disorders Family history Previous attempts ACEs Socioeconomic status
CFI-S?
Convergent functional assessment for suicide
- good to excellent predictive value
- 22 questions
Antidepressant efficacy?
AD’s effective by 6 weeks?
-Up to 1/3 will not show early response by 6 weeks
DSM-5 Mimics of depression
Hormones Grief Drugs Bipolar Tumor Delirium
Bipolar disorder or MDD?
<25 yo
>5 episodes
-Quick on/off of episodes
-Atypical features (hyperphagia, hypersomnia, leaden paralysis, longstanding interpersonal rejection sensitivity)
-depression with psychotic features
-quick response, but wear off of efficacy.
WOW FRAMEWORK for delivering bad news?
Wish we didn’t have to discuss this hard topic?
Worry convo will be difficult?
Wonder if?
GOALS are VITAL
Recognize Strengths (trauma and violence informed discussion)
Recognize abilites
Family
Teach when breaking difficult news?
Advanced directives (CPR, feeding tubes, intubation)
Estate planning?
Will?
Teach how to break news to family - offer to help
When can you terminate a patient-physician relationship?
Check with regulatory body!
Cluster A PD’s? B? C?
A:
Schizoid - Evyn Peters (no emotions, enjoys nothing, likes to be alone)
Schizotypal - Willy Wonka
Paranoid - suspicious AF
B:
Borderline - fear abandonment, self harm, identity issues
Narcissistic - entitled, no empathy, think they’re special
Histrionic - Anjena
ASPD - No remorse, lies, steals,
C:
Dependent - can’t make any decisions ever
Avoidant - extreme version of social anxiety
OCPD - all med students ever. Neurotic, controlling, morally scrupulous, perfectionistic
URTI’s and honey?
Honey works the BEST for kids with URTI’s!
Side effects of lithium
Nausea, vomiting, confusion, concentration, hypothyroid, tremor, diarrhea, ataxia, ECG changes (inverted T waves), weight gain
Labwork for lithium
Lithium level, creatinine, TSH, beta-HCG, calcium
Therapeutic window for lithium
0.6-1.2
3 Methods other than injected anethetic
Topical anesthetic, distraction, sedation
How to reduce pain of injection
Smallest needle possible, warm anesthetic, bicarb, injecting slowly
Alternatives to lidocaine
Tetracaine, procaine, preservative free lidocaine
Complications from toe surgery
Cellulitis, ischemia, nec fasc, reperfusion injury, allergic reaction
Key features of infection
Proximal migration of the lesion, leukocytosis, bony involvement on x-ray, CRP, Pain with passive stretch, fever
Treatment for pediatric asymptomatic bacteriuria
Nothing
When do you treat asymptomatic bacteriuria? List 2
Renal transplant, invasive urologic procedures
What drugs are most likely to cause serotonin syndrome? List 3
SSRI, SNRI, MaOIs
Also triptans, stimulants.
What is on your differential for altered mental status? List 7
Drugs - anti-cholinergic toxicity, malignant hyperthermia, NMS, EtOH/benzo withdrawal Infection - meningitis, encephalitis Metabolic - thyroid storm Failure (liver/kidney) Anemia Cerebral infarct/bleed Endocrine Structural/space occupy
What are the signs and symptoms of serotonin syndrome? List 6
Mental status changes (agitation, delirium) Autonomic dysfunction (changes in vitals) Neuromuscular dysfunction
What is one different symptom in Neuroleptic Malignant Syndrome and not in Serotonin syndrome?
NMS = Rigidity
Serotonin syndrome = Gi symptoms and hypereflexia/clonus
What is the treatment for a Toddles Fracture (Childhood Accidental Spiral Tibial fracture (CAST))?
Non-surgical. Backslab or boot.
What are 5 diagnoses for pediatric limp?
Leg-calves-Perthes
Infection/Inflammation
Malginancy (Ewing’s sarcoma/osteoscarcoma
Pain (fracture)
Slipped capital femoral epiphysis (Half black/half hispanic obese boy)
Something else (referred from above or below)
What is the most common organism for pediatric osteomyelitis?
S. aureus
What are the cutoff values for postural hypotension
20 systolic, 10 diastolic within 3 minutes of standing.
List 8 causes of orthostatic hypotension with compensatory tachycardia.
Dehydration (diarrhea/adrenal insufficiency, dialysis, diuretics, digoxin, antibiotics, cholinesterase inhibitors.
Dysfunctional Heart (myocardium, aortic stenosis)
Drugs (anti-hypertensives, anti-anginas, anti-parkinsonians, anti-depressants, anti-psychotics, anti-BPH meds)
Deconditioning
List 2 causes of orthostatic hypotension without compensatory tachycardia.
Low B12, hypothyroidism, EtOH abuse, diabetic neuropathy, parkinsonism, amyloidosis, beta blocker.
What are 6 possible treatment options for plantar fasciitis?
Weight loss, NSAIDs, stretching, glucorticoid injection, night splinting, orthotics, hypotension.
What is on your differential for anal mass?
Colorectal cancer, Rectal porolapse/varices Anal wart Polyp Skin tag`
What conservative measures are used to treat hemorrhoids?
List 4
PEG Weight loss Increase fibre intake Increase fluid intake Increase physical activity Stool softener Cold packs Sitz baths Baby wipes NSAIDs
When can you start sleep training?
