Family Medicine

FAMILY MEDICINE
Dr. D. Tannenbaum
Angelina Chan, Helen Dempster and Tanya Thornton, chapter editors
Tracy Chin, associate editor
FOUR PRINCIPLES OF FAMILY MEDICINE .. 3 DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Screening Questions
PATIENT-CENTERED CLINICAL METHOD . . . 3 Risk Factors For Depression
Related Issues
PERIODIC HEALTH EXAM (PHE) . . . . . . . . . . . 3 Treatment
Purpose of the PHE Risk of Recurrence
Adult Periodic Health Exam
Additional Preventative Health Care for the Elderly DIABETES MELLITUS (DM) . . . . . . . . . . . . . . . . 16
Definition
HEALTH PROMOTION AND COUNSELLING . . 5 Classification and Epidemiology
Nutrition Diagnosis
Exercise Screening
Stress Management Management
End Of Life Care DIZZINESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Epidemiology
COMPLEMENTARY THERAPIES . . . . . . . . . . . . 7 Diagnosis
Management
COMMON PRESENTING PROBLEMS
DOMESTIC VIOLENCE . . . . . . . . . . . . . . . . . . . . . 19
ALCOHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Epidemiology
Definition Effects of Violence
Epidemiology Detection and Management
History
Investigations DYSPNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Management Definition
Prognosis Differential Diagnosis
History
ANXIETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Physical Examination
Screening Questions
History Investigations
Treatment Management
BRONCHITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 DYSURIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Acute Bronchitis Epidemiology
Acute Exacertabions Of Chronic Bronchitis (A.E.C.B.) Investigations
Management
CEREBROVASCULAR DISEASE . . . . . . . . . . . . . 13
FATIGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CHEST PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Epidemiology
Ischemic Heart Disease (IHD) Approach
Management
COMMON COLD (ACUTE RHINITIS) . . . . . . . . 14
Chronic Fatigue Syndrome
Epidemiology
Prevention
Diagnosis HEADACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Management Etiology
Red Flags for Headache
CONTRACEPTION . . . . . . . . . . . . . . . . . . . . . . . . . 15 Episodic Tension-Type Headache
History Cluster Headache
Physical Examination Migraine Headaches
Counselling
MCCQE 2006 Review Notes Family Medicine – FM1

FAMILY MEDICINE . . . CONT.
HYPERTENSION (HTN) . . . . . . . . . . . . . . . . . . . . 27 SEXUALLY TRANSMITTED

Epidemiology DISEASES (STD’s) . . . . . . . . . . . . . . . . . . . . . . . . . 36
Definition History
Etiology Patients at Risk
Diagnostic Evaluation Organisms
Therapeutic Considerations Prevention
Diagnosis/Investigations
LOW BACK PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Management
Definition
Etiology SKIN LESIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Differential Diagnosis Etiology
History
Physical examination SLEEP PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . 37
Investigations Definition
Management Etiology
Red Flags History
Physical Examination/Investigations
MENOPAUSE/HORMONE REPLACEMENT Management
THERAPY (HRT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Stress-induced Insomnia
Epidemiology Periodic Limb Movements Of Sleep (PLMS) and
Contraindications to HRT Restless Leg Syndrome
Management Circadian Rhythm Disorders
Parasomnias
OBESITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Excessive Daytime Sleepiness
Definition
Epidemiology SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Diagnosis Epidemiology
Investigations History
Management Management
Natural History Prognosis
OSTEOARTHRITIS (OA) . . . . . . . . . . . . . . . . . . . . 34 SORE THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Etiology
Definition
Etiology Investigations and Management
Pathophysiology REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Signs and Symptoms
Investigations
Management
OTITIS MEDIA (OM) (ACUTE) . . . . . . . . . . . . . . 35

Definition
Epidemiology
History
Physical Examination/Diagnosis
Etiology
Management
FM2 – Family Medicine MCCQE 2006 Review Notes

FOUR PRINCIPLES OF FAMILY MEDICINE
College of Family Physicians of Canada Guidelines
1. The family physician is a skilled clinician
• is skilled in diagnosis/management of diseases common to population served
• recognizes importance of early diagnosis of serious life threatening illnesses
2. Family medicine is a community-based discipline
• has good knowledge of and access to community services
• responds/adapts to changing needs and changing circumstances
• collaborates as team member or leader
3. The family physician is a resource to a defined practice population
• serves as a health resource
• promotes self-directed life-long learning
• advocates for public policy to promote health
4. The patient-physician relationship is central to the role of the family physician
• is committed to the person, not just disease
• promotes continuity of patient care
PATIENT-CENTRED CLINICAL METHOD

explore/define patient problems and decide on management together
consider both agendas
• doctor's agenda: history, physical, investigation
• patient's agenda: FIFE = feelings, ideas, function, expectations
find common ground in management and follow-up planning
ADULT PERIODIC HEALTH EXAM

Canadian Task Force on Preventative Health Care established in 1976; first published in 1979
reviews the literature for evidence pertaining to prevention of conditions
aids in developing clinical practice guidelines
incorporates primary and secondary preventive measures
most notable recommendation is the abolition of the annual physical exam; to be replaced by the
periodic health examination (PHE)
PURPOSE OF THE PHE
primary prevention
identify risk factors for common chronic disease
detect asymptomatic disease (secondary prevention)
counsel patients to promote healthy behaviour
update clinical data
enhance patient – physician relationship
Table 1. Classification of Recommendations

A good evidence supporting inclusion of the maneuver
B fair evidence supporting inclusion of the maneuver
C poor evidence regarding the inclusion or exclusion of the

maneuver/condition
D fair evidence supporting exclusion of the maneuver
E good evidence supporting exclusion of the maneuver

Counselling Issues
A. Recommendations
• smoker? If yes, counsel on smoking cessation and offer nicotine replacement therapy
• dental hygiene (dental visits, brushing, flossing)
• folic acid supplementation (ALL females of child bearing age)
0.4 mg 1 month preconception until 3 months postconception
• noise control and hearing protection

. . . CONT.
B. Recommendations
• smokers: referral to valid cessation program after cessation advice
• seat belt use
• moderate physical activity
• diet (counselling on adverse nutritional habits and general dietary advice on fat and cholesterol)
• HRT (assess risk factors, discuss risks and benefits of HRT)
• sun exposure and protective clothing
• alcohol case finding and counselling
• counselling to protect against STDs
for high risk populations only
home visits for child maltreatment (A)
dietary advice on leafy green vegetables and fruit for smokers (B)
Physical Exam
blood pressure measurement (B)
clinical breast exam (50-69 years) (A)
for high risk populations only:
• fundoscopy for diabetics (B)
• skin exam for first degree relative with melanoma (B)
Laboratory/Investigations
mammography (50-69 years) (A)
rubella titres for all women of child bearing age (B)
Pap smear (B)
• voluntary HIV antibody screening for high risk populations (A)
• urine dipstick for adults with insulin-dependent diabetes (A)
• gonorrhea, gram stain/culture, cervical or urethral smear for high risk groups (A)
• mantoux TB skin test for high risk groups (A)
• INH prophylaxis for household contacts and skin test converters (A)
• INH prophylaxis for high risk subgroups (B)
• colonoscopy for cancer family syndrome (B)
• chlamydia, smear culture or analysis for high risk women (B)
Immunizations
rubella for all non-pregnant women of child-bearing age (B)
• amantadine chemoprophylaxis for individuals exposed to influenza index case (A)
• outreach strategies for influenza vaccination for specific subgroups
(e.g. diabetes, chronic heart disease) (A)
• annual immunization for influenza for high risk groups (B)
ADDITIONAL PREVENTATIVE HEALTH CARE
FOR THE ELDERLY
A. Recommendations
• outreach strategies for influenza vaccination
• for high risk populations only
• multidisciplinary post fall assessment
• pneumococcal pneumonia immunization
B. Recommendations
• BP measurement
• influenza vaccination
• hearing impairment assessment (inquiry, whispered voice test)
• visual acuity: Snellen sight card
Reference: Canadian Task Force on Preventative Health Care, 2000.

