FAMILY MEDICINE

D r. D . Tan n e n b au m
S o h al G o yal, Alvi n L ai an d Je n n i fe r T h o m p so n , e d i to rs
D an i e lle G e rvai s-F agn o u , asso ci ate e d i to r
FOUR PRINCIPLES OF FAMILY MEDICINE . . . 2
PATIENT-CENTERED CLINICAL METHOD. . . . . 2
HEALTH MAINTENANCE AND PROMOTION . . 2
N u tri ti o n /We i gh t C o n tro l
E xe rci se
S tre ss M an age m e n t
S m o ki n g
Alco h o l
THE PERIODIC HEALTH EXAMINATION. . . . . . 7
HYPERTENSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
E p i d e m i o lo gy
D e fi n i ti o n
E ti o lo gy
D i agn o sti c E valu ati o n
T h e rap e u ti c C o n si d e rati o n
An ti -H yp e rte n si ve D ru g T h e rap y
DIABETES MELLITUS . . . . . . . . . . . . . . . . . . . . . . 15
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1
COMMON PROBLEMS. . . . . . . . . . . . . . . . . . . . 16
An xi e ty
B ro n ch i ti s
C h e st P ai n
C o m m o n C o ld
D e p re ssi o n
D i zzi n e ss
D ysp n e a
D ysu ri a
E arach e
F ati gu e
H e ad ach e
S le e p P ro b le m s
M u scle o r Jo i n t P ai n
An kle /K n e e P ai n
L o w B ack P ai n
S e xu ally Tran sm i tte d D i se ase s
S i n u si ti s
S ki n L e si o n s
S ki n R ash e s
S o re T h ro at
COUNSELLING. . . . . . . . . . . . . . . . . . . . . . . . . . 28
D o m e sti c Vi o le n ce
C o n trace p ti o n
M e n o p au se /H R T
C o m p le m e n tary T h e rap i e s
F am i ly M e d i ci n e 2 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
FOUR PRINCIPLES OF
FAMILY MEDICINE
1 . T h e fam ily p h ysician m u st b e a skille d p h ysician
skille d in d iagn o sis an d m an age m e n t o f d ise ase s co m m o n to
th e p o p u latio n th at th e y se rve
im p o rtan ce o f e arly d iagn o sis an d d e te ctio n o f se rio u s life
th re ate n in g illn e sse s wh ich p re se n t an d ap p e ar as m in o r o r
se lf-lim ite d illn e sse s
co m p e te n t in p atie n t-ce n tre d clin ical m e th o d
2. T h e d o cto r-p atie n t re latio n sh ip is ce n tral to th e ro le o f th e
fam ily p h ysician
co m m itte d to th e p e rso n rath e r th an ju st th e d ise ase
co n tin u ity o f p atie n t care
fo cu s o n p atie n t's fe e lin gs, e xp e ctatio n s, an d fe ars
3. F am ily m e d icin e is a co m m u n ity-b ase d d iscip lin e
re q u ire s go o d kn o wle d ge o f an d acce ss to a wid e
ran ge o f co m m u n ity se rvice s
m u st re sp o n d to ch an gin g n e e d s an d ad ap t to
ch an gin g circu m stan ce s
co llab o rate as a te am m e m b e r o r le ad e r
4. T h e fam ily p h ysician is a re so u rce to th e ir p atie n t p o p u latio n
acts as a h e alth care re so u rce , e n su rin g h e alth o f
th at p o p u latio n
se lf-d ire cte d life -lo n g le arn in g
ad vo cate p u b lic p o licy to p ro m o te h e alth
PATIENT-CENTRED
CLINICAL METHOD
J a gu id e to e xp lo rin g p atie n t p ro b le m s th at allo ws p h ysician s an d p atie n ts
to d e fin e p ro b le m s an d d e cid e o n m an age m e n t to ge th e r
J co n sid e r th e age n d as o f b o th th e p h ysician an d th e p atie n t an d fin d a
co m m o n gro u n d
d o cto r's age n d a: h isto ry, p h ysical, in ve stigatio n
p atie n t's age n d a: F IF E = fe e lin gs, id e as, fu n ctio n , e xp e ctatio n s
d e ve lo p a wo rkin g h yp o th e sis AN D u n d e rstan d th e p atie n t's illn e ss e xp e rie n ce
HEALTH MAINTENANCE
AND PROMOTION
J h e alth p ro m o tio n is th e m o st e ffe ctive p re ve n tive strate gy
J 40-70% o f p ro d u ctive life lo st an n u ally is p re ve n tab le
NUTRITION/WEIGHT CONTROL
Epide miology
J 25-30% o f p o p u latio n are o b e se ; 1 /3 o f th e m b in ge e at
J 40-50% o f p o p u latio n h ave in cre ase d ch o le ste ro l
J o n ly 1 0-1 5% o f p o p u latio n co n su m e < 30% fat
Diagnos is
J co m p le te d ie t h isto ry: in clu d e p ast atte m p ts to lo se we igh t, su cce sse s,
o b stacle s, go als
J asse ss b o d y m ass in d e x ( B M I) = kg/m
2
n o rm al ran ge : 20.7-27.8 fo r m e n , 20.1 -27.3 fo r wo m e n
20-30% o ve rwe igh t: 27.8-31 .1 fo r m e n , 27.3 -32.3 fo r wo m e n
m o d e rate ly o b e se : 31 .1 -45.4 fo r m e n , 32.3-44.8 fo r wo m e n
m o rb id ly o b e se : > 45.4 fo r m e n , > 44.8 fo r wo m e n
J asse ss p atie n t's se lf-im age
d o e s p atie n t fe e l u n d e rwe igh t, o ve rwe igh t, o r n o rm al?
d o e s p atie n t fe e l th at we igh t in te rfe re s with h e alth ? with activitie s?
scre e n fo r e atin g d iso rd e rs ( se e P sych iatry N o te s)
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 3
N o te s
HEALTH MAINTENANCE
AND PROMOTION . . . CONT.
J p e rso n al/fam ily h isto ry o f o b e sity/n u tritio n p ro b le m s
o b e sity h as stro n g ge n e tic co m p o n e n t
J re vie w o f syste m s; in clu d e sle e p h ab its, ap n e ic sp e lls, O T C m e d icatio n ( e .g. laxative s)
J p h ysical e xam
d ire cte d at p e rtin e n t p o sitive s fro m re vie w o f syste m s
re sp irato ry cap acity
we igh t b e arin g jo in ts
J in ve stigatio n s ( d iscre tio n ary)
fastin g fractio n ate d lip id p ro file
sle e p stu d y
e xe rcise to le ran ce te stin g
Manage me nt
J su cce ss in we igh t co n tro l = at le ast 50% lo ss o f e xce ss we igh t
m ain tain e d at o n e ye ar
J d iscu ss n u tritio n -re late d p ro b le m s
h e art d ise ase , o b e sity, h yp e rte n sio n , o ste o p o ro sis, an e m ia,
d e n tal d e cay, can ce r, gastro in te stin al d iso rd e rs, re sp irato ry
co m p ro m ise , h igh lip id s, d iab e te s, sle e p ap n e a, o ste o arth ritis
J u se C an ad a's F o o d G u id e as a te ach in g gu id e
J co u n se llin g o n d ie t ( wh e n ap p licab le ) ; stre ss we igh t m ain te n an ce
if cu rre n tly in h e alth y we igh t ran ge
d isco u rage fad d ie ts: n o lo n g-te rm b e n e fits
th e re is n o id e al we igh t, b u t rath e r a ran ge o f h e alth y we igh ts
J tre atm e n t ap p ro ach e s
b e h avio u r m o d ificatio n
ve ry e ffe ctive , lo w sid e e ffe cts
d aily re co rd s o f fo o d s e ate n ( e atin g slo we r an d le ss)
ch an ge e n viro n m e n t, p re p aratio n style s, e tc...
lo se ab o u t 0.5 kg/we e k
re ward s wh e n go al ach ie ve d ( can n o t b e fo o d )
p o sitive se lf-affirm atio n
e xe rcise
asso ciate d with lo n g-te rm we igh t m ain te n an ce
20-30 m in u te s, 3 tim e s p e r we e k
gro u p su p p o rt
We igh t Watch e rs, O ve re ate rs An o n ym o u s
u se s b e h avio u r m o d ificatio n
h igh attritio n rate s ( u p to 80%)
su rge ry
J n atu ral h isto ry
o b e sity is a ch ro n ic p ro b le m , re fracto ry to m o st tre atm e n ts
p atie n ts with ce n tral o b e sity are at in cre ase d risk o f
card io vascu lar d ise ase an d d iab e te s m e llitu s
afte r 5 ye ars, < 30% o f p atie n ts m ain tain > 25% o f lo st we igh t
EXERCISE
Epide miology
J 25% e xe rcise re gu larly, 50% o ccasio n ally, 25% se d e n tary
J 1 /3 o f C an ad ian s watch > 1 5 h o u rs o f T V/we e k
J d aily p h ysical activity d e cre ase s with age to m id d le ad u lth o o d ,
th e n in cre ase s
His tory
J asse ss cu rre n t le ve l o f fitn e ss, m o tivatio n an d acce ssib ility to e xe rcise
J m e d ical scre e n
age
p re vio u s le ve l o f activity
cu rre n t m e d icatio n s
d iu re tics affe ct p o tassiu m le ve ls
an tich o lin e rgics in cre ase b o d y te m p e ratu re
in su lin can cau se h yp o glyce m ia
card io vascu lar risk facto rs
C B C , b lo o d su gar, ch o le ste ro l, u rin alysis, stre ss E C G te st
co n train d icatio n s: re ce n t M I, co n d u ctio n ab n o rm alitie s
F am i ly M e d i ci n e 4 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
HEALTH MAINTENANCE
AND PROMOTION . . . CONT.