6 months.
How do you teach sleep training?
Bedtime routine.
Put baby to bed when tired
If crying allow for 2-5 minutes then reassure if needed. Then return and increase intervals between consoling
Maternal benefits to sleep training.
Better quality maternal sleep
Better maternal mood
Better maternal energy
Differential for fever and diarrhea. List 8
Malaria Dengue fever Rickettsial disease (Typhus) Waterborne (Typhoid) Urinary infection Respiratory infection Skin infection Traveler's diarrhea
What tests to do for stool parasites?
Stool O&P
Rectal biopsy
Urine examination for parasite eggs
What drugs treats trematode flatworms?
Praziquantel
What is acute shistosemiasis syndrome?
Katayama fever
What office based test for diabetes? List 2
Random glucose
U/A (ketonuria/glysuria)
What are important elements of history in new diagnosis of diabetes?
Polyuria
Polydyspsia
Polyphagia
Weight loss
What conditions are associated with aortic dissection? List 5
Hypertension Marfan's Ehlers-Danlos Bicuspid aortic valve Cocaine/Meth Lupus Polycystic Kidney Disease Trauma Giant Cell Arteritis
Peak incidence age range for aortic dissection
60-70
30-40 (connective tissue diseases)
What are 5 indications for medical marijuana?
Spasticity secondary to spinal trauma Spasticity secondary to MS Chemotherapy induced N/V Neuropathic pain Palliative pain
What is the medication given to neonates and what is the dose?
Vitamin K - 1 mg
What is an alternative to a vitamin K injection?
PO vitamin K
List 4 of the most common reasons for accessing MAID?
Suffering/fear of suffering Loss of independence or physical abilities Loss of autonomy Loss of pleasure Unacceptable quality of life Difficulty communicating
What is the third line treatment for dyslipidemia?
PCSK9 inhibitors
What is the mechanism of action of a PCSK9 inhibitor?
PCSK9 inhibitors attack to PCSK9. This prevents them from attaching to the LDL receptors in the liver thus allowing the LDL receptor to not be lysed.
Physical exam findings as a result of vertebral compression fractures. List two.
Tenderness to palpation
Visible deformity
Kaiphosis and height loss
What are the conservative treatments for a compression fracture? List 6
Rest NSAIDs Acetaminophen Calcium Vit D Smoking cessation Weightbearing exercises Bisphosphonate Short term opiates
What surgical intervention can be used for compression fractures?
Vertebraplasty
What is the t-score cutoff for osteoporosis?
-2.5
What are the contraindications for bisphosphonate drug holiday?
Fragility fractures of hip or spine.
What are the elements of the FRAX score/what are important elements in history taking for bone health?
Age BMI Femoral head t-score Smoking Race Gender EtOH Previous fracture Family history of fracture Glucocorticoid use RA Secondary Osteoporosis
What clinical features of a hand fracture warrants referral to plastics?
Open fracture Rotational deformities Tendon rupture Unstable fracture Intra-articular
What needs to be documented prior to manipulation?
Neurologic status
Vascular status
What are three types of hand tendon injuries that warrant surgical intervention?
Jersey finger
Mallet finger
Central slip rupture
What are the most common treatment options for fingertip amputation? List 3
Secondary intention
Reattach fingertip as composite graft
Revision amputation.
Antenatal care?
Safety
U/S
Measure mom and baby at each visit
LABS
Complications
Lots more on here - divide into antenatal, in pregnancy, and post-partum Gestational HTN (140/90) PROM TOLAC: labour if no contraindications, but increased risk if <18 mo Labour latent/active 4cm dilation Dystocia (<2cm in 2 hours) Abnormal fetal heartrate Uterine rupture Shoulder dystocia
Shoulder dystocia?
flip woman over (and other stuff John add please and thanks so much yes yes yes)
Postpartum!
Breast/chestfeeding bottom bowels bladder bleeding baby belly blues birth control boinking
Mifeprisone for abortion?
Confirm gestational age
__________
CI: asthma, adrenal failure, steroid use, blood disorders, remove IUD
Advise
how to take, risks, severe pain (opioids) etc.
How to RULE OUT major cardiac events?
>18yo CC/ Chest pain NO ECG changes -Troponin and serial at 3 hours. IF negative, home with follow up -LOW risk: 0.9% 30 day MACE
***CLINICAL SUSPICION»_space; ECG, trops or heart score
AVOID MISSING AORTIC DISSECTION by asking WHAT!?
History: Character, onset, duration, quality, radiation
ASK about >2 then 94% correct diagnosis. If <2 20% are missed!
MONA?
Main goal: PCI <120 mins
Morphine (increased mortality for NSTEMI)
Oxygen >90%
Nitrates for analgesia or pain (no mortality benefit)
ASA 27% mortality benefit
Non cardiac causes of Chest pain?
LUNG - PE< pneumothorax, infxn, pus, blood
Heart - valves, muscle, sac, infection, MI
Esophagus - inflam, acid, spasm, foreign body, rupture, ear
Viral swab for ZOSTER
Hiatus hernia - barium swallor/scope
Esophageal spasm
Dressler’s syndrome is say what?
ddx: ACS, dressler’s (pericarditis), Aunxiety or PNA/PE
Test: CRP, ECHO, CXR
TREAT: High dose ASA and NSAIDS
Colchicine for CVD?