HEALTH PROMOTION AND COUNSELLING
health promotion is the most effective preventive strategy
40-70% of productive life lost annually is preventable
NUTRITION
Guidelines for the General Population
for people > 4 years old
enjoy a variety of foods from each group every day
• grain products
• 5-12 servings/day
• choose whole grain and enriched products more often
• low in fat, cholesterol; high in B vitamins, iron, fiber
• bread, pasta, rice, cereal, crackers, etc.
• vegetables and fruit
• choose dark green and orange vegetables/fruit more often
• high in vitamins, minerals, fiber; low in fat, calories, sodium; no cholesterol
• broccoli, lettuce, carrots, cantaloupe, potatoes, oranges, bananas, peaches, etc.
• milk products
• children 4-9 years, 2-3 servings/day; age 10-16, 3-4/day; adults 2-4/day;
pregnant/breast-feeding, 3-4/day
• choose lower-fat milk products more often
• high in protein, calcium, phosphorus, niacin, riboflavin, vitamins A and D
• milk, cheese, yogurt, ice-cream, etc.
• meat and alternatives
• choose leaner meats, poultry and fish, plus dried peas, bean and lentils more often
• high in protein, B vitamins, iron, other minerals
• beef, chicken, lunch meats, fresh/canned fish, beans, tofu, eggs, peanut butter, etc.
• other foods
• for taste and enjoyment, but may be high in fat or calories, so use in moderation
aim for fat intake < 30% of total energy
• limit saturated fat to < 10% of energy
• limit cholesterol to < 300 mg/d
consume at least 2 fish servings per week
limit salt to < 6 g/day
limit alcohol to low-risk guidelines
balance the number of calories you eat with the number you use
• weight (lbs) X 15 = average number of calories used per day if moderately active
• weight (lbs) X 13 = average number of calories used per day if less active
vegetarian diet is low in fat and cholesterol
soy products can provide high quality protein needed for growth and tissue maintenance
avoid fad diets that purport that one type of food is bad – variety is the key!
Reference: AHA Dietary Guidelines Revision 2000: A statement for healthcare professonals from the nutrition committee of the American Heart Association.
EXERCISE
Epidemiology
25% of population exercise regularly, 50% occasionally, 25% sedentary
1/3 of Canadians watch > 15 hours of TV/week
daily physical activity decreases with age to middle adulthood, then increases
physical activity reduces morbidity and mortality for CAD, hypertension,
obesity, diabetes, osteoporosis, mental health disorders
moderate activity: activities that can be comfortably sustained for at least
60 minutes (walking, slow biking)
vigorous activity: activities of an intensity sufficient to result in fatigue
within 20 minutes (running, shoveling snow)
History
assess current level of fitness, motivation and accessibility to exercise
medical screen
• age
• previous level of activity
• current medications
• diuretics affect potassium levels
• anticholinergics increase body temperature
• insulin can cause hypoglycemia
• cardiovascular risk factors
• CBC, blood sugar, cholesterol, urinalysis, stress ECG test
contraindications: recent MI, conduction abnormalities

. . . CONT.
Management
emphasize benefits of exercise
• increases energy level, strength and flexibility
• improves cardiovascular and metabolic functions
• increases glucose tolerance
• increases feeling of well-being and sex drive
• improves quality of sleep
• decreases depression/anxiety
types of exercise
• emphasize regular, moderate-intensity physical activity
• encourage a variety of self-directed activities (walking/cycling to work, climbing the stairs, raking leaves)
• over several months, progress to level of activity that includes cardiovascular fitness;
development of muscular strength and joint flexibility is also desirable
• aerobic activity involving large muscle groups for 50-60 minutes at
least 3-4 times a week at 60-80% of maximum heart rate
• maximum heart rate = 220 – age (men), 226 – age (women)
• 5-10 minute stretching routine decreases musculoskeletal injuries
Table 2. Target Heart Rate

Age 60% of Max. (beginner) 70% of Max. (intermediate) 80% of Max. (advanced)
20-29 120 140 160
30-39 114 133 152
40-49 108 126 144
50-59 102 119 136
60-69 96 112 128
70-79 90 105 120
Note: If bicycling, subtract five beats from target; if swimming, subtract ten.
STRESS MANAGEMENT
steps to manage stress
• identify sources of stress and make a list
• modify environment/events to decrease stress
• develop coping strategies
• biofeedback, meditation, mental imagery, hypnosis, diaphragmatic breathing, progressive
muscle relaxation, psychotherapy
• focus on goal achievements and personal well-being
• give positive feedback and rewards
for hypertensive patients, individualized cognitive-behavioural interventions are best
END OF LIFE CARE

Domains of Quality End-of-Life Care from Patients’ Perspectives
1. Receiving adequate pain and symptom management
2. Avoiding inappropriate prolongation of dying
3. Achieving a sense of control over end-of-life care decisions
4. Relieving burden on loved ones
5. Strengthening relationships
MD’s Role
to provide adequate pain/symptom management
to offer/suggest: DNRs, advanced directives, care-giver respite, family
supports, patient/family community resources
Principles of Pain Management
general
• commit to providing effective pain control
• educate the patient, family and other caregivers of the plan
• understand the patient's physical, psychological, social and spiritual
beliefs about pain control and dying
• remain flexible to the requests of the patient with respect to alternative/complimentary therapy
• limit investigations to those that will make a difference in management decisions
• do not delay in treating pain

. . . CONT.
analgesic therapy
• hierarchy
• non-opioid ± adjuvant;
• opioid + non-opioid ± adjuvant;
• opioid ± non-opioid ± adjuvant
• progress through hierarchy until pain is relieved
• give po medication where possible (less cumbersome to manage,more patient freedom)
• give regular interval dosing to maintain levels - avoid prn's
• ensure coverage for breakthrough pain
• anticipate and prevent adverse effects
• treat non-pain symptoms (nausea, vomiting, constipation) aggressively
• consider adjuvant therapies (i.e. radiation, surgery, chemotherapy) at regular intervals
monitoring
• monitor frequently - timing depends on severity of pain
• maintain direct communication with other providers (home nursing, physiotherapy)
Reference: Librach SL, Squires BP, The Pain Manual. Principles and Issues in Cancer Pain Management. Toronto: Pegasus Healthcare International. 1997.
COMPLEMENTARY THERAPIES
knowledge of complementary therapies can improve
• communication with patients who choose these therapies
• co-ordination of care
• the well-being of patients through appropriate use of these therapies
many types exist, including (among others): chiropractic, acupuncture, naturopathy, homeopathy,
mind-body therapies, bodywork, reflexology, applied kinesiology, herbal remedies, traditional
Chinese medicine
Herbal Medications
questions to ask patients who may be taking herbal products
• Are you taking an herbal product, herbal supplement or other “natural remedy”?
• If so, are you taking any prescription or nonprescription medications for the same purpose
as the herbal product?
• Have you used this herbal product before?
• Are you allergic to any plant products?
• Are you pregnant or breast-feeding?
Table 3. Common Herbal Medications