Manage me nt
J e m p h asize b e n e fits o f e xe rcise
in cre ase s e n e rgy le ve l, stre n gth an d fle xib ility
im p ro ve s card io vascu lar an d m e tab o lic fu n ctio n s
in cre ase s glu co se to le ran ce
in cre ase s fe e lin g o f we ll-b e in g an d se x d rive
im p ro ve s q u ality o f sle e p
d e cre ase s d e p re ssio n /an xie ty
J typ e s o f e xe rcise
ae ro b ic activity in vo lvin g large m u scle gro u p s fo r
20-30 m in u te s at le ast 3-4 tim e s a we e k at 60-80% o f m axim u m
h e art rate ( age -d e p e n d e n t)
5-1 0 m in u te s stre tch in g ro u tin e d e cre ase s m u scu lo ske le tal in ju rie s
STRESS MANAGEMENT
J ste p s to m an age stre ss
id e n tify so u rce s o f stre ss
ve ry im p o rtan t ste p ( m ake a list)
m o d ify e n viro n m e n t/e ve n ts to d e cre ase stre ss
d e ve lo p co p in g strate gie s
b io fe e d b ack, m e d itatio n , m e n tal im age ry, h yp n o sis,
d iap h ragm atic b re ath in g, p ro gre ssive m u scle re laxatio n ,
p sych o th e rap y
fo cu s o n go al ach ie ve m e n ts an d p e rso n al we ll-b e in g
give p o sitive fe e d b ack an d re ward s
SMOKING
Epide miology
J sin gle m o st p re ve n tab le cau se o f d e ath
J re sp o n sib le fo r 80% o f lu n g can ce rs, C O P D , card io vascu lar d ise ase
J age s 25-34 h ave h igh e st p re vale n ce o f sm o kin g
J 1 5% o f sm o ke rs sm o ke > 25 cigare tte s/d ay
J se e C o m m u n ity H e alth N o te s fo r S tage s o f C h an ge
His tory
J sm o kin g h ab its: am o u n t, d u ratio n , fre q u e n cy, tim e o f d ay
J gain fro m sm o kin g ( e .g. we igh t lo ss, d e cre ase d an xie ty, so cial re latio n sh ip s)
J p e rso n al co n ce rn s ab o u t sm o kin g an d q u ittin g
J fo re se e n b e n e fits fro m q u ittin g
J in te re st in q u ittin g ( a p e rso n will o n ly q u it if th e y are willin g)
J p re vio u s atte m p ts an d re su lts
J m e d ical situ atio n : co u gh , S O B , asth m a, C O P D , H T N
J so cial situ atio n : o th e r sm o ke rs in fam ily/so cial n e two rk
J n ico tin e d e p e n d e n ce
p re o ccu p atio n o r co m p u lsio n to u se
im p airm e n t o r lo ss o f co n tro l o ve r u se
co n tin u e d u se d e sp ite n e gative co n se q u e n ce s
m in im izatio n o r d e n ial o f p ro b le m s asso ciate d with u se
Manage me nt
J 2 im p o rtan t co m p o n e n ts th at n e e d to b e ad d re sse d
p h ysical/ch e m ical ad d ictio n : sym p to m s o f with d rawal ( tre m o rs, irritab ility)
h ab itu al/e n viro n m e n tal facto rs: p sych o lo gical, so cial, an d
sp iritu al co m p o n e n ts
J ad vise o f h e alth risks
J lu n g can ce r, co ro n ary arte ry d ise ase , C O P D , P U D , lo w b irth we igh t
b ab ie s, p re m atu re agin g, u p p e r G I/re sp irato ry can ce rs, re sp irato ry in fe ctio n s
J afte r asse ssin g sm o kin g h ab its
ad vise e ve ry sm o ke r to q u it at e ve ry visit
J asse ss stage o f ch an ge
J m o tivate sm o ke r to atte m p t to q u it
b e n e fits: d e cre ase d re sp irato ry in fe ctio n s, in cre ase d e xe rcise
to le ran ce /e n e rgy, in cre ase d taste /sm e ll
ask fo r a co m m itm e n t to q u it ( se t a d ate )
assist th e sm o ke r to q u it
p h ysician co u n se llin g
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 5
N o te s
HEALTH MAINTENANCE
AND PROMOTION . . . CONT.
J se lf-h e lp m ate rials: re m o ve ash trays/ligh te rs, in cre ase h igh fib re
sn acks/gu m , in cre ase ae ro b ic e xe rcise , se lf-re ward
n ico tin e p atch /gu m
sm o kin g with d rawal p ro gram s
J re ward fo r go als th at are m e t
p lan fo r n e w so cial re latio n sh ip s an d activitie s to m ake it e asie r
to m ake a se rio u s atte m p t to ch an ge b e h avio u r
J fo llo w-u p : se t firm d ate s
J an ticip ate p ro b le m s: we igh t gain , with d rawal sym p to m s
J co n tin u e to m o n ito r/su p p o rt
J d o n o t give u p if faile d
J n ico tin e p atch
co n tin u o u s se lf-re gu late d am o u n t o f n ico tin e
d e cre ase s cravin g an d /o r with d rawal
will n o t re p lace im m e d iate e ffe cts o f sm o kin g, h ab it o r p le asu re
in d icatio n s: n ico tin e d e p e n d e n t, h igh m o tivatio n to q u it sm o kin g
co n train d icatio n s: sm o kin g wh ile o n p atch , alle rgy, M I, C VA
re lative co n train d icatio n : p re gn an cy
d u ratio n o f tre atm e n t: 4-1 2 we e ks u su ally ad e q u ate
J b u p ro p io n ( Z yb an )
ap p ro ve d in C an ad a in Au gu st, 1 998
acts o n d o p am in e rgic ( re ward ) an d n o rad re n e rgic ( with d rawal)
p ath ways
co n train d icatio n s: se izu re d iso rd e r, alco h o lism , e atin g d iso rd e r,
re ce n t M AO I u se , cu rre n t p re gn an cy; cau tio n if u sin g S S R I
( re d u ctio n o f se izu re th re sh o ld )
d o se varie s with am o u n t th e p atie n ts sm o ke s
p atie n t co n tin u e s to sm o ke fo r first we e k o f tre atm e n t an d th e n
co m p le te ly sto p s ( th e rap e u tic le ve ls re ach e d in o n e we e k)
re co m m e n d ab stin e n ce fro m alco h o l d u e to risk o f to xic le ve ls
with live r d ysfu n ctio n
sid e e ffe cts: h e ad ach e , in so m n ia, d ry m o u th , we igh t gain
Natural His tory
J m o st re lap se s o ccu r in first ye ar; m o st try > 5 tim e s b e fo re q u ittin g
ALCOHOL
Epide miology
J 1 0-1 5% o f p atie n ts in fam ily p ractice are p ro b le m d rin ke rs
J o ve r 500 000 C an ad ian s are alco h o l-d e p e n d e n t
J 1 0% o f all d e ath s in C an ad a are alco h o l-re late d
J o ve rall co st > $5 b illio n d o llars in C an ad a
His tory
J H ALT, B U M P, FATAL D T ( se e P sych iatry N o te s)
J asse ss d rin kin g p ro file
se ttin g: tim e , p lace , o ccasio n
so cial n e two rk: d rin kin g p artn e rs
co n su m p tio n : q u an tity ( in stan d ard d rin ks: 1 2 o z b e e r,
5 o z win e , 1 o z sp irits) , fre q u e n cy, rate , we e kly am o u n t,
m axim u m co n su m p tio n at an y o n e o ccasio n in p ast m o n th
p re ssu re s to d rin k: in te rn al an d e xte rn al
asso ciate d activitie s: sp o rts, p artie s
im p act o n : fam ily, wo rk, so cial
J d e te ctio n o f alco h o l ab u se scre e n in g q u e stio n s
D o yo u th in k yo u h ave a d rin kin g p ro b le m ?
CAGE ( 2+re sp o n se ) : se n sitivity 85%, sp e cificity 89%
CAGE Q u e stio n n aire
C - n e e d to C u t d o wn ?
A - An n o ye d b y criticism ab o u t d rin kin g?
G - G u ilty fe e lin gs ab o u t d rin kin g?
E - m o rn in g E ye -o p e n e r?
J b e ware o f alco h o l-re late d m e d ical p ro b le m s
G I: b le e d s, o ral/e so p h age al can ce r, p an cre atitis, live r d ise ase
card iac: alco h o lic card io m yo p ath y
n e u ro lo gic: K o rsako ff's/We rn i cke 's p e rip h e ral n e u ro p ath y
h e m ato lo gic: an e m ia, co agu lo p ath ie s
F am i ly M e d i ci n e 6 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
HEALTH MAINTENANCE
AND PROMOTION . . . CONT.
Table 1. Dis tinguis hing Proble m Drinking from Se ve re
Alcohol De pe nde nce
Clinical Fe ature Proble m Drinking Alcohol De pe nde nce
wi th d rawal sym p to m s n o o fte n
am o u n t co n su m e d we e kly m o re th an 1 2 m o re th an 60
d ri n ks m o d e rate ly ( < 4 d ai ly) o fte n rare ly
so ci al co n se q u e n ce s n o n e o r m i ld o fte n se ve re
p h ysi cal co n se q u e n ce s n o n e o r m i ld o fte n se ve re
so ci ally stab le u su ally o fte n n o t
n e gle cts m ajo r re sp o n si b i li ti e s n o ye s
Source: Kahan, M. (in Canadian Family Physician 1996, Vol. 42, pg. 662)
Manage me nt
J 25-30% o f ab u se rs e xh ib it sp o n tan e o u s im p ro ve m e n t o ve r 1 ye ar
J 60-70% o f in d ivid u als with jo b s an d fam ilie s h ave an im p ro ve d
q u ality o f life 1 ye ar p o st-tre atm e n t
J acco u n t fo r p atie n t's cu ltu ral b ackgro u n d , se xu al p re fe re n ce , n e e d
fo r ch ild care
J sign ifican t h e alth risks asso ciate d with > 2 o z/d ay ( wo m e n ) an d
> 4 o z/d ay ( m e n )
J tre atm e n t strate gie s
b rie f p h ysician -d ire cte d in te rve n tio n fo r p ro b le m d rin ke rs
re vie w safe d rin kin g gu id e lin e s
co m p are co n su m p tio n to C an ad ian n o rm s
o ffe r in fo rm atio n o n h e alth e ffe cts o f d rin kin g
h ave p atie n t co m m it to d rin kin g go al
re vie w strate gie s to avo id in to xicatio n ( e .g. alte rn ate
alco h o lic with n o n -alco h o lic d rin ks, avo id d rin kin g o n
e m p ty sto m ach )
ke e p d aily re co rd o f alco h o l co n su m p tio n
o rd e r G G T an d M C V
h ave re gu lar fo llo w-u p
re fe r fo r fu rth e r tre atm e n t if p ro b le m p e rsists
Alco h o lics An o n ym o u s
o u tp atie n t/d ay p ro gram m e s fo r th o se with ch ro n ic,
re sistan t p ro b le m s
in -p atie n t p ro gram if re fracto ry to o th e r tre atm e n t
p h arm aco lo gic
d isu lfiram ( An tab u se ) : b lo cks co n ve rsio n o f
ace tald e h yd e to ace tic acid ( wh ich le ad s to flu sh in g,
h e ad ach e , n au se a, h yp o te n sio n , h yp e rve n tilatio n , an xie ty)
b e n zo d iaze p in e s, -b lo cke rs fo r with d rawal sym p to m s;
se e P sych iatry N o te s fo r lo ad in g p ro to co ls
fam ily tre atm e n t
lo o k fo r sp o u se /ch ild ab u se
su p p o rts: Al-An o n , Al-A-Te e n
J p ro gn o sis
re lap se o fte n o ccu rs an d sh o u ld n o t b e vie we d as failu re
m o n ito r re gu larly fo r sign s o f re lap se ( e .g. m isse d
ap p o in tm e n ts, ce ssatio n o f tre atm e n t)
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 7
N o te s
THE PERIODIC HEALTH
EXAMINATION
J C an ad ian Task F o rce o n P re ve n tative H e alth C are e stab lish e d in 1 976;
first p u b lish e d in 1 979
J re vie ws th e lite ratu re fo r p re ve n tab ility o f co n d itio n s
J aid s in d e ve lo p in g clin ical p ractice gu id e lin e s
J in co rp o rate s p rim ary an d se co n d ary p re ve n tive m e asu re s
J m o st n o tab le re co m m e n d atio n is th e ab o litio n o f th e an n u al
p h ysical e xam ; to b e re p lace d b y p e rio d ic h e alth asse ssm e n ts ( P H A)
Purpos e of the PHE
J p rim ary p re ve n tio n
J id e n tify risk facto rs fo r co m m o n ch ro n ic d ise ase
J d e te ct asym p to m atic d ise ase ( se co n d ary p re ve n tio n )
J co u n se l p atie n ts to p ro m o te h e alth y b e h avio u r
J u p d ate clin ical d ata
J e n h an ce p atie n t - p h ysician re latio n sh ip
Table 2. Clas s ifications of Re comme ndations
A th e re is go o d e vid e n ce to su p p o rt th e re co m m e n d atio n th at th e
m an o e u vre /co n d itio n b e co n sid e re d in a p e rio d ic h e alth e xam
B th e re is fair e vid e n ce to su p p o rt th e re co m m e n d atio n th at th e
m an o e u vre /co n d itio n b e co n sid e re d in a p e rio d ic h e alth e xam
C th e re is p o o r e vid e n ce re gard in g th e in clu sio n o r e xclu sio n o f th e
m an o e u vre /co n d itio n in a p e rio d ic h e alth e xam , b u t th e
re co m m e n d atio n s can b e m ad e o n o th e r gro u n d s
D th e re is fair e vid e n ce to su p p o rt th e re co m m e n d atio n th at th e
m an o e u vre /co n d itio n b e e xclu d e d fro m co n sid e ratio n in a p e rio d ic
h e alth e xam
E th e re is go o d e vid e n ce to su p p o rt th e re co m m e n d atio n th at th e
m an o e u vre /co n d itio n b e e xclu d e d fro m co n sid e ratio n in a p e rio d ic
h e alth e xam
F am i ly M e d i ci n e 8 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
THE PERIODIC HEALTH
EXAMINATION . . . CONT.