Antiinflammatories- trial for effectiveness ongoing.
eg. Colchicine after MI = significantly lower risk of ischemic CV events.
ONLY WORKS FOR SECONDARY PREVENTION
Heart failure mortality?
50% mortality after 5 years
2 types of heart failure?
HFpEF - manage rate, volume, risk factors
Reduced EF: modulate neurohormonal pathway, meds, device therapy
SLGT2 meds are good for what?
3 places where SLGT2 meds are great:
DM and CVdz,
DM2+over 50 +risk of CV disease,
DM, age >30yo (and something else re: renal dz)
Treatment for preserved EF or not in Heart failure
HF: ACE or ARB Beta blocker Corticoid antagonist PLUS diuretic ALSO SLGT2 EVEN IF NO DIABETUS!
Cardiac amyloidosis FUN FACTS?
NEW TREATMENT!
1/4 over 80yo
If HF unexplained or associated with NEUROPATHY or CARPAL TUNNEL (bilateral)
-Order SPEP, EPEP, and sFLC
Monoclonal protein??
Heart failure non med treatment?
Diet Exercise Smoking Symptom and weight monitoring, vaccines sx control and palliative care early Med adherence Self monitoring symptoms and weight
Non-modifiable risk factors to breast CA
Age >50 PHx Sex FHx CUMULATIVE estrogen exposure!! Radiation
What affects cumulative estrogen exposure for breast cancer?
Estrogen early menarche older menopause Nulliparity Postmenopausal HRT Post menopausal obesity
Screening for Breast CA?
NO!
No mammogram <50 yo, no breast self exam, no clinician breast exam
Breast CA approach
RED FLAGS: Risk factors Firm, fixed and lymph nodes Past or family hx ???? more
MONITOR: smooth, rubbery, mobile, cystic
IF worried and >30 yo: Mammogram, U/S and core biopsy
Side effects of treatment for breast CA?
CMO Valvular dz fatigue secondary malignancy ovarian insufficiency (not failure) lymphedema
REFER for breast ca?
Nursing breast advocate Breast surgeon Cancer agency Rapid access breast clinic Counselling Physio/massage (lymphatic drainage) Medical genetics (if extensive family history (BRCA?)
Treatment for obesity (conservative tx failed)?
bupropion - naltrexone
Orlistat
Liraglutide (3cc/day injection)
Sx: gastric bypass, sleeve gastrectomy, gastric band,
COUNSEL: major procedure and surgical risk.
TREAT: like new patient
Obesity
ASK ASSESS - MRS SWELPS ADVISE - as your doc, I recommend AGREE ARRANGE ADVOCATE
Vaping for smoking cessation?
DON’T VAPE!
-vaping related lung injury!
Treatment for obesity (conservative tx failed)?
bupropion - naltrexone
Orlistat
Liraglutide (3cc/day injection)
…..1 more
Sx: gastric bypass, sleeve gastrectomy, gastric band,
COUNSEL: major procedure and surgical risk.
TREAT: like new patient
Obesity questions? (there are 6 A’s lol)
ASK ASSESS - MRS SWELPS ADVISE - as your doc, I recommend AGREE ARRANGE ADVOCATE
M-SASQ?
> 8 drinks men, >6 female ??? Finish me!
Pharmacological options for smoking cessation?
In order of most-least effective:
- Varenicline (no black box suicide warning)
- Bupropion UNLESS: sz d/o, eating d/o, EtOH withdrawal, allergy, MAO-i use
- Patch, gum, pills, spray, lozenge, inhaler
M-SASQ?
Screen better than CAGE for alcohol use disorder:
> 8 drinks men, >6 female ??? Finish me!
Low risk alcohol use guidelines?
Women: 2/day. 10/week
Men 3/day and 15/week
Meds for Alcohol use disorder (AUD)
Naltrexone - NNT: 12. Don’t use if liver enzymes >3ULN
Acamprosate (666mg TID) - 2nd best
Disulfiram (antabuse) - only if CLOSE supervision (ie. exam says concerned wife) as can have cardiac issues or choke on their vom and dieeeeee
Opioid Assisted Therapy?
Methadone - may have better uptake
Buprenorphine-naloxone
SE: CAT: constipation, amenorrhea, lower testosterone
NSAIDs for acute MSK pain?
Ibuprofen
Use 200-400 mg is equivalent to 600-800 mg and NO greater pain relief
Don’t duplicate treatment
Ketorolac: lower dose is better for moderate to severe acute pain in adults.
Use 10 mg IV/IM
Offer analgesia with investigation
Opioid guideline dosing and indication?
-Chronic cancer pain
Chronic non cancer pain:
New starts: Maximum 50 mg MED
Taper to 90 mg if currently higher
MED: morphine equivalents/day
Non-opioid treatment for pain?
ONLY if no other options:
TCA
Nabilone
NSAIDS
Non meds CBT Exercise Physio Self-management
Opioids in acute pain in elderly?
Morphine = hydromorphone
Rx: <3 days, rarely >7
Slow taper:
5% drop every 2-8 weeks
Taper rest periods
-make agreement with patient so they share your pain in prescribing opiates.
Opioid withdrawal?
Pain - neuropathic or not? Agitated (clonidine if BP >90/50 and pulse >50 Diarrhea Cramping Sweating - oxybutinin
Cannabis indications?