Common Name Reported Uses (not necessarily Possible Adverse Effects Possible Drug Interactions
effective)
Aloe Vera strong laxative, topical: used for burns intestinal obstruction, Crohn's, K-dependent cardiac drugs
in children or in pregnancy
Chamomile common cold, GI spasm, heartburn, rare sensitization, emesis, anaphylaxis delayed GI drug absorption
colitis, IBS possible
Evening Primrose CNS stimulant, decongestant, headache, restlessness, tachycardias, cardiac glycosides MAOIs
bronchospasm hyperglycemia, diuresis
Echinacea boils, erysipelas, septicaemia, cancer, rare sensitization potentiates warfarin
syphilis, common cold, flu
Garlic migraine, arthritis, allergies, and heart rate, mouth ulcers, potentiates antithrombotic
antipyrexia muscle stiffness medications
Ginger elevated lipids, high blood pressure, can increase bleeding time, gastric potentiates warfarin, aspirin
high serum glucose irritation, halitosis
Ginkgo energy enhancer aggressive behaviors, headache, potentiates CNS stimulants
menstrual abnormalities .
Goldenseal slows cognitive deterioration in some platelet aggregation inhibition anticoagulants, MAOIs
dementia
Marijuana reduces cognitive function, ocular panic, confusion, anxiety, psychosis, antagonizes methylcholine
pressure, bronchodilator, mild exaggerated apprehension of sensory
appetite stimulant and antiemetic stimuli, SVT, ovulatory dysfunction
effects, esp. against methotrexate
therapy
Psyllium stabilizes diarrhea, relieves avoid in intestinal stricture, ileus, or delayed GI drug absorption
constipation, lowers cholesterol obstruction
St. John’s Wort mild to moderate depression, increased photosensitivity, headache, MAOIs, BCP
seasonal affective disorder nausea and dizziness
Valerian hypnotic without residual a.m. headache, palpitations, paradoxical other sedatives
sedation, anxiolytic insomnia

COMMON PRESENTING PROBLEMS
ALCOHOL
DEFINITION
one standard drink = 13.6 g of absolute alcohol
• beer (5% alcohol) = 12 oz
• wine (12-17%) = 5 oz
• fortified wine = 3 oz
• hard liquor (80-proof) = 1.5 oz
diagnostic categories occur along a continuum
• abstinence
• low-risk drinking
• 2 drinks/day maximum
• 9 drinks/week maximum for women, 14 drinks/week maximum for men
• at-risk drinking
• consumption above low-risk level but no alcohol-related physical or social problems
• problem drinking
• consumption above low-risk level with one or more alcohol related physical or social
problems but no clinical features of established alcohol dependence
• alcohol dependence
• DSM-IV criteria of 3 or more of the following in the same 12-month period
• tolerance
• withdrawal
• alcohol consumed in larger amounts or over a longer period of time than intended
• persistent desire or unsuccessful efforts to decrease alcohol use
• great deal of time spent obtaining, using or recovering from alcohol
• neglecting important activities (social, job, recreational) because of drinking
• continued consumption despite knowledge of alcohol-related physical or
social problems
EPIDEMIOLOGY
10-15% of patients in family practice are problem drinkers
over 500,000 Canadians are alcohol-dependent
10% of all deaths in Canada are alcohol-related
overall cost > 5 billion dollars in Canada
most likely to miss diagnosis in women, elderly, patients with high socioeconomic status
HISTORY
assess drinking profile
• setting, time, place, occasion, with whom
• pressures to drink: internal and external
• impact on: family, work, social
• quantity-frequency history
• how many drinks per day?
• how many days per week?
• maximum number of drinks on any one day in the past month?
rapid screen
• Do you think you have a drinking problem?
• Have you had a drink in the last 24 hours?
CAGE questionnaire to screen for alcohol abuse
• 2+ for men, 1+ for women: sensitivity 85%, specificity 89%
• Have you ever tried to Cut down on your drinking?
• Have you every felt Annoyed by others telling you to cut down?
• Have you ever felt Guilty about your drinking?
• Have you ever had to have an E ye-opener in the morning?
medical presentations of alcohol problems
• trauma
• GI: gastritis, dyspepsia, recurrent diarrhea, bleeds, oral/esophageal cancer, pancreatitis, liver disease
• cardiac: hypertension, alcoholic cardiomyopathy
• neurologic: Korsakoff’s/Wernicke’s encephalopathy, peripheral neuropathy
• hematologic: anemia, coagulopathies
• other: insomnia, social/family dysfunction, sexual problems
if identified positive for alcohol problem
• identify other drug use
• identify medical/psychiatric complications
• ask about substance abuse among family members
• ask about drinking and driving
• ask about past recovery attempts and current readiness for change

ALCOHOL. . . CONT.
Table 4. Distinguishing Problem Drinking from Severe

Alcohol Dependence
Clinical Feature Problem Drinking Alcohol Dependence

withdrawal symptoms no often
amount consumed weekly more than 12 more than 60
drinks moderately (< 4 daily) often rarely
social consequences none or mild often severe
physical consequences none or mild often severe
socially stable usually often not
neglects major responsibilities no yes
Source: Kahan, M. in Canadian Family Physician 1996, Vol. 42, pg. 662
INVESTIGATIONS
GGT and MCV for baseline and follow-up
AST, ALT, platelets (thrombocytopenia)
MANAGEMENT
brief physician-directed intervention for problem drinkers
• review safe drinking guidelines
• compare consumption to Canadian norms
• offer information on health effects of drinking
• have patient commit to drinking goal
• review strategies to avoid intoxication (e.g. alternate alcoholic with non-alcoholic drinks,
avoid drinking on empty stomach, start drinking later in evening, sip do not gulp;
keep a glass of non-alcoholic drink in your hand)
• keep daily record of alcohol consumption
• have regular follow-up
• refer for further treatment if problem persists
Alcoholics Anonymous
• outpatient/day programs for those with chronic, resistant problems
• in-patient program if
• dangerous or highly unstable home environment
• severe medical/psychiatric problem
• addiction to drug that may require in-patient detoxification
• refractory to other treatment programs
• family treatment (Al-Anon, Al-A-Teen, screen for spouse/child abuse)
pharmacologic
• Diazepam for withdrawal (see Psychiatry Chapter for loading protocols)
• Disulfiram (Antabuse)
• blocks conversion of acetaldehyde to acetic acid (which leads
to flushing, headache, nausea, hypotension, hyperventilation,
anxiety if alcohol is ingested)
• Naltrexone
• competitive opioid antagonist that decreases cravings, mean drinking days and relapse rates
• note: prescription opioids become ineffective and can trigger withdrawal in
opioid-dependent patients
PROGNOSIS
relapses are common and should not be viewed as failure
monitor regularly for signs of relapse
25-30% of abusers exhibit spontaneous improvement over 1 year
60-70% of individuals with jobs and families have an improved quality of
life 1 year post-treatment
Reference: Kahan, M. (in Canadian Family Physician 1996, Vol. 42, pg. 662)

ANXIETY
SCREENING QUESTIONS
if positive answers, follow up with symptom-specific questions (See Table 5)
• Have you felt unusually worried about things recently?
• Do you tend to be an anxious person?
• Have you ever felt like something bad was going to happen?
to differentiate anxiety disorders, consider symptoms and their duration
HISTORY
associated symptoms (see Table 5)
risk factors: family history of anxiety or depression, past history of anxiety, stressful life event,
isolation, gender (women)
rule out
• cardiac (post MI, arrhythmias)
• hyperthyroidism
• diabetes
• COPD
• asthma
• somatoform disorders
• psychotic disorders and medications (amphetamines, theophylline, thyroid preparations,
diet pill abuse or withdrawal from alcohol, benzodiazepines, street drugs)
assess substance abuse, comorbid depression, suicidal ideations
Table 5. RED FLAGS for Detection of Anxiety Disorders in Primary Care
Symptom Screening Question
Anxiety/worry Have you felt more worried than usual
Do you experience episodes of intense worry? (Does the worry have a particular focus?)
Do you feel your level of anxiety is excessive?
Phobias Do you avoid or fear social situations?
Are there any specific things that you fear or avoid?
Do you feel the fear is excessive?
Obsessions Do any repetitive intrusive thoughts bother you?
Compulsions Do you do anything repetitively?
Irritability Have you or your family noticed that you have been more irritable?
Sleep Disturbance Have you had difficulty falling asleep or staying asleep?
Do you find that you’re easily fatigued?
Do you have difficulty concentrating?
Do you find your mind going blank?
Autonomic Hyperactivity Have you experienced: dizzy spells/hot flashes/chills/nausea/diarrhea?
Appetite Disturbance Have you lost your appetite?
Traumatized Do you have recurrent upsetting memories of an event that made you feel frightened
or helpless?
Motor Tension Have you felt agitated or on edge?
Chronic Somatization Have you experienced repeated non-response to treatment?
Dermatological Problems Have you had any skin problems for a prolonged period of time?
Large Medical Chart Chronic, frequent users of medical system
Adapted from: From Anxiety Review Panel. Evans M, Bradwejn J, Dunn L (Eds.). Guidelines for the Treatment of Anxiety Disorders in Primary Care.
Toronto: Queen’s Printer of Ontario. 2000: 39.
TREATMENT (see Psychiatry Chapter)