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THE PERIODIC HEALTH
EXAMINATION . . . CONT.
A
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N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1 1
HYPERTENSION
EPIDEMIOLOGY
J m o st co m m o n o u tp atie n t d iagn o sis ( 20% o f p o p u latio n )
J risk facto rs: fam ily h isto ry, age , m ale , b lack race , o b e sity,
alco h o l/to b acco u se
DEFINITION
Table 3. Clas s ification of Blood Pre s s ure
dBP (mmHg)
< 90 n o rm al B P
90 - 1 04 m ild h yp e rte n sio n
1 05 - 1 1 4 m o d e rate h yp e rte n sio n
> 1 1 5 se ve re h yp e rte n sio n
s BP whe n dBP
< 90 mmHg
< 1 40 n o rm al B P
1 40 - 1 59 b o rd e rlin e iso late d systo lic h yp e rte n sio n
> 1 60 iso late d systo lic h yp e rte n sio n
Acce le rate d Hype rte ns ion
J sign ifican t re ce n t in cre ase in B P o ve r p re vio u s h yp e rte n sive le ve ls
asso ciate d with e vid e n ce o f vascu lar d am age o n fu n d o sco p y b u t
with o u t p ap ille d e m a
Malignant Hype rte ns ion
J su fficie n t e le vatio n in B P to cau se p ap ille d e m a an d o th e r
m an ife statio n s o f vascu lar d am age
J n o t d e fin e d b y ab so lu te le ve l o f B P, b u t o fte n re q u ire s
B P o f at le ast 200/1 40
J d e ve lo p s in ab o u t 1 % o f h yp e rte n sive p atie n ts
Is olate d Sys tolic HTN
J sB P > 1 60 m m H g, d B P < 90 m m H g
J asso ciate d with p ro gre ssive re d u ctio n in vascu lar co m p lian ce
J risk facto r fo r C VD an d IH D
J u su ally b e gin s 5th d e cad e ; u p to 1 1 % o f 75 ye ar o ld s
ETIOLOGY
J e sse n tial ( p rim ary) h yp e rte n sio n ( 90%)
u n d e te rm in e d cau se
J re n al h yp e rte n sio n ( 5%)
re n al p are n ch ym al d ise ase ( 3%)
re n o vascu lar h yp e rte n sio n ( < 2%)
J e n d o crin e ( 4-5%)
o ral co n trace p tive s ( 4%)
p rim ary h yp e rald o ste ro n ism ( 0.5%)
p h e o ch ro m o cyto m a ( 0.2%)
C u sh in g syn d ro m e ( < 0.2%)
h yp e rp arath yro id ism ( < 0.2%)
J co arctatio n o f th e ao rta ( 0.2%)
J e n zym atic d e fe cts
J n e u ro lo gical d iso rd e rs
J d ru g-in d u ce d h yp e rte n sio n
p ro lo n ge d co rtico ste ro id u se
J h yp e rcalce m ia fro m an y cau se
J watch fo r lab ile , " wh ite co at" h yp e rte n sio n
DIAGNOSTIC EVALUATION
J systo lic > 1 40 an d /o r d iasto lic > 90 o n th re e se p arate
re ad in gs o ve r 6 m o n th s
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F am i ly M e d i ci n e 1 2 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
HYPERTENSION . . . CONT.
ELEVATED BP AT FIRST VISIT
ASK
J H i sto ry o f an gi n a o r M I ? If his tory pos itive
J H i sto ry o f T I A o r stro ke ?
J H i sto ry o f p e ri p h e ral vascu lar i n su ffi ci e n cy?
J H i sto ry o f re n al i n su ffi ci e n cy?
J E xo ge n o u s cau se s o f h yp e rte n si o n ?
E xce ss alco h o l co n su m p ti o n
O ral co n trace p ti ve s
C o n ju gate d e stro ge n s
N S AI D s
C o n si d e r J P h ysi cal E xam i n ati o n
S to p p i n g i n clu d e fu n d o sco p i c e xam i n ati o n fo r
h yp e rte n si ve re ti n o p ath y
J I n ve sti gati o n s
E C G
u ri n alysi s
se ru m cre ati n i n e
fasti n g p lasm a glu co se ,
li p i d s
also co n si d e r C B C , e le ctro lyte s, ch e st x-ray
STILL HIGH AT
SECOND VISIT JR I S K FAC T O R S
M ale ge n d e r
B lack race
H i gh e r B P i n ran ge
S m o ki n g
Figure 1. Se arch for Targe t Organ Damage H i gh ch o le ste ro l
Adaptedfrom: TheCanadian Hypertension Society, 1993. G lu co se i n to le ran ce
J su sp e ct se co n d ary cau se s an d co n sid e r fu rth e r in ve stigatio n s if
o n se t o f H T N b e fo re age 30 o r afte r age 60
H T N re fracto ry to tre atm e n t
acce le rate d o r m align an t h yp e rte n sio n
su sp icio u s clin ical situ atio n
p re se n ce o f p aro xysm al h e ad ach e , p alp itatio n s an d
d iap h o re sis m ay su gge st p h e o ch ro m o cyto m a
p re se n ce o f re n al b ru its m ay in d icate re n o vascu lar h yp e rte n sio n
p re se n ce o f h yp o kale m ia an d h yp e rn atre m ia m ay
su gge st h yp e rald o ste ro n ism
J fo llo w-u p
1 -2 m o n th s fo r m ild H T N ; 1 -2 we e ks fo r m o d e rate H T N
im m e d iate tre atm e n t fo r se ve re o r acce le rate d /m align an t H T N
THERAPEUTIC CONSIDERATIONS
Ge ne ral Cons ide rations
J n o n p h arm aco lo gical ( re co m m e n d atio n grad e )
sm o kin g ce ssatio n
salt ( D ) an d alco h o l ( C ) re strictio n
satu rate d fat in take re d u ctio n
we igh t re d u ctio n ( B ) if > 1 1 5% id e al b o d y we igh t
re gu lar ae ro b ic e xe rcise ( B )
b e h avio u ral th e rap ie s ( B ) ( se e S tre ss M an age m e n t S e ctio n )
p o tassiu m ( B ) /calciu m su p p le m e n ts ( C )
J p h arm aco lo gical
p atie n ts u n d e r 60 ye ars o ld
n o o rgan d am age : tre at wh e n d iasto lic > 1 00, gre y zo n e b e twe e n 90-1 00
with targe t o rgan d am age , tre at wh e n d iasto lic > 90
p atie n ts o ve r 60 ye ars o ld
tre at wh e n systo lic > 1 60, gre y zo n e 1 40-1 60
tre at wh e n d iasto lic > 1 05, gre y zo n e 90-1 05
ch o o se o n e an tih yp e rte n sive age n t b ase d o n th e in d ivid u al p atie n t
( se e F igu re 2 an d Tab le 4)
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1 3
N o te s
HYPERTENSION . . . CONT.
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O R
O R
F am i ly M e d i ci n e 1 4 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
HYPERTENSION . . . CONT.
INITIAL THERAPY
ABSENT Co-Exis ting Me dical Conditions PRESENT
and Targe t Organ Damage
L o w D o se T h i azi d e o r B e ta-B lo cke r
P arti al R e sp o n se o r Ad ve rse R e acti o n MONOTHERAPY
as ap p ro p ri ate
( se e tab le )
SUBSTITUTE
B e ta-B lo cke r o r L o w D o se th i azi d e
MONOTHERAPY
wi th Alp h a-B lo cke r
Partial Re s pons e AC E I n h i b i to r
C alci u m An tago n i st
C e n trally Acti n g D ru g
Combine
T h i azi d e an d B e ta-B lo cke r
Not Controlle d
L o w D o se T h i azi d e wi th B e ta-B lo cke r wi th
Alp h a-B lo cke r, AC E I n h i b i to r, COMBINE Vaso d i lato r
C alci u m An tago n i st Two Drugs ( Alp h a-B lo cke r,
o r C e n trally Acti n g D ru g d i h yd ro p yri d i n e , o r h yd ralazi n e )
Still Not Controlle d
Othe r Drug Combinations
co n si d e r N o n -C o m p li an ce , S e co n d ary H yp e rte n si o n ,
o r O th e r D ru gs as a C au se
Figure 2. Pharmacological Tre atme nt of Hype rte ns ion
Adaptedfrom: TheCanadian Hypertension Society, 1993.