Refractory neuropathic, palliative pain, chemotherapy induced nausea and vomiting
Spasticity
CFPC’s position on marijuana?
<25 yo,
History of psychotic illness,
Avoid in pregnancy
Assess for MOOD, ANXIETY, ABUSE
Driving and pot?
4-6-8 Don’t Drive IF:
>4 hours post inhalation
>6 hrs post ingestion
>8 hours if experienced euphoria
Cannabis use in geriatrics?
AVOID if: mental health, SUD, brain or banlance issues, CV dz
Assess:
CUDIT (cannabis use disorder inventory) screen
Falls and driving risk
4 R’s of chronic pain management long term?
Ressass regularly
Relationship and shared decision-making
Reconsider diagnosis
Refer when appropriate
Canadian C-Spine rules?
High risk? Radiography
Low risk? ROM
Able to ROM neck? Yes? No rads
High risk: >65 yo
Dangerous mechanism
Paresthesia
LOW: Simple rearend MVA Sitting in ED Ambulatory at any time Delayed onset of pain Absence of midline tenderness
Does NOT apply IF: Acute paralysis Known vertebral disease Previous C-spine injury Outside of trauma Unstable vitals or GCS <15
<16 yo (Use NEXUS)
NO C-spine rules for kids No neuro deficit spinal alert intoxicated ??
Unstable neck stuff (incomplete)
Jefferson’s fracture
Bilateral cervical facet dislocation?
C-Spine standard of care?
CT. Skip X-ray.
Chronic neck pain imaging indications:
Pain in ONE or BOTH upper extremities
Motor/sensory/reflex deficits
IMAGING not needed unless:
Hx of trauma
Persistent symptoms IF >4-6 w treatment
Red flags: malignancy, myelopathy, abscess…think about IVDU!
Neck pain that isn’t neck pain…Name 7!
MI Carotid artery dissection Basilar artery dissection Mass/cancer Foreign body Lymphoma Polymyalgia rheumatica (typical: Female >50yo)
Common causes of neck pain (ergonomics)
Occupational (ergonomics!)
Driving
Neurology - refer
QRS approach to neck pain
Quit spine board - remove ASAP
Refere - massage, physio, chiro, massage, neurosx if alarm features
Start - anesthesia, neck brace, c-collar
Menopause conservative treatment start and stops?
STOP: smoking, drinking, caffeine
START: exercise and weight loss
- Can be managed WITHOUT HRT or meds!!
- CAM: Just say NO!
Bloodwork for menopause?
Nah. Clinical diagnosis.
Just say NO to FSH!
Pharm and non-pharm vasomotor symptoms of menopause?
Vasomotor treatment:
Menopause 5?
Fan Layers Cool environment No hot drinks Optimize sleep
Meds?
HRT SSRI Anticonvulsants TCA Progestin OCPs
Vaginal or internal sx of menopause treatment?
START:
Lubricant
Non-medicated gel
Estrogen tabs (reduce MILD not severe sx), moisture, rings or creams.
Hormone sensitive breast CA and topical estrogens?
NO man. Defs not.
Psych/Sex symptoms of menopause?
Treat confounders:
Sleep
Relationship
QU sx. of menopause (formerly vag atrophy and urinary sx)
SSRI
Menopause +/- uterus treatment considerations?
DO they have a uterus?
GIVE PROGESTIN or BAZEDOXIFENE
No uterus: no progestin
HRT for Intolerable menopause symptoms?
SAFE if:
Safe for < 5 years (risk increases 2%/y for negative outcome).
within 10 years of LMP
Transdermal patches work best
Who cannot have estrogen for menopause?
THINK CLOT RISK!!!! Migraine w aura Smoker >35yo Uncontrolled HTN Malignancy DVT Stroke CAD DM with end organ damage Liver disease FHx. or PHx of clotting dz
Who cannot have estrogen for menopause?
THINK CLOT RISK!!!! Migraine w aura Smoker >35yo Uncontrolled HTN Malignancy DVT Stroke CAD DM with end organ damage Liver disease FHx. or PHx of clotting dz
Approach to cat bite?
Cat bite:
typical pathogen - pasteurella multocida
which abx? Amox-clav prophylactic. If pen allergy: ??
how to close it? DON’T
Vaccines? Tetanus and rabies
lidocaine with epi? OK to use in fingers, nose, ears
Rabies guidelines?
Dog, cat and ferret - give RabIg and 4 doses of HDCV or PCECV and test animal
Bites tx?
Bites: - add abx if closing: stitches loose and drain dog bites? ok to close Cat? Avoid closing
Peds laceration repair?
Intranasal midazolam or fentanyl
IV/IM ketamine
Blanket burrito
Topical LET (lidocaine, epi, tetracaine)
How to close a wound?
Suture for close approximation
Staple for scalp or non cosmetic
Steri-strip
Glue for low tension tears/flaps
Deep: absorbable
Cosmetic? Doesn’t matter
DON’T close wound if?
Deep puncture
Hi-tension
Infected
“Smelly Sneaker Syndrome”-pseudomonas and think of osteomyelitis
Timing:
18 hours old on face,
24 hours on head,
consult plastics
When do you remove sutures?
face -5 days
over a joint or scalp 10-14d
Everything else: 7 days
F/U sooner if signs of infection
MOST important steps in management of poisonings?
ABC’s
Consider SECOND or many poisons!!!