ANXIETY. . . CONT.
Figure 1. Differentiating Anxiety Disorders

From Anxiety Review Panel. Evans M, Bradwejn J, Dunn L (Eds.). Guidelines for the Treatment of Anxiety Disorders in Primary Care. Toronto: Queen’s Printer of
Ontario. 2000: 41.
BRONCHITIS
ACUTE BRONCHITIS
Epidemiology
most frequent LRTI in adults (especially in winter months)
80% viral: rhinovirus, coronavirus, adenovirus, influenza
bacterial: M. pneumoniae, C. pneumoniae, S. pneumonia
Differential Diagnosis
asthma
URTI
occupational exposure
chronic bronchitis
sinusitis
pneumonia
allergic aspergillosis
reflux esophagitis
CHF
bronchogenic CA
other aspiration syndromes
Diagnosis
definition: acute respiratory tract infection where cough (+/– phlegm) is the predominant feature
symptoms
• productive cough (especially at night) and wheezing (most common symptoms)
• dyspnea, recent URTI
• substernal chest pain with cough, deep respiration and movement
• ± mild fever
signs
• purulent sputum (the result of either viral or bacterial etiologies)
• rhonchi, wheezing, prolonged expiratory phase
• ? pneumonia if crackles, chills, fever or toxic
investigations (acute bronchitis is typically a clinical diagnosis)
• r/o pneumonia and CHF with CXR if abnormal vitals (HR > 100 bpm, RR > 24, T > 38)
• r/o asthma if repeated/prolonged, with methacholine challenge test or bronchodilator
improved symptoms
• sputum smear/culture = non-informative
BRONCHITIS . . . CONT.
Management for Uncomplicated Acute Bronchitis
applies to immunocompetent adults without comorbidities (e.g. COPD, CHF)
rule out serious illness (pneumonia) 4
• in healthy, nonelderly adults, pneumonia is rare in the absence of abnormal vital signs or
asymmetrical lung sounds (no signs of focal consolidation i.e. rales, egophony, fremitus)
• CXR warranted if: cough lasts 3 weeks or longer, abnormal vital signs present,
signs of focal consolidation present
no current evidence for routine antibiotic treatment for acute bronchitis regardless of duration of cough 3,4
• no consistent impact on duration or severity of illness or complications from bronchitis with
antibiotic treatment
• if pertussis infection suspected (if persistent cough (> 2-3 weeks) and exposure),
perform diagnostic test and start antimicrobial therapy to reduce shedding of
pathogen and spread of infection
patient satisfaction with care depends most on physician-patient communication rather than
antibiotic therapy 4
• discuss lack of benefit of antibiotic treatment for uncomplicated acute bronchitis
• set realistic expectations for the duration of patient’s cough (10-14 days from office visit)
• refer to the cough illness as a “chest cold” rather than bronchitis
• personalize the risk of unnecessary antibiotic use: increased likelihood of infection
with antibiotic resistant bacteria, side effects (GI), rare anaphylaxis
primary prevention through risk factor reduction is important: smoking cessation, reduction of
irritant exposures
symptomatic relief: rest, fluids, antipyretics, antitussives
frequent bronchial hyperresponsiveness in patients with uncomplicated acute bronchitis:
RCTs show consistent benefit of albuterol therapy for uncomplicated acute bronchitis
in reducing duration and severity of symptoms 4
treatment with antibiotics if elderly, comorbidities exist, pneumonia/toxic is suspected
• 1st line: tetracycline 250 mg qid or, erythromycin 1 g divided bid, tid or qid
• 2nd line: doxycycline 100 mg bid for 1st day then 100 mg od, or clarithromycin 250-500 mg bid,
or azithromycin 500 mg x1 then 250 mg od x4
Reference
1. Hueston WJ, Mainous AG. Acute bronchitis. American Family Physician. March 15, 1998. Vol 57. Pg 1270-9.
2. Ontario Anti-infective Review Panel, Toronto Canada, Anti-Infective Guidelines for Community-acquired Infections, 2nd Ed., 1997.
3. Orr PH, Scherer K, Macdonald A, Moffatt MEK. Randomized placebo-controlled trials of antibiotics for acute bronchitis: A critical review of the literature.
The Journal of Family Practice 1993;36:507-512.
4. Gonzales R, Bartlett JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Emerg Med.
2001 Jun;37(6):720-7.
ACUTE EXACERTABIONS OF CHRONIC BRONCHITIS (A.E.C.B.)

defined clinically as excessive cough, productive of sputum on most days,
for at least 3 months a year during at least two consecutive years
most common cause = cigarette smoking
Treatment
50% of A.E.C.B. is non-bacterial; use of antimicrobials controversial
with mild-moderate clinical presentation (limited underlying lung disease)
• 1st line: Tetracycline 250 mg qid or TMP/SMX 1DS tab bid or Amoxicillin 500 mg tid
• 2nd line: Doxycycline 100 mg bid first day then 100 mg daily or Azithromycin 500 mg first day
then 250 mg daily x 4 days
with severe clinical presentation (extensive underlying lung disease and/or
other risk factors including age > 65 years, comorbidities such as CHF, DM, CRF)
• 1st line: TMP/SMX 1 DS tab bid or Amoxicillin/Clavulanate 500 mg tid or
Cefaclor 250-500 mg tid or Cefuroxime AX 250 mg - 500 mg bid +/– Erythromycin 1 g/day
in divided doses; or Azithromycin 500 mg first day then 250 mg daily x 4 days
• 2nd line: Ciprofloxacin 500-750 mg bid
Reference: Ontario Anti-infective Review Panel, Toronto Canada, Anti-Infective Guidelines for Community-acquired Infections, 2nd Ed., 1997.

CEREBROVASCULAR DISEASE
see Neurology Chapter for definitions, vascular territories and treatment details
History
symptoms
risk factors (HTN is most important), head trauma
medications and medical conditions that predispose patient:
hypercoagulable states (i.e. OCP), giant cell arteritis , anti-coagulants, etc.
Physical Examination
note level of consciousness, speech and cognition
blood pressure
complete neurological examination
cardiac exam, carotid bruits
Investigations
lab: CBC, FBS, lipid profile, PT/PTT/INR
cardiac: ECG, echocardiography, holter monitor
carotid doppler
imaging: CT (method of choice in acute situations)
Reference: Smucker WD, Disabato JA, Krishen AE. Systematic approach to diagnosis and initial management of stroke. American Family Physician 1995 July; 52(1):225-34.
CHEST PAIN
see Cardiology Chapter
Table 6. Differential Diagnosis of Chest Pain
Cardiac Non-cardiac
Pulmonary GI MSK/Neuro. Psychologic
Angina Pneumonia GERD Arthritis Anxiety

MI with pleurisy PUD Chondritis Panic
Pericarditis Pneumothorax Rib fractures
Myocarditis PE Herpes Zoster
Aortic dissection Pulmonary hypertension
ISCHEMIC HEART DISEASE