J targe t B P sh o u ld b e < 1 40/90
m ay b e lo we r fo r d iab e tic
co rre ctio n n e e d n o t b e rap id
J re fe rral is in d icate d fo r case s o f re fracto ry h yp e rte n sio n ,
su sp e cte d se co n d ary cau se o r wo rse n in g re n al failu re
J h o sp italizatio n is in d icate d fo r m align an t h yp e rte n sio n ( d iasto lic
b lo o d p re ssu re > 1 30, re tin al h e m o rrh age s, b u lgin g d iscs, m e n tal
statu s ch an ge s, in cre asin g cre atin in e )
Factors Adve rs e ly Affe cting Prognos is
J p re se n ce o f ad d itio n al m o d ifiab le risk facto rs
J p re se n ce o f u n co n tro llab le risk facto rs
e arly age o f o n se t, m ale se x, b lack race , fam ily h isto ry
J e vid e n ce o f targe t o rgan d am age
J m align an t h yp e rte n sio n
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1 5
N o te s
DIABETES MELLITUS
Epide miology
J 5% o f C an ad ian p o p u latio n h as D M ; 1 .5 m illio n affe cte d
J N O T E : D M is u n d e r-d iagn o se d ; fo r e ve ry d iagn o sis th e re is o n e u n d iagn o se d
J 85-90% Typ e II ( p e ak in cid e n ce age 50-55)
risk facto rs: fam ily h isto ry, o b e sity, h isto ry o f ge statio n al d iab e te s, age
J 1 0-1 5% Typ e I ( p e ak in cid e n ce age 1 0-1 5)
au to im m u n e
Diagnos is
J sym p to m s o f d iab e te s ( fatigu e , p o lyu ria, p o lyd ip sia, u n e xp lain e d
we igh t lo ss) o f d iab e te s p lu s a casu al p lasm a glu co se
valu e > 1 1 .1 m m o l/L
J fastin g p lasm a glu co se ( F P G ) > 7.0 m m o l/L
a p lasm a glu co se valu e in th e 2-h sam p le o f th e O G T T > 1 1 .1 m m o l/L
Manage me nt
J afte r d iagn o sis, th e in itial visits sh o u ld fo cu s o n
d u ratio n o f d iab e te s p rio r to d isco ve ry
asso ciate d risk facto rs fo r m acro /m icro vascu lar d ise ase
an y cu rre n t co m p licatio n s ( h e art, e ye s, kid n e y, vascu latu re )
p atie n t e d u catio n
J m u st wo rk with p atie n t to ach ie ve b lo o d glu co se le ve ls th at are
n o rm al as m u ch o f th e tim e as p o ssib le , wh ile avo id in g h yp o glyce m ic
e p iso d e s
J n o n p h arm aco lo gic
e xe rcise o ve rco m e s in su lin re sistan ce b y d e p le tin g m u scle
glyco ge n an d b y in d u cin g glu co se sto rage ( Typ e II o n ly)
d ie t
strive to stay with in 1 0% o f id e al b o d y we igh t
d e rive m o st calo rie s fro m co m p le x carb o h yd rate s
avo id sim p le su gars an d satu rate d fats
m u st h ave re gu lar m e als, syn ch ro n ize d with p e ak actio n o f in su lin
J p h arm aco lo gic
o ral h yp o glyce m ic age n ts ( Typ e II o n ly) ( se e F igu re 3)
in su lin ( Typ e I an d II)
in itially: sin gle d o se o f in te rm e d iate in su lin b e fo re
b re akfast ( 0.3-0.6 u /kg/d ay)
fo r b e tte r co n tro l: in te rm e d iate -actin g o r
re gu lar-actin g in su lin ( N P H /R e gu lar give n twice d aily
( 2/3 in m o rn in g, 1 /3 in e ve n in g)
clo se m o n ito rin g n e ce ssary fo r ad ju stm e n ts
se e E n d o crin o lo gy N o te s
J fo llo w u p
F P G , H b A1 c, u rin alysis, B U N , cre atin in e
B P, p lasm a lip id s, E C G
o p h th alm o lo gy
Typ e II - co n su lt at tim e o f d iagn o sis an d fo llo w u p
e ve ry two ye ars
Typ e I - co n su lt with in 5 ye ars o f d iagn o sis an d e ve ry
ye ar afte rward s
p ro te in u ria
Typ e II - scre e n at tim e o f d iagn o sis an d e ve ry ye ar
Typ e I - scre e n with in first 5 ye ars o f d iagn o sis an d th e n
e ve ry ye ar
p e rip h e ral n e u ro p ath y: p e rio d ic h e alth e xam
lip id p ro file : e ve ry 1 -3 ye ars in ad u lts
fo o t care : fo o t e xam s at le ast an n u ally
F am i ly M e d i ci n e 1 6 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
DIABETES MELLITUS . . . CONT.
Type II
N o n -o b e se ( 20%) O b e se ( 80%)
S u lfo n ylu re a B igu an id e
e g. glyb u rid e e g. m e tfo rm in
F B S h igh F B S h igh
Ad d B igu an id e Ad d S u lfo n ylu re a
F B S h igh
C o n sid e r
In su lin
Figure 3. Initial The rape utic Strate gy in Type II Diabe te s
COMMON PROBLEMS
ANXIETY
J se e P sych iatry N o te s
J h isto ry ( scre e n in g q u e stio n )
h ave yo u b e e n u n u su ally wo rrie d ab o u t th in gs re ce n tly?
BRONCHITIS
Epide miology
J m o st fre q u e n t L R T I in ad u lts ( e sp e cially in win te r m o n th s)
J viral ( 90%) : rh in o viru s, co ro n aviru s, ad e n o viru s, in flu e n za viru s
J b acte rial: H . influenza, Mycoplasma, Pneumococcus
Diagnos is
J sym p to m s
p re ce d e d b y U R T I
in itially n o n p ro d u ctive co u gh th at b e co m e s p ro d u ctive
su b ste rn al ch e st p ain with co u gh in g, d e e p b re ath in g, o r m o ve m e n t
ab se n t o r m ild fe ve r
J sign s
m ay h e ar rh o n ch i, wh e e ze s o r m ay b e cle ar
d ysp n e a, fe ve r, ch ills, crackle s, an d m o re to xic ap p e aran ce
su gge st p n e u m o n ia
J in ve stigatio n s
m ain ly a clin ical d iagn o sis ( ge n e rally n o in ve stigatio n s re q u ire d )
m ay u se sp u tu m sm e ar/cu ltu re , ch e st x-ray to ru le o u t p n e u m o n ia
Manage me nt
J co m p le te sm o kin g ce ssatio n
J re st, flu id s, an tip yre tics, an titu ssive s
J ran d o m ize d co n tro lle d trials h ave sh o wn b e n e fit o f 2-ago n ists
o ve r an tib io tics
J an tib io tics ( if age > 55 o r fre q u e n t p u ru le n t co u gh , h igh fe ve r, to xic p atie n t)
1 st lin e : te tracyclin e , e ryth ro m ycin
2n d lin e : d o xycyclin e , clarith ro m ycin , azith ro m ycin
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1 7
N o te s
COMMON PROBLEMS . . . CONT.
CHEST PAIN
J m an y cau se s: u se h isto ry, p h ysical an d in ve stigatio n s in ap p ro ach
to d iagn o sis
Diffe re ntial Diagnos is
J card iac: an gin a, M I, m yo card itis, p e ricard itis
J p u lm o n ary: p n e u m o th o rax, P E , p n e u m o n ia, n e o p lasm , T B
J G I: e so p h age al sp asm , e so p h agitis, G E R D , P U D , h e rn ia, ch o le cystitis,
ch o le lith iasis, p an cre atitis
J vascu lar: d isse ctin g ao rtic an e u rysm
J M S K /so ft tissu e : h e rp e s zo ste r, m astitis, co sto ch o n d ritis,
fractu re d rib , m u scle strain
J p sych o lo gical: an xie ty, p an ic
COMMON COLD
Epide miology
J le ad in g u p p e r re sp irato ry tract in fe ctio n ( U R T I)
J p e ak in win te r m o n th s
J ad u lts ave rage 2-4 co ld s/ye ar, ch ild re n ave rage 6-1 0 co ld s/ye ar
J rh in o viru se s m o st co m m o n cau se
o th e rs: ad e n o viru s, R S V, in flu e n za, p arain flu e n za
J tran sm issio n p rim arily o ccu rs b y h an d co n tact with th e in fe ctio u s
age n t wh ich can su rvive o n o b je cts o r skin
J in cu b atio n p e rio d 1 -5 d ays
His tory
J lo cal sym p to m s: sn e e zin g, n asal co n ge stio n , rh in o rrh e a, scratch y/so re
th ro at, n o n -p ro d u ctive co u gh
J co n stitu tio n al sym p to m s: m alaise , h e ad ach e , m yalgias, m ild fe ve r
J p rio r e p iso d e s an d tre atm e n t, sm o kin g h isto ry, e p id e m ics
J sick co n tacts
J h isto ry m u st in clu d e in q u iry in to sym p to m s re latin g to e n tire
re sp irato ry tract
o talgia, facial/d e n tal p ain , h o arse n e ss, sp u tu m , d ysp n e a, wh e e zin g
Phys ical Findings
J b o ggy n asal m u co sa, e ryth e m ato u s n aso p h aryn x, +/ e n large d
p o ste rio r lym p h o id tissu e , p o st-n asal d rip , e n large d lym p h n o d e s
J sign s o f se co n d ary b acte rial in fe ctio n : in cre asin g fe ve r, lo calize d
p ain , p ro d u ctive co u gh
Manage me nt
J co n sid e r p atie n t e xp e ctatio n s
J p atie n t e d u catio n
sym p to m s p e ak b y se co n d o r th ird d ay an d u su ally
su b sid e with in o n e we e k
co u gh m ay p e rsist fo r d ays to we e ks d u e to m icro sco p ic
in flam m atio n an d se n sitizatio n o f co u gh re ce p to rs
se co n d ary b acte rial in fe ctio n s can p re se n t with in 3-1 0 d ays
afte r o n se t o f co ld sym p to m s
J tre atm e n t is fo r sym p to m atic re lie f
h yd ratio n is b e st so lu tio n
co n ge stio n : sym p ath o m im e tics, d e co n ge stan ts
ach e s, p ain an d fe ve r: ace tam in o p h e n , AS A ( n o t in ch ild re n )
lo o se n se cre tio n s: e xp e cto ran ts ( n o t co n siste n tly e ffe ctive )
co u gh : d e xtro m e th o rp h an o r co d e in e
Pre ve ntion
J avo id ae ro so l e xp o su re , wash h an d s an d ke e p th e m away fro m m u co sal
m e m b ran e s
J h igh d o se vitam in C o ccasio n ally u se d b u t n o t p ro ve n
DEPRESSION
Jse e P sych iatry N o te s
JN O T E : d e p re ssio n co m m o n ly p re se n ts as a p h ysical co m p lain t
( e .g. fatigu e )
F am i ly M e d i ci n e 1 8 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
COMMON PROBLEMS . . . CONT.