Call poison control
If patient unconscious in the ED and you don’t know why???
Dextrose
Oxygen
Narcan (0.4 mg to start, but up to 10 mg)
Thiamine
Stimulant vs. Anticholinergic toxidrome….
Vitals high and pupils dilated:
Sweating: stimulant (sympathomimetics like coffee, cocaine, amphetamine or ecstacy)
Treatment: none really
Vitals up and pupils dilated:
Flushed and not sweating…Anticholinergic toxidrome!
TCA, tegretol, anti-parkinson’s, antipsychotic, jimson weed
Treatment: physostigmine
Antidotes to OD of beta blocker, iron, acetaminophen?
Betablocker OD - use glucagon
Iron OD: Deferoxamine
Acetaminophen OD - NAC and ABC’s
Best medicine for poisoning?
Prevention!!!!
Recurrent Otitis Media …refer to ENT when?
> 3 episodes in 6 mo
>4 independent episodes that you’re sure is acute otitis media in 1 year
Conjunctivitis - to treat or not to treat?
65% goes away without antibiotics
All antibiotics have equal evidence
If wear contacts? Fluoroquinolone tx.
Stable vs. unstable fracture?
Stable = Won’t displace under normal physiologic circumstance or stress
Vitals, pupils and sweating in cholinergic, opioid, benzo and sedative-hypnotic toxidromes? Treatment?
Cholinergic: Normal vitals, pinpoint pupils, diaphoretic
Tx: Atropine, pralidoxime
Opioid: Decreased vitals, pinpoint pupils, No sweating
Tx: Naloxone
Sedative hypnotic - decreased vitals, normal pupils
Tx: None really
Benzo’s - normal vitals, pupils and no sweating
Tx. Flumazenil (seizure risk!!)
What causes a cholinergic toxidrome?
Mushrooms
Organophosphates/insecticides/nerve agents/Sarin gas
Causes of Sedative-hypnotic toxidrome?
Anti-epileptics, barbiturates, muscle relaxants
Before treatment of UTI what questions
Allergies? Recent UTI? Recent urine cx?
Consult local resistance algorithm
Uncomplicated UTI rx?
Septra DS
Nitrofurantoin
Complicated UTI rx?
Fluoroquinolone 3rd gen cefalosporin Broad if severe: Penem Pip-tazo
Get blood cx before ABX!
When should I sound alarm for UTI?
Pyelonephritis Sepsis Obstruction Impacted stone Retention
Risks of UTI?
Very young Very old Middle age man with BPH (obstructive voiding) Prenatal Chronic pancreatitis
Reinfection v. relapse of UTI?
Culture
Re-treat for 7-14 days
Reconsider diagnosis
Refer - upper tract imaging, cystoscopy, urodynamics
Diagnose recurrent UTI if all this ruled out- consider self treatment or prophylaxis?
–> prophylactic daily if menopausal woman, post coital if younger woman. Think of prostate U/S for BPH men.
Treatment in children’s UTI
Cefixime 7-10 days and is weight based
Which kids need bladder U/S post UTI
Febrile and <2yo with UTI
Recurrent
Complicated
MUST be: within 2 week window of UTI because looking for hydronephrosis. This is Positive U/S and THEN you will order VCUG
Asymptomatic bacteriuria ALWAYS….EXCEPT….
If prego eggo’s as it can increase risk of preterm labour
Epistaxis
Anterior are 90%
90% resolve with pressure and packing.
Causes of epistaxis?
Trauma/tumor Infection Meds Exogenous (temp, weather Bleeding disorder
Mgmt MILD epistaxis? SEVERE? Posterior bleed?
Mgmt mild epistaxis:
-blow dose
2 sprays oxymetazoline
-Pinch x 10 mins
Severe: ABC's Movies LABS Tranexamic acid can help! Freeze & cauterize* and pack with gauze, rapid rhino, foley
Do NOT cauterize both sides.
Posterior - identify by packing and keep bleeding. Call ENT!
Next steps management for nosebleeds?
SAFETY - admit for monitoring if posterior
Next Visit - follow up w family doctor
OFFER labs only if severe.
Refer all unless anterior, source clearly identified.
NO antibiotics needed.
Croup - remember 6! Age of onset and Mild to severe croup pharm and non-pharm
Occurs from 6 mo-36 mo…CAN have up to age 6yo.
MILD tx: ABC’s, antipyretics, fever, PO fluid, reassure parents, humidified O2. Dexamethasone 0.15 mg/kg
MODERATE: Dexamethasone = 0.6 mg per kg. (Likely to be equivalent to prednisolone 1 mg/kg)
SEVERE: Inhale epinephrine
Bugs of croup!
#1 cause: Parainfluenza Influenza RSV Adenovirus (also in pink eye!) Metapneumovirus
Ddx stridor?
Croup
Foreign body (UNTIL PROVEN OTHERWISE!)
Tracheo-malacia
Safety- protect airway, ensure no foreign ingestion.
Next visit - If epinephrine given then see <24h later.
Recurrent Croup tx approach?
Recurrent croup: Refer
Start antipyretics and analgesia, but NOT abx as ALWAYS viral!
Teach that course can fluctuate but symptoms should resolve in 3-4 days.
NO dexamethasone if recurrent croup. Must consider if it is more severe: Bacterial Tracheitis
Wheeze, stridor, not improving in 1 week, looks bad..what is the black box if NOT croup?