2-part treatment strategy
risk factor modification: multiple risk factors confer multiplicative risk (not merely additive)
• obesity: promote dietary measures to achieve ideal BMI (20-25)
• physical inactivity:encourage moderate exercise 30-60 minutes at least 3x/week
• smoking: encourage smoking cessation therapy using bupropion or a nicotine patch and a
counseling program; note: smoking cessation aids are safe for patients with ischemic heart disease
• diet: a low saturated fat and high fibre diet (B)
• diabetes mellitus: HbA1c < 7%
• hypertension
• dyslipidemia: initiate therapy with HMG CoA reductase inhibitors if
LDL-C is >3 mmol/L (target <2.5 mmol/L)
• age: advancing age should not limit access to use of therapy and
may confer greater benefit
drug therapy
1. disease modifying drugs (reduce mortality): beta-blockers,
antiplatelet agents, ACE inhibitors, lipid modifying drugs
2. symptom modifying drugs: beta-blockers, nitrates, calcium channel blockers

CHEST PAIN . . . CONT.
Stable Ischemic Heart Disease
beta-blocker for all post MIpatients

anti-platelet therapy for al patients
ACEi’s for patients > 55l years old
anti-lipid therapy for patients with dyslipidemia
symptoms persist
add beta-blocker (if not already using it) + PRN sub-lingual nitrate
symptoms persist
add nitrate or CCB
symptoms persist
add CCB or nitrate
symptoms persist
consider coronary artery revascularization
Figure 2. Treatment Algorithm for Stable Ischemic Heart Disease

Adapted from: Ontario Drug Therapy Guidelines for Stable Ischemic Heart Disease in Primary Care. Ontario Program for Optimal Therapeutics. Toronto: Queen’s Printer of
Ontario: 2000, 10.
COMMON COLD (ACUTE RHINITIS)

EPIDEMIOLOGY
leading URTI; peaks in winter months
incidence: adults = 2-4/year, children = 6-10/year
organisms: mainly rhinoviruses; others: adenovirus, RSV, influenza, parainfluenza
• incubation = 1-5 days
• transmission: hand contact with agent; can survive on objects/skin
PREVENTION
avoid contacts; frequent hand washing; avoid hand to mucous membranes
DIAGNOSIS
history
• prior episodes, treatments, smoking history, epidemics, sick contacts
• respiratory tract symptoms
• otalgia, facial/dental pain, hoarseness, sputum, dyspnea, wheezing
symptoms
• local - sneezing, congestion, rhinorrhea, sore throat, non-productive cough
• general - malaise, headache, myalgias, mild fever
signs
• boggy nasal mucosa with drip, erythematous nasopharynx, +/– enlarged post lymphoid
tissue and enlarged lymph nodes
• 2˚ bacterial infection: fever, localized pain, productive cough
MANAGEMENT
patient education
• symptoms peak at day 1-3 and usually subside within one week
• cough persists for days to weeks
• no antibiotics indicated because of viral etiology
• 2˚ bacterial infection can present within 3-10 days after onset of cold symptoms
symptomatic relief
• hydration
• relieve congestion: sympathomimetics, decongestants, expectorants
• analgesics and antipyretics: acetaminophen, ASA (not children)
• cough suppression: dextromethorphan or codeine

CONTRACEPTION
see Gynecology Chapter
HISTORY
relationships, sexual history
• presently or previously sexually active?
• consensual?
• number of previous partners?
• age at first intercourse?
contraindications and side effects of contraceptive methods
current and previous methods of contraception, expectations
obstetrical and gynecological history
• age of menarche? cycle length, frequency, regularity, flow? LMP? DUB?
• last pap, any abnormal paps?
• pregnancies and outcomes?
STD history
PHYSICAL EXAMINATION
blood pressure and breast, abdominal and pelvic exams (including pap +/– STD testing if sexually active)
essential
COUNSELLING
benefits and drawbacks of contraceptive methods
• warn patients that the OCP does not protect against STDs; use condom
• benefits of oral contraceptives
• A: anemia decreased
• B: benign breast disease and cysts decreased
• C: cancer (ovarian and endometrial decreased), cycles regulated
• D: dysmenorrhea decreased
• E: endometriosis decreased
how to use contraceptive methods effectively
• how and when to take OCP: wait until next cycle, start pill on first day of next period,
take pill at same time each day, let anyone prescribing medications know that she’s on OCP,
what to do if she misses a pill
role of emergency contraception (differentiate it from abortive methods)
• emergency contraception = “the morning after pill” = Ovral (high dose OCP)
• given only within 72 hours of unprotected intercourse
• take 2 tablets now (with gravol) and again in 12 hours
• counsel re: nausea side effect (gravol, take pills with food); only effective in 75% of cases;
if pregnancy is established, there is no risk of harm to the fetus from having taken these pills
References
1.Heath CC, Sulik SM. Contraception and preconception counselling. PRIM CARE; Clinics in Office Practice, march 1997; 24(1):123-33.
2.Glasier A. Drug Therapy: Emergency Postcoital Contraception. NEJM, Oct. 1997;337(15):1058-1064.
DEPRESSION
see Psychiatry Chapter
lifetime risk of Major Depressive Disorder = 10-25% for women and 5-12% for men
often presents as nonspecific, vague complaints; 85% of cases may go undiagnosed
identification and early treatment improves outcomes
SCREENING QUESTIONS
are you depressed? - high specificity and sensitivity
do you have problems sleeping? - for those not willing to admit
have you lost interest or pleasure in the things you usually like to do?
if yes to screening questions, continue with diagnostic criteria questioning regarding symptomatology
RISK FACTORS FOR DEPRESSION
chronic medical illness
comorbidity with other psychiatric disorders (e.g. 70% co-exist with anxiety)
family history or personal history of depression
stressful life event
increased burden of determinant of health (e.g. poverty)
isolation
RELATED ISSUES
suicidality and homicidality
functional impairment (e.g. work, relationships, etc.)
patient initiated self-treatment
temporal relationships (e.g. seasonal, chronic, etc.)

DEPRESSION . . . CONT.
TREATMENT
phases of treatment
• acute phase (6-12 weeks): relieve symptoms in all patients
• continuation phase (4-9 months): prevent relapse in all patients
• if maintenance is not required, taper meds over 1-2 months and observe for 6 months
• maintenance phase (> 1 year): to prevent recurrence in some patients (those with recurrent course,
severe episode with suicide attempt, chronic duration of episode)
RISK OF RECURRENCE
after 1 depressive episode = 50%
after 2 depressive episodes = 70%
after 3 depressive episodes = 90%
Reference: Guidelines for the diagnosis and pharmacological treatment of depression: 1st edition revised. CANMAT, 1999.
DIABETES MELLITUS
DEFINITION
diabetes mellitus is a metabolic disorder characterized by the presence of
hyperglycemia due to defective insulin secretion, insulin action or both
associated with significant long term sequelae; damage to various organs,
especially the kidney, eye, nerves, heart and blood vessels
CLASSIFICATION AND EPIDEMIOLOGY
major health concern, personally affecting up to 10% of Canadians
leading cause of new-onset blindness and renal dysfunction
Type 1: autoimmune destruction of pancreatic beta-cells and prone to ketoacidosis
• 10-15% of DM, peak incidence age 10-15
Type 2: ranges from insulin resistance with relative insulin deficiency to predominant
secretory defect with insulin resistance
• 85-90% of DM, peak incidence age 50-55
• risk factors: family history, obesity, prior GDM, age > 40
gestational: diabetes first recognized during pregnancy
DIAGNOSIS
Diabetes Mellitus
persistent hyperglycemia is the hallmark of all forms of diabetes
diagnosis of diabetes mellitus:
• symptoms of diabetes (fatigue, polyuria, polydipsia, unexplained weight loss)
plus a casual PG value ε 11.1 mmol/L
OR
• a fasting plasma glucose (FPG) ε 7.0 mmol/L
OR
• a fasting plasma glucose in the 2-hour sample of the oral glucose challenge test
(OGTT)ε 11.1 mmol/L
in all cases, a confirmatory test must be done on another day in the absence of
unequivocal hyperglycemia accompanied by acute metabolic decompensation
Impaired Fasting Glucose (IFG)
FPG 6.1-6.9 mmol/L
Impaired Glucose Tolerance (IGT)
PG 2 h after 75 g glucose load 7.8-11.0 mmol/L
SCREENING
GDM
all pregnant women between 24 and 28 weeks gestation, with the exception of those in a very
low risk group (lean Caucasian women < 25 years with no personal or family history of diabetes
or large babies)
Type 2 Diabetes
mass screening for type 2 DM is not recommended
FPG q3 years in those > 45 years
more frequent or earlier testing (or both) if:
• a first degree relative with DM
• member of a high risk population (eg. Aboriginal, Hispanic, Asian and African descent)
• HDL δ 0.9 mmol/L
• fasting TGs > 2.8 mmol/L