DIZZINESS
Epide miology
J acco u n ts fo r 1 % o f p atie n t visits
J fre q u e n cy o f p re se n tatio n rise s ste ad ily with age
J m o st co m m o n p re se n tin g co m p lain t o f am b u lato ry p atie n t age > 75
Dizzine s s
Ve rtigo Nonve rtiginous
( Ve sti b u lar ( N o n ve sti b u lar
De s cription: e xte rn al wo rld se e m s to re vo lve aro u n d i n d i vi d u al a wh i rli n g se n sati o n
o r th e i n d i vi d u al re vo lve s i n sp ace fe e li n g li gh th e ad e d , gi d d y , d aze d , o r
an i llu si o n o f m o ti o n m e n tally co n fu se d
a ro cki n g se n sati o n
Ps ychoge nic
Ce ntral Pe riphe ral a d i agn o si s o f Vas cular Ocular
b rai n ste m i n n e r e ar e xclu si o n
ce re b e llar ve sti b u lar n e rve
i d i o p ath i c
M n i re s
B P V
Etiology: tu m o u r tu m o u r VB I d e cre ase d vi su al
stro ke trau m a B asi lar m i grai n e acu i ty
d ru gs d ru gs T I A
i n fe cti o n o rth o stati c
h yp e rte n si o n
S to ke s Ad am s
arrh yth m i a
C H F
ao rti c ste n o si s
Figure 4. Diffe re ntial Diagnos is of Dizzine s
Diagnos is
J h isto ry
ask p atie n t to d e fin e d izzy
d u ratio n o f attack
flash - p sych o ge n ic
a m in u te - B P V, vascu lar
m in u te s to 24 h o u rs M n i re s
d ays - acu te ve stib u lar
m o n th s to ye ars - p sych o ge n ic, C N S , m u ltise n so ry lo ss
e xace rb atin g e ve n ts
wo rse with h e ad m o ve m e n t: ve stib u lar
wo rse with e ye s clo se d : ve stib u lar
n o e ffe ct with clo su re o f e ye s o r h e ad
m o ve m e n t: n o n -ve stib u lar
asso ciate d sym p to m s
n e u ro lo gic
tran sie n t d ip lo p ia, d ysp h agia, ataxia ( T IA, VB I, arrh yth m ias)
p e rsiste n t se n so ry an d m o to r d e ficits ( C VA, C N S )
au d io lo gic
h e arin g lo ss, tin n itu s, o talgia ( lab yrin th itis,
M n i re s, o to to xicity, tu m o u r
n o n -sp e cific
n au se a, vo m itin g
p ro m in e n t with p e rip h e ral; n o t ce n tral
Manage me nt ( se e O to laryn go lo gy N o te s)
J O T C m e d icatio n s ( e .g. d ip h e n h yd ram in e )
DYSPNEA ( se e R e sp iro lo gy an d P e d iatrics N o te s)
Diffe re ntial Diagnos is
J re sp irato ry: airway d ise ase ( e .g. asth m a, C O P D ) , p are n ch ym al lu n g
d ise ase ( e .g. p n e u m o n ia) , p u lm o n ary vascu lar d ise ase , p le u ral
d ise ase , n e u ro m u scu lar an d ch e st wall d iso rd e rs
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 1 9
COMMON PROBLEMS . . . CONT.
J card io vascu lar: e le vate d p u lm o n ary ve n o u s p re ssu re , d e cre ase d
card iac o u tp u t, se ve re an e m ia
J an xie ty/p sych o so m atic
COPD/As thma
His tory
Jd ysp n e a +/ co u gh , o n se t, d u ratio n , alle viatin g an d aggravatin g facto rs
Jasso ciate d sym p to m s: wh e e zin g, sp u tu m , fe ve r, ch ills, ch e st p ain , we igh t lo ss
Jsm o kin g, alco h o l, alle rge n ic e xp o su re
Jo th e r re sp irato ry p ro b le m s/m e d ical co n d itio n s
Jcu rre n t m e d icatio n s an d p re vio u s tre atm e n ts
Jre q u ire o xyge n ? h o sp italizatio n s o r IC U stay?
Jd e te rm in e fu n ctio n al lim itatio n
Phys ical
Jvitals, le ve l o f co n scio u sn e ss
Jre sp irato ry e xam : cyan o sis, clu b b in g, sign s o f re sp irato ry d istre ss,
wh e e zin g, crackle s, d e cre ase d air e n try, in cre ase d re so n an ce
J" b lu e b lo ate rs" an d " p in k p u ffe rs"
Jcard io vascu lar e xam : p e rip h e ral e d e m a, e le vate d JVP, S 3, S 4 ( co r p u lm o n ale )
Inve s tigations
JC B C , d iffe re n tial, AB G , o xyge n satu ratio n , P F T, p e ak flo w, C XR , E C G ,
sp u tu m cu ltu re
Manage me nt
Jasth m a
e n viro n m e n tal co n tro l ( sm o kin g, p e ts, carp e ts)
p h arm aco th e rap y
sh o rt te rm re lie f: 2-ago n ists +/ an ti-ch o lin e rgics
lo n g te rm p re ve n tio n : in h ale d co rtico ste ro id s, so d iu m
cro m o glycate , le u ko trie n e re ce p to r an tago n ists, o ral
co rtico ste ro id s
always co n sid e r ae ro ch am b e r to o p tim ize d ru g d e live ry
JC O P D
sm o kin g ce ssatio n
p n e u m o co ccal an d in flu e n za vaccin e s
e xe rcise train in g, P T /O T
o xyge n
2-4 L /m in 24 h o u rs a d ay if P aO 2 > 55 m m H g,
O 2 satu ratio n < 90% o r P aO 2 55-59 m m H g an d e vid e n ce
o f co r p u lm o n ale o r p o lycyth e m ia
ip ratro p iu m b ro m id e +/ -2 ago n ists +/ lo n g actin g
th e o p h yllin e +/ co rtico ste ro id s
b ro ad sp e ctru m an tib io tics in d icate d in acu te b ro n ch itis
DYSURIA
Epide miology
J 25% o f wo m e n e xp e rie n ce an e p iso d e o f acu te d ysu ria p e r ye ar
J se co n d to U R T I as cau se o f p h ysician visits b y se xu ally active wo m e n
J n o n -in fe ctio u s: p o o r h ygie n e , alle rgic re actio n , ch e m icals, fo re ign
b o d ie s, trau m a
N o te s
F am i ly M e d i ci n e 20 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
COMMON PROBLEMS . . . CONT.
Table 5. Etiology, Signs and Symptoms of Dys uria
Infe ction Etiology Signs and Symptoms
UTI/Cys titis E . coli, S. saprophyticus, in te rn al d ysu ria th ro u gh o u t
Proteusmirabilis, Enterobacter, m ictu ritio n , fre q u e n cy,
Klebsiella, Pseudomonas u rge n cy, in co n tin e n ce ,
h e m atu ria, n o ctu ria, b ack
p ain , su p rap u b ic d isco m fo rt,
lo w grad e fe ve r ( rare )
ure thritis C. trachomatis, N. gonorrhea in itial d ysu ria, h isto ry o f
h e rp e s, Trichomonas, Candida ch lam yd ia/go n o rrh e a if
n o vagin al d isch arge
vaginitis Candida, Gardnerella, vagin al d isch arge , irritatio n ,
Trichomonas, C. trachomatis, d ysp are u n ia, d ysu ria o n
atro p h ic, h e rp e s, co n d ylo m ata o u tsid e
accu m in ata, D o d e rle in s cyto lysis
pye lone phritis sam e o rgan ism s as cystitis in te rn al d ysu ria, fe ve r,
ch ills, flan k p ain , C VA
te n d e rn e ss
Inve s tigations
J u rin e R &M , C &S
J we t p re p aratio n
J vagin al swab fo r cu ltu re ( in clu d in g ch lam yd ia)
Manage me nt ( se e G yn e co lo gy an d U ro lo gy N o te s)
J U T I/cystitis: T M P -S M X d o u b le d o se B ID X 3 d ays, n itro fu ran to in , am o xicillin
J u re th ritis
go n o co ccal: ce ftriaxo n e ( 250m g IM sin gle d o se ) ,
n o rflo xacin ( 800 m g P O sin gle d o se )
ch lam yd ia: d o xycyclin e ( 1 00 m g B ID X 7 d ays) ;
azith ro m ycin ( 1 g P O sin gle d o se )
always tre at fo r b o th
J p ye lo n e p h ritis
in p atie n t: am p icillin an d ge n tam icin
o u tp atie n t: T M P -S M X, cip ro flo xacin , n o rflo xacin o r o th e r q u in o lo n e
EARACHE (Otitis Me dia) ( se e O to laryn go lo gy N o te s)
His tory
J p e ak age 3 m o n th s - 3 ye ars
J re ce n t U R I
J su d d e n o n se t o f se ve re e arach e
J h e arin g lo ss, tin n itu s, d isch arge
J fe ve r, asso ciate d n au se a, vo m itin g, d iarrh e a
Phys ical
J in cre ase d te m p e ratu re
J tym p an ic m e m b ran e : e ryth e m ato u s, b u lgin g
J o to rrh e a: b lo o d y, se ro san gu in o u s, p u ru le n t
Etiology
J S . pneumoniae, H. influenza, M. catarrhalis
Manage me nt
J an tib io tics
1 st lin e : am o xicillin , T M P -S M X
2n d lin e : am o xicillin /clavu lin ate , ce p h alo sp o rin s
Controve rs y of Antibiotics Us e
J tre n d e xists to ward a d e cre ase in u se o f an tib io tics
J stu d ie s sh o w th at 60% o f ch ild re n are p ain fre e with in 24 h o u rs o f
p re se n tatio n with o u t an tib io tics u se
J ch ild re n re ce ivin g an tib io tics h ave alm o st twice th e am o u n t o f vo m itin g,
d iarrh e a, an d rash e s
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 21
COMMON PROBLEMS . . . CONT.