Bacterial Tracheitis….
DON’T give dex!!!
Meningitis tests?
Kernig - extend Knee with hip flex
Brudzinski Lift Brain (head) off bed
-mod PPV but no NPV.
Management for Meningitis?
Do NOT wait for lab
Start IV Abx and droplet precautions NOW!
Abx are a RESUSCITATION DRUG in meningitis!
What type of meningitis needs steroids?
Good for strep. pneumococcal specifically..but won’t know that right away.
BUT doesn’t make others worse! Dex needs to be given 15-20 mins or at same time of Abx. NO VALUE if given afterwards.
Meningitis Investigations?
LP:
Bloodwork incl cultures
CT if indication that is NOT meningitis, worry focal lesion causing.
*Consider CT before LP if worried about increased ICP. (has specific risk facters)
Who needs a CT before LP?
Immunocompromised Hx. CNS dz or lesions New onset sz Papilledema Decreased GCS Focal neuro deficits
LP results and tx. meningitis
Bacteria: Made of protein and eat glucose. High protein, low glucose, lots of WBC…
Once treated will decrease protein, increase glucose, and WBC’s
Ceftriaxone and vanco
Add ampicillin if listeria
Add valacyclovir if viral.
Peds patients meningitis: Steroids only if H. flu and <2 hours from antibiotics
ALWAYS attempt LP
All start with CTX and vanco
Contraindications to LP in peds?
ALWAYS attempt UNLESS contraindicated:
Bleeding (coagulopathy)
Blisters
Brain
Low BP
Peds meningitis
Ecoli and GBS
Ceftriaxone, vanco, ampicillin if listeria concern or immunocompromised
Prophylaxis timeline and meds for meningitis
Must give if exposed 7 days before sx onset to 24 h post treatment.
Rifampin, ciprofloxacin and ceftriaxone
REPORTABLE DISEASE!! esp meningitis secondary to neisseria.
Anaphylaxis approach
Call 911 ABC's Movies Supine UNLESS seizure, pregnant or decreased LOC epinephrine
Epi dose for anaphylaxis?
Dose: 0.01 mg/kg (1:1000) 1 mg/mL
Route: Intramuscular NOT subcutaneous!
Allergy alphabet
Adrenaline Breathing Corticosteroids Diphenhydramine Epi again or IV fluits Fluids Glucagon if on beta blocker H2 blocker ranitidine Inhaled salbutamol
Anaphylaxis discharge?
Discharge criteria:
Observe for at least 4-8 hours
Rebound in 23% - Steroids do NOT help reduce this.
Doses for anaphylaxis?
Rule of 5’s
Gender for eating disorders?
BOTH!
Screening tool for EDs? SCOFF!
SICK when you are feeling full Lost CONTROL Lost more than 1 stone (14 lbs in 3 mo?) Believe yourself to be fat when others say you are thin Feel food dominates your life?
Consider eating disorder if…
Weight loss
Palpitations
Excess exercise
Amenorrhea NO LONGER REQ’D for anorexia diagnosis
Types of eating disorders?
Anorexia
Bulimia
Binge Eating
ED differential?
Anxiety OCD Personality disorder Bullying Poverty/access to food Excessive exercise Depression Substance use
Ameonorrhea and NO ED?
Relative energy deficiency in sport RED-S
Formerly female athlete triad!
Occurs in any gender
ED non-pharm management
Dietitian Psychiatrist Group or individual counseling Psychologist Online training/course CBT School counselor
BMI in eating disorders?
Mild: <17.5
Mod: 16-16.99
Severe: 15-15.99
Extreme: <15
Sexual abuse (rule of 3 not to forget if treatment)
Medical assessment is NOT same as forensic assessment
Pregnancy prevention
STI counseling / Post exposure prophylaxis
Sexual assault medical history/assessment?
- Medically pertinent hx
- Pregnancy risk
- STI risk
- Does patient want exam?
Pregnancy prevention post assault
Copper IUD (up to 5 days)
Levonorgestrel
Ullipristal
Combined hormonal contraceptive
How do you prevent and support future of sexual assault patient?
Prevent:
Mental health
COunselling SQ Sexual assault crisis centre Victim assistance Psychiatry if indicated.
WHen do you report sexual assault?
VOLUNTARY unless under 18yo
What do you want to provide education on to patients post sexual assault?
This is sexual assault
Not their fault
I support your decisions
“many people feel” , “it’s common to feel”… “It seems to me you are…”
Higher risk for interpersonal (domestic) violence?
- Elderly
- Pregnant women
- Children
- Immigrant
What MUST you do for patients of domestic violence?
Safety plan!!!! Get detailed! Repeat this at every visit.
Warn of escalation
Assess danger (first, worst, last)
-Write it down (maybe), NUMBERS in their phone (shelters? etc.)
-Guns, isolated, cell reception?
Learning disabilities ddx?
3E’s:
Visual impairment
Hearing impairment
Education - intellectual disability, neurocutaneous disorders, TBI, seizure disorder
Sleep disorder
ADHD onset?
Adult ADHD…does it exist?
Symptoms before 12 years old. (6/9)
Yes! (5/9)
ADHD Med classes?