DIABETES MELLITUS. . . CONT.
annual testing considered if
• history of IGT
• presence of complications associated with DM
• history of GDM or baby with birth wt over 4 kg
• presence of HTN, presence of CAD
MANAGEMENT
General Goals of Therapy
to avoid the acute complications (e.g. ketoacidosis, hyperglycemia, infection)
to prevent long-term complications
• microvascular: nephropathy, retinopathy, neuropathy
• macrovascular: CAD, atherosclerosis, peripheral vascular disease
to minimize negative sequelae associated with therapies (e.g. hypoglycemia, weight gain)
Specific Goals of Therapy
fasting or pre-meal glucose
• optimal (target goal): 4-7 mmol/L
• suboptimal (action may be required): 7.1-10.0 mmol/L
• inadequate (action required): >10.0 mmol/L
HbA1c
• optimal: < 0.07
• suboptimal: 0.07 – 0.084
• inadequate: > 0.084
blood pressure
• adults: < 130/80
• children: corresponding age-adjusted 90th percentile values
lipids
• LDL cholesterol δ 2.5 mmol/L
• total cholesterol: HDL ratio < 4
• triglyceride level < 2.0 mmol/L
Assessment and Monitoring
initial assessment
• medical history: symptoms, past history, functional inquiry, family history, risk factors,
social factors, medications, lifestyle
• social and psychological factors: support, finances, insurance
• physical exam to monitor eye, thyroid, kidney, foot, nerve, cardiac, and vascular complications
• FPG, HbA1c, urinalysis, BUN, creatinine, plasma lipids, ECG, urine dip for proteinuria
• ophthalmology consult (type 1 within 5 years, type 2 at diagnosis)
• counselling
• monitoring: methods, frequency, quality control
• hypoglycemia: awareness, symptoms, frequency, treatment, prevention
• antihyperglycemic medications: oral agents, insulin; type, dose, self-adjustments
q2-4 months
• history
• diabetes directed history: lifestyle, activity, glucose monitoring, hypoglycemia
(awareness and frequency), use of insulin and oral agents
• assess progress toward decreasing long term complications
• physical: blood pressure, foot exam
• investigations: HbA1c q2-4 mo and FPG as needed
• adjust treatment plan if necessary
annually
• calibrate home glucose monitor
• complete neurological exam (and rest of physical examination as per PHE)
• ophthalmology consult
• dipstick analysis of screen for gross proteinuria
• if negative, microalbuminuria screening with a random daytime urinary
albumin:creatinine ratio yearly in Type 2; yearly after 5 years, post-pubertal in Type 1
• if positive, a 24 hour urine test for endogenous creatinine clearance rate
and microalbuminuria every 6-12 months
• fasting lipid profile including total, HDL, LDL cholesterol and TG levels
• resting or exercise ECG if appropriate (age > 35 years)
Nonpharmacologic Management
diet
• all people with DM should see a registered dietician
• strive to attain healthy body weight
• avoid simple sugars; encourage complex carbohydrates
• decrease saturated fat to <10% of calories
physical activity and exercise
• promotes CV fitness, increased insulin sensitivity, lower BP and improved lipid profile

DIABETES MELLITUS. . . CONT.
Pharmacologic Management
see Endocrinology Chapter for details
type 1 DM
• aim for optimal glucose levels
• multiple daily injections (3 or 4 per day) or the use of continuous subcutaneous insulin infusion
(CSII) usually required
• elevated microalbuminuria (30-299 mg albumin in 24 h) or overt nephopathy (> 300 mg albumin
in urine in 24 h) should be treated with an ACE inhibitor even in the absence of HTN
type 2 DM
• stepwise approach
• for those with a high degree of hyperglycemia (FPG > 10 mmol/L), metformin or a sulfonylurea
may be chosen as a first agent
• metformin is associated with less weight gain and less hypoglycemia that sulfonyureas but GI side
effects may be a limiting factor and it is contraindicated with significant renal or hepatic insufficiency
• advance to next level if glycemic goals are not achieved within 2-4 months
• ACE inhibitors are recommended for all hypertensive type 2 patients; normotensive
patients with elevated microalbuminuria may also benefit from ACE inhibitor therapy
References
1998 clinical practice guidelines for the management of diabetes in Canada. Supplement to CMAJ 1998: 159 (8 Suppl).
Report of the Working Group on Hypercholesterolemia and other Dyslipidemias. Recommendations for the management and treatment of dyslipidemia. CMAJ May 16,
2000; 162 (10).
Ontario Program for Optimal Therapeutics. Ontario guidelines for the pharmacotherapeutic management of diabetes mellitus. Fall 2000.
DIZZINESS
EPIDEMIOLOGY
1% of patient visits
frequency proportional to age; commonest complaint of ambulatory patients age > 75
Dizziness
Vertigo Nonvertiginous
(Vestibular) (Nonvestibular)
Description: • external world seems to revolve around individual • a “whirling sensation”
or the individual revolves in space • feeling “lightheaded”, “giddy”, “dazed”, or
• an “illusion of motion” “mentally confused”
• a “rocking sensation”
Psychogenic
Central Peripheral • diagnosis of Vascular Ocular
• brainstem • inner ear exclusion
• cerebellar • vestibular nerve
• idiopathic
• Menière’s
• BPV
Etiology: • tumour • tumour • VBI • decreased visual

• stroke • trauma • basilar migraine acuity
• drugs • drugs • TIA
• infection • orthostatic
hypotension
• Stokes Adams
• arrhythmia
• CHF
• aortic stenosis
Figure 3. Differential Diagnosis of Dizziness
DIAGNOSIS
History
define and elaborate
• vertiginous, non-vertiginous, pre-syncopal, pre-ictal
• similar to standing too quickly vs. getting off an amusement ride
• step by step explanation of previous diet, feelings, activities and resolutions
• dizziness diaries - onset, precipitating factors, timing, duration, alleviators
duration
• instant (psychogenic)
• 1 minute (BPV, vascular, vertebral basilar insufficiency)
• minutes to hours (Menière’s)
• days (acute vestibular)
• months to years (psychogenic, CNS, multisensory loss)