FATIGUE
Epide miology
J 5-1 0% o f o ffice visits to p rim ary care p h ysician s
J F > M , e sp e cially p are n ts o f ch ild re n /n e wb o rn s
J fre q u e n t u se rs o f th e h e alth care syste m
J u p to 80% are p sych o lo gical in o rigin
J ch ro n ic fatigu e syn d ro m e < 5% o f ch ro n ic fatigu e
Approach
J asse ss fo r p re se n ce o f an xie ty o r d e p re ssio n
J asse ss fo r cu rre n t life stre sse s, p ast trau m a, an d ab u se
J fo cu se d h isto ry an d p h ysical e xam with e m p h asis o n m e d icatio n s,
e xistin g ch ro n ic illn e sse s, an d p o ssib le in fe ctio n
J in ve stigatio n s as in d icate d b y h isto ry an d p h ysical m ay in clu d e : C B C
an d d iffe re n tial, E S R , e le ctro lyte s, u rin alysis, B U N , cre atin in e , p lasm a
glu co se , T S H , C XR , E C G , se ro lo gie s ( E B V, C M V, H IV, VD R L , if in d icate d )
Table 6. Organic vs . Ps ychologic Fe ature s
Fe ature s Organic Ps ychologic
re as on for le s s activity u n ab le u n willin g
ons e t n o t stre ss-re late d stre ss-re late d
duration < 1 -2 m o n th s > 3 m o n th s
wors e e n d o f d ay/afte r m o rn in g/u n affe cte d
e xe rcise b y re st
re lie ve d by re st e xe rcise
family su p p o rtive p ro b le m atic
as s ociations fe ve r, ch ills vagu e sym p to m s
we igh t lo ss, swe ats
pas t me dical co n cu rre n t m e d ical p sych iatric
his tory illn e ss/m e d icatio n s h isto ry
Manage me nt
J sp e cific tre atm e n t fo r sp e cific cau se s
J if e tio lo gy u n d e te rm in e d ( m o st case s)
p h ysician su p p o rt, re assu ran ce an d fo llo w-u p are ve ry im p o rtan t
b e h avio u ral o r gro u p th e rap y
ae ro b ic e xe rcise p ro gram
d ru g th e rap y ( e .g. vitam in s)
p ro gn o sis: afte r 1 ye ar, 40% are n o lo n ge r fatigu e d
Chronic Fatigue Syndrome (CDC working clas s de finition)
J m ajo r crite ria ( m u st m e e t b o th )
n e w o n se t o f p e rsistin g, re lap sin g o r d e b ilitatin g fatigu e th at
im p airs d aily activitie s > 50% o f p re -m o rb id le ve ls fo r
at le ast 6 m o n th s
e xclu sio n o f o th e r p h ysical an d p sych o lo gical co n d itio n s
J m in o r crite ria ( 8/1 1 o r 6/1 1 an d 2 p h ysical fin d in gs)
m ild fe ve r, so re th ro at, te n d e r lym p h n o d e s, m yalgia, arth ralgia,
m u scle we akn e ss, p ro lo n ge d fatigu e afte r e xe rcise , h e ad ach e s,
n e u ro p sych iatric sym p to m s, sle e p d istu rb an ce s, rap id o n se t o f
m ain sym p to m s
J m in o r crite ria ( p h ysical fin d in gs)
lo w grad e fe ve r, n o n -e xu d ative p h aryn gitis, p alp ab le o r te n d e r
an te rio r/p o ste rio r ce rvical/axillary n o d e s
J m an age m e n t
stro n g d o cto r-p atie n t re latio n sh ip
ge n tle e xe rcise p ro gram ( d o n o t fatigu e )
lo w d o se an tid e p re ssan t
N S AID s if in d icate d
N o te s
F am i ly M e d i ci n e 22 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
COMMON PROBLEMS . . . CONT.
HEADACHE
Etiology
J m u scle co n tractio n /te n sio n : 50%
J vascu lar h e ad ach e s ( m igrain e s/clu ste r : 1 0%
J m ixe d h e ad ach e s: 1 5-20%
J in tracran ial/in flam m ato ry h e ad ach e s: < 1 %
Re d Flags for He adache
J h e ad ach e s d u e to m e n in gitis, trau m a, su b arach n o id h e m o rrh age ,
tu m o u r, te m p o ral arte ritis
J h isto ry: h e ad ach e wo rse at n igh t, fe ve r, n e ck stiffn e ss, se izu re s,
trau m a, ch an ge s in L O C /b e h avio u r, vo m itin g, n e w o n se t, se ve re ,
ve ry yo u n g/o ld p atie n ts
J p h ysical e xam : fu n d i, K e rn ig's/B ru d zin ski's sign s, fo cal
n e u ro lo gic fin d in gs
J in ve stigatio n s: o n ly wh e n in d icate d
Mus cle Contraction/Te ns ion He adache s
J co m m o n asso ciatio n s: yo u n g fe m ale s, p o sitive fam ily
h isto ry ( 40%) , stre ss
J sym p to m s
lo catio n : b ilate ral, o ccip u t-ve rte x
q u ality: n o n -th ro b b in g, lasts h o u rs to we e ks
asso ciatio n s: d e p re ssio n , sle e p an d ap p e tite d istu rb an ce ,
d ifficu lty with wo rk an d re latio n sh ip s, stre ss-re late d
J sign s
m u scle tigh tn e ss, trigge r p o in ts, d e cre ase d ran ge o f m o tio n
( ce rvical arth ritis, in fe ctio n , in flam m atio n )
J m an age m e n t
acu te : ace tam in o p h e n 650-1 000 m g q 4-6 h ,
N S AID s, m u scle re laxan ts
p re ve n tative : -b lo cke rs, T C A, e d u catio n , co u n se llin g, stre ss
m an age m e n t, e xe rcise , d ie tary ch an ge s
e arly fo llo w-u p to m o n ito r re sp o n se
J se e N e u ro lo gy N o te s
Migraine He adache s
J b e n ign , re cu rre n t e p iso d ic h e ad ach e s wh ich m ay b e
se ve re an d th ro b b in g
J 85% are co m m o n m igrain e ( with o u t au ra)
J l5% are classical m igrain e ( with au ra) : tran sie n t visu al
o r se n so ry sym p to m s lastin g 1 0-30 m in u te s b e twe e n p ro d ro m e
an d h e ad ach e
J ce re b ral isch e m ia le ad in g to visu al sym p to m s like fo rtificatio n
sp e ctra ( zig zags) , scin tillatin g sco to m a ( sp o ts) an d te ich o p sia
( flash in g ligh ts)
J also se n so ry, m o to r, lan gu age o r p e rce p tu al p ro b le m s
Symptoms
J lo catio n : u n ilate ral b u t o ccasio n ally b ilate ral, rare ly p o ste rio r
J q u ality: th ro b b in g, lasts h o u rs to 2 d ays
J asso ciatio n s: n au se a, vo m itin g, an o re xia, p h o to p h o b ia, p h o n o p h o b ia
J p ro d ro m e : an y tim e o f d ay o r n igh t: irritab le o r d e p re sse d m o o d ,
in cre ase d o r d e cre ase d activity, ap p e tite cravin gs, flu id re te n tio n
Signs
J d u rin g h e ad ach e : p allo r, d iap h o re sis, tach ycard ia, m ild h yp e rte n sio n ,
d ilate d p u p ils, d iste n d e d scalp ve sse ls, te n d e r scalp
Trigge rs
J h e re d ity p lu s e n viro n m e n t: stre ss, stre ss le t d o wn , fatigu e ,
in cre ase d /d e cre ase d sle e p , fastin g, caffe in e , m e n stru atio n , o vu latio n , O C P,
E tO H , fo o d with tyram in e ( ch e e se ) , p h e n yle th ylam in e ( ch o co late ) ,
n itrite s, M S G , we ath e r
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 23
COMMON PROBLEMS . . . CONT.
Exace rbating Factors
J e xe rtio n , strain in g, co u gh in g, b e n d in g, n o ise , ligh t
Manage me nt
J re assu ran ce , life style ch an ge s, re m o val o f trigge rs
J p h arm aco th e rap y ( in d icate d if th e h e ad ach e s th re ate n to d isru p t th e
p atie n t's ab ility to fu n ctio n n o rm ally)
m ild attacks ( p atie n t can co n tin u e h is/h e r u su al activitie s with
m in im al d isru p tio n )
AS A, N S AID s
m o d e rate attacks ( p atie n ts' activitie s are m o d e rate ly im p aire d )
N S AID s: ib u p ro fe n , n ap ro xe n so d iu m , m e fe n am ic acid
se le ctive 5-H T re ce p to r ago n ist: su m atrip tan ( P O o r S C )
( n o t co n cu rre n tly o r with in 24 h o f e rgo tam in e o r D H E )
n o n -se le ctive 5-H T re ce p to r ago n ist: D H E ( S C , IM o r IV)
se ve re attacks ( p atie n t u n ab le to co n tin u e h is/h e r n o rm al
activitie s an d can fu n ctio n in an y cap acity o n ly with se ve re
d isco m fo rt an d im p aire d e fficie n cy)
1 st lin e : D H E ( S C , IM o r IV) , su m atrip tan ( P O o r S C ) ,
m e to clo p ram id e ( IV p re fe rre d ) , ch lo rp ro m azin e ( IV o r IM ) ,
p ro ch lo rp e razin e ( IV o r IM )
alte rn ative if ab o ve in e ffe ctive : ke to ro lac, d e xam e th aso n e
last re so rt: m e p e rid in e
Table 7. Us ual Clinical Fe ature s
Te ns ion He adache Common Migraine Clas s ic Migraine Clus te r He adache
in cid e n ce ve ry co m m o n co m m o n n o t co m m o n u n co m m o n
age o f o n se t 1 5-40 1 0-30 20-40
se x b ias m o re fe m ale s m o re fe m ale s m o stly m ale s
fam ily h isto ry o f h e ad ach e fre q u e n t ve ry fre q u e n t in fre q u e n t
h e ad ach e fre q u e n cy variab le , can b e d aily variab le , b u t n e ve r d aily d aily d u rin g clu ste r
stre ss, fatigu e , m e n stru atio n
trigge rs stre ss o r fatigu e o ral co n trace p tive s, ce rtain fo o d s, alco h o l, o n ly d u rin g clu ste r
alco h o l, we ath e r ch an ge s,
ligh ts, o d o rs
o n se t d u rin g sle e p e xtre m e ly rare n o t u n co m m o n typ ical
warn in g n o n e n o n e visu al o r n o n e
se n so ry au ra
lo catio n b ilate ral, fro n tal o fte n u n ilate ral, so m e tim e s b ilate ral u n ilate ral, o rb ital, te m p o ral, an d m alar
o r n u ch o -o ccip ital
se ve rity m ild to m o d e rate m o d e rate to se ve re e xtre m e ly se ve re
e xace rb ato rs stre ss o r fatigu e m o ve m e n t, h e ad jarrin g, h e ad -lo w p o sitio n n o n e
co n co m itan ts n o n e n au se a, so m e tim e s vo m itin g, p h o to p h o b ia, u n ilate ral su ffu sio n o f e ye with p to sis an d te arin g
so n o p h o b ia, e tc... stu ffin g an d rh in o rrh e a o f ip silate ral n o stril
d u ratio n o f h e ad ach e h o u rs to d ays h o u rs to all d ay - se ld o m m o re th an two d ays 20-90 m in u te s
e xam in atio n d u rin g little d istre ss; so m e tim e s m ild to se ve re d istre ss, se ve re d istre ss, e ye ch an ge s as n o te d ab o ve
h e ad ach e te n se te n d e r scalp an d n e ck te n d e rn e ss o f scalp arte rie s
m u scle s
TableUsual Clinical Featuresof Headaches, (Sandoz, Headache, 1992 Edition), by John Edmeads
SLEEP PROBLEMS
Etiology
Jp rim ary sle e p d iso rd e r
Jse co n d ary - p sych iatric d iso rd e r, d ru g an d alco h o l ab u se , m e d ical/su rgical
p ro b le m s ( C O P D , h yp e rth yro id , d e liriu m , sle e p ap n e a)
His tory
Jo n se t, d u ratio n , p atte rn
Jch ie f sle e p sym p to m ( in itial in so m n ia, wakin g at n igh t)
Jd aytim e p e rfo rm an ce
Jco llate ral fro m b e d p artn e r ( sn o rin g, m o ve m e n ts, ap n e ic e p iso d e s)
Jm e d ical asse ssm e n t ( R O S , m e d icatio n s, d ru gs, alco h o l, caffe in e , sm o kin g)
Jp sych o lo gical asse ssm e n t ( stre sso rs, scre e n fo r p sych iatric d iso rd e rs)
N o te s
F am i ly M e d i ci n e 24 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
COMMON PROBLEMS . . . CONT.