Stimulants - methylphenidate or amphetamine. First line = long acting
NRI - atomoxetine
Alpha 2 agonist - guanfacine, clonidine
CADDRA - “DATER” mnemonic for considerations of medication not working in ADHD?
Dosage - increase, and duration of effect long enough?
All 1st line trialed
Time for response and side effects to normalize?
Examine targets. Standardized measures?
Review como’s and lifestyle
CADDRA - “DATER” mnemonic for considerations of what to do if medication not working in ADHD?
Dosage - increase, and duration of effect long enough?
All 1st line trialed
Time for response and side effects to normalize?
Examine targets. Standardized measures?
Review como’s and lifestyle
Non-medication treatments for ADHD?
Patient and family psychoeducation Psychological treatment Educational accommodations Occupational accomodations Psychoeducational assessment CBT
Fun fact about bisphosphonates? (Random fact)
Bisphosphonates increase bone density by 3-5%
Bone density readings must be 6-10% apart to be trusted…otherwise, could be due to something else.
ADHD treatment if has SUD?
Consider atomoxetine or vyvanse (prodrug) first!
Dirty wound?
Is there dirt in it? Open wound Crush Tear Burn Frostbite ?vaccinated or <3 tetanus vaccines
Lipid testing and the elderly?
Canadian:
>75 yo do NOT test lipids
Lipid testing and the elderly?
Canadian:
>75 yo do NOT test lipids
Vaginal bleeding… get worried IF…
First trimester?
Abnormal uterine bleeding?
Post menopause?
Vaginal bleeding in first trimester ddx?
- Threatened abortion - viable intrauterine pregnancy
Mangement: serial U/S, Serial beta HCG, preautions
- Missed abortion - no fetal heartbeat or growth failure
MGMT: Surgical (96%) Medical Management? (81%) Expectant management (56%) - % = success rate
- Complete abortion - bleeding, cramping have stopped
Mgmt: NOTHING unless major bleed / Rh Neg (WinRHO) - Ectopic Pregnancy
-Pain, <7 weeks, tubal risk factors
Mgmt: Expectant, medical or surgical, serial bHCG and U/S and consult surgical candidate to save the tube!
Risk factors for abnormal uterine bleeding?
RF: estrogen exposure, hyperandrogenism
Abnormal uterine bleeding (AUB) investigations?
Endometrial biopsy
Pap
Colposcopy
We worry about cancer! So do they!
Mgmt of Abnormal Uterine Bleeding?
Hormonal - LNG, IUS, OCP, progestin
Non-hormonal: NSAIDs and tranexamic acid
Surgical - ablation, hysterectomy, polypectomy, myomectomy
Who do you investigate when post-menopausal vaginal bleeding? What tests?
Everyone with a uterus!!!
Pelvic exam, pap, U/S or endometrial biopsy, REFER!
Vaginitis diagnosis?
- History - LMP, G’s and P’s
- Look at the skin / vagine
- Do some tests!
What tests?
Swabs Wet mount pH test KOH prep Biopsy
Ddx of itchy vag?
Not all that itches is yeast
Not all discharge is yeast
Not all yeast much be treated
Ddx:
Eczema, psoriasis, lichen sclerosis, or simplex, neoplasm - VIN, vulvar cancer
GU syndrome of menopause (atrophic vaginitis)
Rashes - contact dermatitis
Bugs: HSV, Trich, PID, BV
Vagine discharge with normal tests and normal skin?
Normal Variant!! Physiological discharge. Can be thin, thick, more often discharge…can change with hormones or pregnancy
Screen for vaginitis?
Don’t screen
Even if pregnant
Not even for BV
Only if symptomatic vaginitis
Vaginitis in kids?
Foreign body
STI …REPORTABLE!!!!
Irritant
UNLIKELY yeast!
67 yo Male w nocturia, frequency, urgency. Screen?
NOT ONE IF THERE ARE SYMPTOMS!!!
PSA?
One recommendation: Don’t use for screening
Uro recs: If > 10 years life expectancy then DISCUSS PSA.
Start at 50 yo if lower risk and 40 yo if higher
PSA test comes back elevated (22ug/L). Next step?
CFP 2015 guideline
Think 10-20 rule:
If PSA is 10-20 it’s semiurgent
<10 is low risk
>20 is hi risk / urgent
Physical exam
IF abnormal and PSA >10 then URGENT
IF normal and PSA <10 non urgent
Then REFER TO UROLOGY FOR PROSTATE BIOPSY URGENTLY!
What is high risk for prostate CA?
Age Hi-risk race Family Hx Smoking Obesity
BPH Management?
Dx with hx and physical - don’t forget abdominal exam (urinary retention) and rectal exam.
U/A and midstream C/S
PSA if alive for >10 years
Treat ONLY IF BOTHERSOME. Use IPSS (international prostate symptom score
Non pharm mgmt and pharm mgmt for BPH?
D/C NSAIDs, saw palmetto, antihistamines, decongestants, and excess fluid, caffeine, alcohol
Start:
- Alpha blocker (tamsulosin)
- 5 alpha reductase inhibitor
- 1 & 2
- Antimuscarinics
- 1 & 4
- PDE 5 inhibitors
REFER:
If suspect prostate CA
If bothered +/- meds ineffective for surgery considerations
Prostatitis
If no fevers, chills, myalgia or malaise?
More likely UTI or STI… they would look shitty if had prostatitis as systemic.
Most common bugs for prostatitis?