DIZZINESS . . . CONT.
exacerbations
• worse with head movement or eye closure (vestibular)
• no change with head movement and eye closure (nonvestibular)
associated symptoms
• neurologic
• transient diplopia, dysphagia, ataxia (TIA, VBI, arrhythmias)
• persistent sensory and/or motor deficits (CV, CNS)
• audiologic
• hypoacusia, tinnitus, otalgia (labyrinthitis, Menière’s, ototoxicity, tumour)
• non-specific
• nausea, vomiting (usually peripheral; not central)
Physical Exam/Investigations
syncopal
• O/E: cardiac, peripheral vascular, neurologic
• ECG, 24h Holter, treadmill stress test, loop ECG, tilt table testing, carotid doppler, EEG
vertiginous
• O/E: ENT, neurologic
• Dix-Hallpike, audiometry, MRI
non-syncopal, non-vertiginous
• Physical ––> cardiac, neurologic
• 3 minute hyperventilation trial, ECG, EEG
MANAGEMENT
see Otolaryngology Chapter
dependent on results of history, physical and investigations
refer when significant central disease suspected or when vertigo of peripheral origin is persistent or atypical
References
1. Ruckenstein MJ. A practical approach to dizziness: Questions to bring vertigo and other causes into focus. Postgrad Med., March 1995;97(3):70-81.
2. Weinstein BE, Devons CAJ. The dizzy patient: Stepwise workup of a common complaint. Geriatrics, June 1995;50(6):42-49.
DOMESTIC VIOLENCE
emotional, physical, sexual, financial abuse
EPIDEMIOLOGY
20-30% of women in clinical setting may be abuse victims
• women at 3x greater risk than males
• 75% of women sexually/physically abused were assaulted by current/former partner,
family member or date
• wife assault is leading cause of homicide for Canadian women
• MD recognition rates as low as 5%
occurs in all socioeconomic, educational and cultural groups with increased incidence in pregnancy,
disabled women, age group 18-24
80% of male batterers were abused and/or witnessed wife abuse in their families as children
67% of battered women witnessed their mothers being abused
30-60% chance of child being involved in homes where spousal abuse occurs
5% of elders abused
EFFECTS OF VIOLENCE
psychological: depression, PTSD, suicide attempts, drug/alcohol abuse
physical: pain, serious bleeding injuries, bruises, welts, burns (electrical, cigarette, acid),
dislocated/broken bones, torn ligaments, perforated eardrums, dental injuries, panic like symptoms
(e.g. headaches, chest pain, palpitations)
• often labeled as panic attacks or "functional"
• injuries often minimized by patient and/or partner; injuries may not fit history
multiple visits to the physician with nonspecific complaints
DETECTION AND MANAGEMENT
S - Screen ALL patients (MD often first person to get disclosure)
• question and examine woman (or man) alone
• ask subtle non-judgmental questions: Sometimes women who present with these symptoms
have difficulty in their relationships: Are you having difficulties?
• ask direct non-judgmental questions: Are you afraid of your partner?
Have you been pushed or shoved?
C - Community resources for the abused should be mobilized/provided
• marital counseling not appropriate until woman is safe and violence is under control
A - Avoid being directive; be supportive and patient
R - Reassure patient they are not to blame and spousal abuse is a crime
• report suspected or known child abuse (mandatory)
• spousal abuse is a criminal act, but not reportable
E - Exit plans should be developed to ensure patient safety
• women most at risk for homicide when attempting to leave home or following separation
D - Document all evidence of abuse (pictures, sketches) and related visits
• quote patient directly in chart
DYSPNEA
see Respirology and Pediatrics Chapters
DEFINITION
abnormal or uncomfortable breathing in the context of what is normal for a given person
DIFFERENTIAL DIAGNOSIS
respiratory: airway disease (e.g. asthma, COPD), parenchymal lung disease (e.g. pneumonia),
pulmonary vascular disease, pleural disease, neuromuscular and chest wall disorders
cardiovascular: elevated pulmonary venous pressure, decreased cardiac output, severe anemia
anxiety/psychosomatic
HISTORY
dyspnea +/– cough, onset, duration, alleviating and aggravating factors
associated symptoms: wheezing, sputum, fever, chills, chest pain, weight loss
smoking, alcohol, allergen exposure
other respiratory problems/medical conditions
current medications and previous treatments
require oxygen? hospitalizations or ICU stay?
determine functional limitation
PHYSICAL
vitals, level of consciousness
respiratory exam: cyanosis, clubbing, signs of respiratory distress,
wheezing, crackles, decreased air entry, increased resonance
"blue bloaters" (chronic bronchitis) and "pink puffers" (emphysema)
cardiovascular exam: peripheral edema, elevated JVP, S3, S4 (cor pulmonale)
INVESTIGATIONS
CBC, differential, oxygen saturation, spirometry, ABG, CXR, ECG, sputum culture
the best tool for early identification of COPD is spirometric screening of high risk patients;
full PFTs are not required
Table 7. Differentiating COPD from Asthma

COPD Asthma
Age of Onset usually in 6th decade any age
Role of Smoking directly related not directly related but has adverse effects
Reversibility of airflow obstruction is chronic and persistent airflow obstruction is episodic and usually
Airflow Obstruction reversible with therapy
Evolution slow, cumulative disabling pattern episodic
History of Allergy infrequent over 50% patients
Symptoms chronic cough, sputum and/or dyspnea dyspnea, chest tightness, wheeze and cough usually intermittent
and of variable intensity
Diffusing Capacity decreased (more so in pure emphysema) normal (for pure asthma)
Hypoxemia chronic in advanced stages not usually present episodic with severe attacks
Spirometry may have improvement with bronchodilators marked improvement with bronchodilators or steroids
but not universally seen
Chest X-ray often normal often normal or episodic hyperinflation;

increased bronchial markings (chronic hyperinflation during asthma attack
bronchitis) and chronic hyperinflation
(emphysema) often co-exist
Adapted from: Canadian Respiratory Review Panel. Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). 1998.

DYSPNEA . . . CONT.
MANAGEMENT
Asthma
environmental control and education (smoking, pets, carpets)
pharmacotherapy
• short term relief: ß2-agonists qid prn
• if using ß2-agonists > 3x/week, need to add regular anti-inflammatory medication
• long term prevention: inhaled glucocorticosteroids are best option for initial anti-inflammatory
treatment (initial daily dose equivalent to 200-1000 µg/day beclomethasone dipropionate,
generally divided bid)
• if asthma control not yet achieved and on moderate doses of steroids (500-1,000 µg/day),
consider addition of other therapy as an alternative to increased doses of inhaled steroids
• e.g. long acting inhaled ß2-agonists, leukotriene receptor antagonists
• severe asthma may require additional treatment with prednisone
always consider aerochamber to optimize drug delivery by puffer
consider turbohaler and disc delivery (powder)
patient should seek medical attention if using bronchodilators > 3-4x/week (unless using for exercise)
or > 3x/day regularly
COPD
prevention of further lung damage
• smoking cessation
• immunization: pneumococcal and influenza vaccines
• avoidance of occupational and air pollutants
pharmocotherapy
• step-wise approach
• if regularly symptomatic: ipratropium bromide 20 ug/puff, 2-4 puffs tid-qid + short acting
ß2-agonist prn; may use combination therapy (Combivent) to simplify treatment
• if using a substantial amount of short acting ß2-agonist or symptoms are greater at night or
early morning: consider long acting ß2-agonist
• if still regularly symptomatic despite maximum bronchodilator therapy, try 2 week oral
corticosteroid trial
• if steroid responder (i.e. improvement in post bronchodilator FEV 1 > 20%),
switch to inhaled corticosteroids to minimize adverse effects
• oxygen
• 2-4 L/min 24 hours a day if PaO2 < 55 mm Hg, O2 saturation
< 90% or PaO 2 55-59 mm Hg and evidence of cor pulmonale
or polycythemia
• use antibiotics in treatment of acute exacerbations of chronic bronchitis
References
1. Canadian asthma consensus report, 1999. CMAJ 1999; 161(11 Suppl).
2. Morgan, WC, Hodge, HL. Diagnostic evaluation of dyspnea. American Family Physician. February 15, 1998.
3. Canadian Respiratory Review Panel. Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). 1998.
DYSURIA
EPIDEMIOLOGY
25% of women experience an episode of acute dysuria per year
second most common cause of physician visits by sexually active women (after URTI)
non-infectious causes: poor hygiene, allergic reaction, chemicals, foreign bodies, trauma
Table 8. Etiology, Signs and Symptoms of Dysuria