Phys ical/Inve s tigations
Jad d re ss sp e cific m e d ical p ro b le m s ( C B C with d iffe re n tial, T S H )
Jsle e p d iso rd e r clin ic re fe rral if su sp e ct p rim ary cau se
Manage me nt
Jn o n -p h arm aco lo gic
first lin e m an age m e n t - p ro m o te go o d sle e p h ygie n e ( avo id caffe in e ,
n ico tin e , alco h o l, e xe rcise re gu larly, u se b e d o n ly fo r se x, sle e p ,
sickn e ss, co m fo rtab le sle e p e n viro n m e n t, go to b e d wh e n d ro wsy)
p ro gre ssive re laxatio n
co gn itive tre atm e n ts
Jp h arm aco gical
u se d in co n ju n ctio n with n o n -p h arm aco lo gical tre atm e n t
b e n zo d iaze p in e s ( o n ly fo r sh o rt p e rio d o f tim e )
cyclo p yrro lo n e ( zo p iclo n e )
se d atin g an tid e p re ssan ts ( trazo d o n e )
MUSCLE OR JOINT PAIN ( se e O rth o p e d ics, R h e u m ato lo gy an d N e u ro su rge ry N o te s)
Diagnos is
J h isto ry fo r M S K in ge n e ral sh o u ld in clu d e :
ch ie f co m p lain t: p ain , in stab ility, an d /o r we akn e ss
co n trib u tin g m e ch an ism
J wh e re an d wh e n is th e p ain wo rst
o n se t an d d u ratio n
we igh t-b e arin g statu s
p atte rn , stiffn e ss ( m o rn in g o r afte r activity)
p re vio u s attacks ( im p o rtan t risk facto r
aggravatin g an d alle viatin g facto rs
p re vio u s tre atm e n t
e ffe ct o n fu n ctio n : o ccu p atio n , AD L s, lim itatio n s
p sych o so cial h isto ry
asso ciate d sym p to m s
tre atm e n t go als
ANKLE /KNEE PAIN
J sp rain s are th e m o st co m m o n M S K in ju ry in sp o rts
J p ain can b e fro m acu te in ju ry, o ve ru se in ju ry, o r o th e r co n d itio n
J trau m atic ( sp rain s, strain s, d islo cate d fractu re s, o ve ru se syn d ro m e s)
J n o n -trau m atic ( arth ritis, o ste o m ye litis, n e o p lasm )
J R e d flags: h e m arth ro sis, kn e e p ain /lim p in ch ild with a n o rm al kn e e
e xam , p o o r re sp o n se to tre atm e n t, b o n y/jo in t swe llin g, fe ve r, rash
Manage me nt
J An kle sp rain : co n sid e r N S AID s, sp lin tin g, e arly m o b ilizatio n ,
p h ysio th e rap y, ice , co m p re ssio n
LOW BACK PAIN
J se e O rth o p e d ics an d N e u ro su rge ry N o te s fo r m o re d e tails
Epide miology
J 4-5% o f p rim ary care visits ( life tim e p re vale n ce 85%)
J large st WS IB cate go ry
J 1 cau se o f ch ro n ic d isab ility
J 80-85% o f b ack p ain is n o n -sp e cific
J classify as u n co m p licate d b ack p ain , co m p licate d b ack p ain , p ain d u e
to syste m ic d ise ase o r re fe rre d p ain
J re d flags ( B AC K PAIN )
B : b o we l o r b lad d e r d ysfu n ctio n
A: an e sth e sia ( sad d le )
C : co n stitu tio n al sym p to m s/m align an cy
K : ch ro n ic d ise ase
P : p are sth e sias
A: age > 50
I: IV d ru g u se
N : n e u ro m o to r d e ficits
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 25
COMMON PROBLEMS . . . CONT.
Phys ical Examination
J in sp e ctio n o f sp in e : cu rvatu re , p o stu re
J p alp atio n : p arasp in al, b o n y te n d e rn e ss
J ran ge o f m o tio n o f b ack
J straigh t le g raise s, fe m o ral stre tch
J p h ysical e xam fo r n e rve ro o t in ju ry
J m u st always ru le o u t le ss co m m o n b u t p o te n tially se rio u s cau se s
su rgical e m e rge n cie s
cau d a e q u in a syn d ro m e : fe cal in co n tin e n ce , u rin ary
re te n tio n , sad d le an e sth e sia, d e cre ase d an al to n e
ab d o m in al ao rtic an e u rysm : p u lsatile ab d o m in al m ass
m e d ical co n d itio n s
n e o p lastic ( p rim ary, m e tastatic)
in fe ctio u s ( o ste o m ye litis, tu b e rcu lo sis)
in flam m ato ry ( se ro n e gative sp o n d ylo arth ro p ath ie s)
m e tab o lic ( o ste o p o ro sis with fractu re s, o ste o m alacia,
P age t's d ise ase )
visce ral ( p ro statitis, e n d o m e trio sis, p ye lo n e p h ritis, p an cre atitis)
Manage me nt
J o rd e r x-rays an d ap p ro p riate lab s in p re se n ce o f an y re d flags
J e xp lain d iagn o sis an d n atu ral h isto ry co n fid e n tly
90% o f lo w b ack p ain will im p ro ve with in 2-8 we e ks
re assu ran ce is ve ry im p o rtan t
J e d u cate p atie n t ab o u t p re ve n tio n an d co n sid e r p h ysio th e rap y o r
b ack sch o o l in o ccu p atio n al se ttin gs
J m e d ical
N S AID s
ace tam in o p h e n
J p h ysical
m an ip u latio n o f lo w b ack d u rin g first m o n th o f sym p to m s
ap p licatio n o f h e at o r co ld
J e xe rcise
te m p o rary avo id an ce o f activitie s th at in cre ase m e ch an ical
stre ss o n sp in e
b e d re st > 4 d ays is co n train d icate d
grad u al re tu rn to n o rm al activitie s
co n d itio n in g e xe rcise s fo r tru n k m u scle s afte r 2 we e ks
J if n o im p ro ve m e n t afte r o n e m o n th o f co n se rvative th e rap y co n sid e r
fu rth e r in ve stigatio n s
J co n sid e r su rge ry wh e n th e re is clin ical e vid e n ce o f n e rve ro o t
irritatio n o r n e u ro lo gical d e ficit afte r o n e m o n th o f co n se rvative
th e rap y
SEXUALLY TRANSMITTED DISEASES ( se e G yn e co lo gy N o te s)
J se xu al h isto ry
are yo u se xu ally active ? typ e s o f activitie s?
wh e n d id yo u start b e in g se xu ally active ?
se x with m e n , wo m e n o r b o th ?
n u m b e r o f p artn e rs? d u ratio n o f in vo lve m e n t with e ach ?
p ro b le m s re late d to se xu al activity ( p ain , d ysp are u n ia,
e jacu latio n , o b tain in g/m ain tain in g an e re ctio n , re ach in g
o rgasm , lu b ricatio n )
J S T D h isto ry
are yo u aware o f S T D s? h ave yo u e ve r h ad o n e ? e ve r b e e n te ste d ?
take co n trace p tio n h isto ry ( se e G yn e co lo gy N o te s)
sym p to m s su ch as ge n ital b u rn in g, itch in g, d isch arge , so re s, ve sicle s
asso ciate d sym p to m s su ch as fe ve r, arth ralgia, lym p h ad e n o p ath y
last P ap te st an d re su lts
h isto ry o f trave l
h o w is th is affe ctin g yo u r life ? yo u r re latio n sh ip s?
J co n se rvative m an age m e n t
co u n se l re gard in g th e risks o f H IV, h e p atitis, S T D s
co u n se l ab o u t se xu al p ractice s, co n trace p tio n
u rin ate afte r se xu al co n tact
N o te s
F am i ly M e d i ci n e 26 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
COMMON PROBLEMS . . . CONT.
SINUSITIS ( se e O to laryn go lo gy N o te s)
Epide miology
J 4.6% o f p h ysician visits b y yo u n g ad u lts
J fifth m o st co m m o n d iagn o sis fo r wh ich an tib io tics are p re scrib e d
Table 8. Clinical Diagnos is of Acute Bacte rial Sinus itis
Bas e d on 5 s igns and s ymptoms
m axillary to o th ach e
p o o r re sp o n se to d e co n ge stan ts
h isto ry o f co lo u re d n asal d isch arge
p u ru le n t n asal se cre tio n s
ab n o rm al tran sillu m in atio n
Numbe r of s igns and s ymptoms Re comme nde d cours e of action
4-5 x-rays
1
n o t re q u ire d , tre at all
2-3 x-ray all, tre at b ase d o n re su lts
< 2 n o x-rays o r tre atm e n t n e ce ssary
1
Wate rs vie w x-ray is su fficie n t; x-rays sh o u ld n o t b e p e rfo rm e d in ch ild re n < 1 ye ar o f age
Adaptedfor Lowet al.: CMAJ 1997; 156: S1-S14.