UTI bugs (which are???)
Infertility?
(An)ovulatory?
Variable menstrual interval and flow?
Tubal dysfcn (?scarring)
Inflammation - endometriosis, ectopic, surgery, crohns
Infection - STI’s, PID, ruptured appendix
Anatomic
Adhesions
Tx: Pelvic U/S
Infertility don’t forget the….
MAN! -Sperm Partner Underwear Work environment?
Also think of:
Erectile dysfunction
Coital frequency and timing
Dysparenuia
Freeze the eggs? Risks?
Thawed oocyte survival rates are 80-90%
Live birth rates likely similar to fresh
Age of freezing matters
RISKS: Infection, anesthesia, Controlled ovarian stimulation, oocyte retrieval and pregnancy at advanced maternal age
Ovarian reserve testing?
Consider Anti mullerian hormone for women aged:
>35 y
<35 y with RF for decreased ovarian reserve? single ovary ovarian surgery poor response to FSH Chemo/radiation Unexplained fertility
Infertility tx beyond referral
Referral (ya but what else…)
Testing
Treatment options
Adoption
Investigations in infertility?
Pelvic
Pap
Partner
Ovulation - Day 3 FSH, Estrogen, TSH, prolactin, midluteal progesterone
Hyperandro
DHEA-S, 17-OH progesterone, total
Pelvic us or hysterosalpingogram
Semen analysis
Prevention of infertility?
Screen and treat for STI
Counsel re risk of tubal damange
Quit smoking, MJ, optimize BMI
Referral for infertility?
12 mo if no RFs
6 mo if RF’s or >35 yo
IMMEDIATELY if >40y
What % of people conceive in 12 months?
90%
If unexplained infertility what do you NOT treat with?
Do not offer if unexplained infertility:
Natural - cycle intrauterine insemination
Clomiphene citrate alone
Aromatase inhibitors alone
Consider further investigations/tx with infertility?
IF: No pregnancy after 12 mo, regular intercourse, normal ovulator fcn, normal semen, 1 patent tube
Laparoscopy only if tubal/pelvic pathology suspected, invitro fertilization etc.
PID tx?
- Antibiotics:
Cefoxitin and docycycline
Ceftriaxone and doxy
Clindamycin and gentamycin - Treat partner,
- contact tracing,
- NO SEX x 7 days
Contraindications, risk, side effects
Start OCP on sunday and won’t get period on weekend
Who can’t have estrogen?
Migraine w aura Smoker >35y >15 cigs uncontrolled HTN Malignancy DVT Stroke CAD DM with end organ damage Liver disease
Conception counseling…START…
folic acid
Iron
Vaccines
QUIT: smoking, teratogenic meds, alcohol, drugs
Sex PLUS…
History is the ABC's: Abuse Babies/contraception Cancer s: STI's
Gender diversity history taking?
What is(are) your partner(s) genders? What kind of sex do you have? How do you refer to your genitals?
“anything you’d like me to know about your gender identity?”
Age of consent?
Age of consent:
16 yo if non-exploitative
18yo if exploitative sex (power differential, porn, prostitution)
Consenting youth?
Youth: 12-13 yo - up to 2 years older
Age 14-15yo -up to 5 years older
Contraception questions
Last menses?
Contraception types?
Adherence?
Infertility?
OFFER contraception and EMERGENCY contraception
HPV vaccine?
HPV vaccine = cancer prevention vaccine!
STI history taking?
Do you use internal or external condoms?
Prev STI?
Trade sex for money or drugs?
Discuss prevention, offer testing, treatment, and contact tracing/treatment, report to public health
Erectile dysfunction hx taking?
ASK... Morning wood sexual preferences Contraception age of partner(s)
Erectile dysfunction hx taking?
ASK... Morning wood sexual preferences Contraception age of partner(s)
Priapism?
Foreverection!!!
- Ischemic or not?
Doppler US
Cavernosal blood gas
NON ISCHEMIC: watch & wait, 5 alpha reductase inhibitor - finasteride
GNRH agonist- leuprolide
ISCHEMIC:
Needle drain
Intracavernosal phenylephrine
Surgical shunt if >48h
Sexual dysfunction in females?
Topical estrogen for vaginal sx
Testosterone - short term only
Sildenafil - inconsistent results
Referrals in sexual dysfunction?
Refer for counseling (individual or couples) CBT Mindfulness Pelvic floor physio Body image counseling
REFER to doctors: Urology, sexual medicine, endocrinology, psychiatry
Investigations in sexual dysfunction?
Glucose
Chol/ HDL/LDL/Trig/non HDL
Testosterone
+/- PRL, TSH, LH FSH
HIV pre-exposure prophylaxis
> 90% reduction in HIV acquisition!!!
1 pill x __days?
PREP labs?
bHCG
Hepatitis labs
Renal functions
Screen STI’s (q3mo) swab every site!!
TALK ABOUT CONDOMS….
PREP labs?
bHCG
Hepatitis labs
Renal function
Screen STI’s (q3mo) swab every site!!
TALK ABOUT CONDOMS….
lil guy OR elder abuse consideration?
- Speak to patient without caregiver
- Check competence….
PSA and DRE?
Post DRE can have transient PSA elevation…wait 3 days and should go back to normal
BPH tx…make sure you pre- and post- measure?
Blood pressure before and after as treatment can lower BP