Manage me nt
J am o xicillin 500 m g P O T ID , T M P /S M X if alle rgic
J d e co n ge stan ts
SKIN LESIONS ( se e D e rm ato lo gy N o te s)
Appe arance of Common Skin Cance rs
J M align an t M e lan o m a
A: asym m e try
B : b o rd e r irre gu larity
C : co lo u r ch an ge
D : d iam e te r > 1 cm
E : e cce n tricity
J B asal ce ll carcin o m a
p e arly, tran slu ce n t, ro lle d te lan gie ctatic b o rd e r; ce n tral u lce ratio n
J S q u am o u s ce ll carcin o m a
p laq u e /n o d u le with varyin g d e gre e s o f scalin g, cru st, e ro sio n ,
an d u lce ratio n
SKIN RASHES
J rash e s th at are co m m o n in fam ily p ractice : p so riasis, ato p ic d e rm atitis, se b o rrh e ic
d e rm atitis, acn e ro sace a, acn e vu lgaris, tin e a, e xan th e m s, p ityriasis
ro se a, su n - an d d ru g-re late d ( se e D e rm ato lo gy N o te s)
SORE THROAT
Etiology
J viral m o st co m m o n cau se an d o fte n m ay m im ic b acte rial in fe ctio n
ad e n o viru s
p rim arily su m m e r m o n th s, lasts 5 d ays
so re th ro at, rh in itis, co n ju n ctivitis, fe ve r
co xsackie viru s
p rim arily su m m e r m o n th s
p h aryn gitis with sm all, te n d e r b liste rs o n so ft p alate ,
u vu la, to n sils; b liste rs ru p tu re an d le ave e ryth e m ato u s
u lce rs
m ay also se e u lce ratio n s o n h an d s an d fe e t ( h an d , fo o t
an d m o u th d ise ase ) o r G I sym p to m s ( vo m itin g, d iarrh e a)
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 27
COMMON PROBLEMS . . . CONT.
h e rp e s sim p le x viru s
like co xsackie viru s b u t u lce rs fe we r an d large r
E B V ( in fe ctio u s m o n o n u cle o sis)
p h aryn gitis, to n sillar e xu d ate , fe ve r, lym p h ad e n o p ath y,
fatigu e , an d rash
J b acte rial
G ro u p A S tre p to co cci ( G AB H S )
b y far th e m o st co m m o n b acte rial cau se
m o st co m m o n b e twe e n age s 5-1 7 ye ars
fo u r classic sym p to m s
fe ve r
to n sillar o r p h aryn ge al e xu d ate
swo lle n , te n d e r an te rio r ce rvical n o d e s
ab se n ce o f co u gh
Table 9. SORE THROAT SCORE*
P O IN T S
Is C O U G H AB S E N T ? 1
Is th e re a H IS T O R Y O F F E VE R O VE R 38C ( 1 01 F ) ? 1
Is th e re T O N S IL L AR E XU D AT E ? 1
Are th e re S WO L L E N , T E N D E R AN T E R IO R N O D E S ? 1
Age 3-1 4 ye ars 1
Age 1 5-44 ye ars 0
Age > 45 ye ars 1
In co m m u n itie s with m o d e rate le ve ls o f stre p in fe ctio n
( 1 0% to 20% o f so re th ro ats) :
S C O R E
0 1 2 3 4
C h an ce th at p atie n t 2-3% 3-7% 8-1 6% 1 9-34% 41 -61 %
h as stre p th ro at
S u gge ste d actio n N o cu ltu re C u ltu re all, tre at o n ly C u ltu re all, tre at with
o r an tib io tic if cu ltu re is p o sitive p e n icillin o n clin ical gro u n d s
1
1
C lin ical gro u n d s in clu d e a h igh fe ve r o r o th e r in d icato rs th at th e p atie n t is clin ically u n we ll an d is
p re se n tin g e arly in th e th e co u rse o f th e illn e ss. If th e p atie n t is alle rgic to p e n icillin , u se e ryth ro m ycin .
* L im itatio n s:
* T h is sco re is n o t ap p licab le to p atie n ts le ss th an 1 5 ye ars o f age .
* If an o u tb re ak o r e p id e m ic o f illn e ss cau se d b y G AS is o ccu rin g in an y co m m u n ity, th e sco re
is in valid an d sh o u ld n o t b e u se d .
AdaptedfromCentor RM et al.: MedDecisMaking1981; 1: 239-246;
McIsaacWI, WhiteD, TannenbaumD, LowDE: CMAJ 1998; 158(1):75-83.
Importance of Diagnos is
J m u st d istin gu ish viral fro m b acte rial to d e cre ase th e in cid e n ce o f
co m p licatio n s fro m G AB H S
J p u rp o se o f tre atm e n t
d e cre ase in cid e n ce o f rh e u m atic fe ve r ( ve ry lo w in cid e n ce )
d e cre ase su p p u rative co m p licatio n s ( ab sce ss)
d e cre ase sp re ad o f d ise ase
J n o te : in cid e n ce o f glo m e ru lo n e p h ritis n o t d e cre ase d b y an tib io tic tre atm e n t
Diagnos is and Tre atme nt
J go ld stan d ard fo r d iagn o sis is th ro at cu ltu re
J rap id te st fo r stre p to co ccal an tige n o n ly 85% se n sitive
J if rap id te st p o sitive , take a cu ltu re an d tre at th e p atie n t
im m e d iate ly with an tib io tics
J if rap id te st n e gative , take a cu ltu re an d call th e p atie n t if
cu ltu re is p o sitive to start an tib io tics
J th e re is n o in cre ase d in cid e n ce o f rh e u m atic fe ve r with a 48 h o u r
d e lay in an tib io tic tre atm e n t
J p e n icillin is d ru g o f ch o ice ; e ryth ro m ycin if p e n icillin alle rgic
J th e re is n o th e rap y e xce p t sym p to m atic fo r viral p h aryn gitis
N o te s
F am i ly M e d i ci n e 28 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
COUNSELLING
DOMESTIC VIOLENCE
J e m o tio n al, p h ysical, se xu al ab u se
Epide miology
J 25% o f wo m e n h ave e xp e rie n ce d vio le n ce fro m cu rre n t o r p ast p artn e r
J p h ysician s u n d e r-e stim ate p re vale n ce ( at 1 -2%)
Effe cts of Viole nce
J p sych o lo gical: d e p re ssio n , P T S D , su icid al id e atio n an d
atte m p ts, alco h o lism
J p h ysical: p e lvic p ain , p an ic like sym p to m s ( e .g. h e ad ach e s,
ch e st p ain , p alp itatio n s)
o fte n lab e lle d as p an ic attacks o r " fu n ctio n al"
De te ction and Manage me nt
J scre e n AL L p atie n ts; ask d ire ctly an d n o n -ju d ge m e n tally
J b e p atie n t an d re frain fro m b e in g d ire ctive
J re assu re th at it is n o t th e ir fau lt
J re m in d th at sp o u sal ab u se is a crim in al act b u t is n o t
re p o rtab le b y p h ysician s
n o te : su sp e cte d ab u se in ch ild re n M U S T b e re p o rte d
J d e te rm in e le ve l o f safe ty an d m ake an e xit p lan
J facilitate co n tact with co m m u n ity re so u rce s
J fu lly d o cu m e n t all e vid e n ce o f ab u se ( e .g. p ictu re s, ske tch e s)
CONTRACEPTION ( se e G yn e co lo gy N o te s)
J h isto ry
co n train d icatio n s, re latio n sh ip s/se xu al h isto ry
cu rre n t an d p re vio u s m e th o d s o f co n trace p tio n , e xp e ctatio n s
o b ste trical an d gyn e co lo gical h isto ry, S T D h isto ry
J b e n e fits o f o ral co n trace p tive s
A: an e m ia d e cre ase d
B : b e n ign b re ast d ise ase an d cysts d e cre ase d
C : can ce r ( o varian d e cre ase d ) , cycle s re gu late d
D : d ysm e n o rrh e a d e cre ase d , re d u ctio n in S T D s
MENOPAUSE/HRT ( se e G yn e co lo gy N o te s)
Epide miology
J m e an age o f ce ssatio n o f m e n stru atio n = 51 .4 ye ars
J C an ad ian fe m ale life sp an = 81 .2 ye ars
a wo m an will sp e n d o ve r 1 /3 o f h e r life in m e n o p au se
risk o f C VD an d o ste o p o ro sis in cre ase s d ram atically afte r
m e n o p au se
J co n train d icatio n s to H R T
A: acu te live r d ise ase /ch ro n ically im p aire d live r
B : b le e d in g ( u n d iagn o se d vagin al)
C : can ce r ( b re ast o r u te ru s)
D :D VT ( acu te vascu lar th ro m b o sis o r th ro m b o e m b o lic d ise ase )
Manage me nt
J e n co u rage p h ysical e xe rcise an d vitam in D /calciu m su p p le m e n ts
J ro u tin e u se o f H R T still co n tro ve rsial
H R T ro u tin e s in clu d e : cyclic e stro ge n +p ro ge ste ro n e , co n tin u o u s
e stro ge n +p ro ge ste ro n e , e stro ge n rin g, e stro ge n ge l,
ralo xife n e ( S E R M )
COMPLEMENTARY THERAPIES
J kn o wle d ge o f co m p le m e n tary th e rap ie s can im p ro ve
co m m u n icatio n with p atie n ts wh o ch o o se th e se th e rap ie s
co -o rd in atio n o f care
th e we ll-b e in g o f p atie n ts th ro u gh ap p ro p riate u se o f th e se
th e rap ie s
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s F am i ly M e d i ci n e 29
COUNSELLING . . . CONT.
J m in d -b o d y th e rap ie s
b ase d o n th e in se p arab ility an d in te ractio n o f co gn itive an d
e m o tio n al p ro ce sse s with th e b o d y's o rgan syste m s
b io fe e d b ack: le arn in g to m o d ify o n e s o wn vital fu n ctio n s
also h yp n o sis, m e d itatio n an d m in d fu l e xe rcise su ch as yo ga
an d tai ch i
J ch iro p ractic
th e rap y fo cu se s m ain ly o n m an u al ad ju stm e n t o r m an ip u latio n
o f th e sp in e
J b o d ywo rk
trad itio n al m assage
J re fle xo lo gy
th e ap p licatio n o f p re ssu re to p o in ts o f th e h an d s/fe e t th at are
b e lie ve d to co rre sp o n d to re lie vin g te n sio n , stim u latin g d e e p
re laxatio n , in cre asin g circu latio n , an d m o d ifyin g n e rve im p u lse s
little re se arch availab le
J ap p lie d kin e sio lo gy
th e id e n tificatio n o f we akn e ss in sp e cific m u scle s an d th e u se
o f te ch n iq u e s to co rre ct th e se im b alan ce s
th e rap e u tic to u ch
e n e rgy-b ase d h e alin g syste m
J acu p u n ctu re
d e ve lo p e d as p art o f C h in e se trad itio n al m e d icin e
b ase d o n h e alth b e in g d e p e n d e n t o n " ch i"
( th e vital life e n e rgy)
J h e rb al re m e d ie s
m an y availab le b u t little re se arch at th is tim e
Drawing by KimAuchinachie