Infection Etiology Signs and Symptoms
UTI/Cystitis E. coli, S. saprophyticus, internal dysuria throughout micturition, frequency,
Proteus mirabilis, Enterobacter, urgency, incontinence, hematuria, nocturia, back pain,
Klebsiella, Pseudomonas suprapubic discomfort, low grade fever (rare)
Urethritis C. trachomatis, N. gonorrhea initial dysuria, history of chlamydia/gonorrhea if
herpes, Trichomonas, Candida no vaginal discharge
Vaginitis Candida, Gardnerella, vaginal discharge, irritation, dyspareunia, external dysuria
Trichomonas, C. trachomatis, (when urine comes in contact with inflammation on outside)
atrophic, herpes, condylomata
accuminata, Doderlein’s cytolysis
Pyelonephritis same organisms as cystitis internal dysuria, fever, chills, flank pain radiating to groin,
CVA tenderness

DYSURIA. . . CONT.
INVESTIGATIONS
urine dipstick, R&M, C&S
if vaginal discharge present: microscopy (“wet mount”), KOH test, pH culture for yeast and Trichomonas
endocervical swab for N. gonorrhea and C.trachomatis ; urethral specimen for Chlamydia will increase positive
yield by up to 30%
MANAGEMENT (see Gynecology and Urology Chapter)
UTI/Cystitis
1st line: TMP-SMX double dose BID X 3 days, trimethoprim or nitrofurantoin
2nd line: amoxicillin, ciprofloxacin
pregnant women with bacteruria must be treated even if asymptomatic
Urethritis
gonorrhea: cefixime 400 mg po single dose or ceftriaxone 250 mg IM single dose
chlamydia: azithromycin 1 g po in single dose or doxycycline 100 mg BID X 7 days)
always treat for both and reportable to Public Health
all patients should return 4-7 days after completion of therapy for clinical evaluation
Pyelonephritis
inpatient: ampicillin and gentamicin
outpatient: TMP-SMX, ciprofloxacin, norfloxacin or other fluoroquinolone
FATIGUE
EPIDEMIOLOGY
13% of office visits to family physicians; 20-30% of office visits to primary care physicians
• peaks in ages 20-40
• women 3-4x > men
fatigue of < 6 months duration in adult most commonly has psychosocial causes (up to 80%)
chronic fatigue syndrome (CFS) found in < 5% of cases that present with fatigue
APPROACH
Fatigue < 6 Months Duration (refer to Table 9)
most commonly psychosocial causes, especially work, marital or financial stress, grieving a recent loss,
or history of abuse
physical causes of fatigue are less common than psychosocial causes and can usually be diagnosed
by a focused history and physical examination
laboratory investigations for fatigue should be used only when specific diagnoses, suggested by
history and physical examination, are identified
see guidelines in Table 9 for approach to fatigue < 6 months duration
• guidelines in Table 9 are based on level 3 evidence (descriptive studies and expert opinion);
no level 1 or 2 evidence exists
• these guidelines are intended for adult patients only; in general, children should be investigated
more rigorously
Fatigue > 6 Months Duration
must determine if patient meets criteria for CFS
MANAGEMENT
specific treatment for specific causes
if etiology undetermined (most cases)
• physician support, reassurance and follow-up very important
• behavioural or group therapy
• aerobic exercise program (keep it simple: 30 minutes per day of walking)
• inquire about herbal medications (patients are often embarrassed/intimidated to discuss this subject)
• review all medications, watching for drug-drug interactions and side effects
• prognosis after 1 year, 40% are no longer fatigued

FATIGUE. . . CONT.
Table 9. Guidelines for Investigating Adult Patients with Fatigue of Less
than 6 Months Duration
Investigation Always Perform? Perform only in these situations
Appropriate assessment for presence of anxiety Yes

of depression?
Appropriate assessment of current life stresses and Yes

past trauma and abuse
Focused history and physical with special emphasis on Yes (to determine
medications, existing chronic illnesses, and presence whether lab investigations
of infection, particularly viral are necessary)
Hemoglobin test No • presence of symptoms, e.g. pallor, tachycardia,

dyspnea
• dietary or FHx suggesting risk of anemia
• > age 65*
WBC count No • fever or other evidence of infection

• weight loss, lymphadenopathy
• > age 65*
Erythrocyte sedimentation rate No • evidence of inflammatory arthritis

• concern about occult malignancy
• > age 65*
Electrolytes No • taking meds known to affect electrolytes,

e.g. diuretics, steroids
• indication of medical condition (Cushing’s, Addison’s,
parathyroidism)
Renal function tests (urea, creatinine, urinalysis) No • taking meds known to affect renal function
• signs or symptoms associated with renal disease
(hypertension, edema, pruritus)
Glucose No • history of GDM (women)

• known dx of DM
• polydipsia, polyuria
• unexplained peripheral neuropathy
• > age 65*
TSH No • goiter
• hx of thyroiditis
• symptoms and signs of hypothyroidism
• > age 65*
Chest X-ray No • smoker with cough or hemoptysis (especially if > age 50)
• hx of occupational exposure (e.g. asbestos)
• exposure to tuberculosis
Other investigations • as indicated by history and physical

• weight loss and changes in bowel habits should
prompt GI investigations
* The elderly are not well represented in the literature. The group’s consensus, after consultation with experts in care of the elderly, is to lower the threshold for investigation in this group
Reference: Godwin, M et al. Investigating fatigue of less than 6 months duration. Canadian Family Physician. February, 1999. Vol 45, p 373-379.
CHRONIC FATIGUE SYNDROME(myalgic encephalomyelitis)

Definition (CDC 1994)
presence of unexplained, persistent fatigue, not relieved by rest, which results in occupational,
social and personal difficulties, and with no identifiable medical or psychological cause
concurrent presence of at least four of the following symptoms for a minimum of six months
• impairment of short-term memory or concentration, severe enough to cause a substantial reduction
in the patient’s normal activities
• sore throat
• tender cervical or axillary lymph nodes
• muscle pain, multi-joint pain with no joint swelling or redness
• new headache
• unrefreshing sleep
• post-exertion malaise lasting more than 24 hours
FATIGUE. . . CONT.
fatigue must be a new, not lifelong, condition with a definite time of onset
often first appears as a viral URTI marked by some combination of fever,
headache, muscle aches, sore throat, earache, congestion, runny nose,
cough, diarrhea, and fatigue
Epidemiology
F>>M, Caucasians > other groups, majority in their 30s
proposed causes: likely multifactorial; can include infectious agents and
immunological factors, neurohormonal factors, psychological factors
Approach
full history and physical
mental status examination
no specific laboratory tests that diagnose CFS
initial tests: CBC, ESR, ALT, protein, albumin, ALP, Ca, PO 4 , glucose, BUN, electrolytes,
creatinine, TSH, urinalysis, additional tests as clinically indicated
Differential
physical diagnoses
• anemia, sleep apnea, medications, Hep B and C, orthostatic hypotension, adrenal
function, SLE, narcolepsy, neoplasia, severe obesity, MS, Cushing’s syndrome
psychiatric diagnoses
• EtOH and drug abuse, generalized anxiety, dementia, schizophrenia, compensation syndrome,
bipolar syndrome, eating disorder, personality disorder, major depression, somatoform disorder
Treatment
based on good physician/patient relationship
an understanding physician can limit frequent requests for consultation
and avoid demand for excessive investigations
select medications based on target symptoms, expected side effect
profile, contraindications, patient preference, cost
• muscle pain: TCA, muscle relaxants
• sleep dysregulation: antidepressants and get patient to wake before 10 AM
• depression: antidepressants
• fatigue: no known treatment
Course
3% have complete resolution and 17% have improvement within 18 months
favourable outcomes are seen in the following
• patient attitude
• maintaining employment
• maintaining the greatest number of physical activities possible
• healthy sleep habits; excessive rest should be discouraged
• changes in various habits in order to encourage adjustment to fatigue
• patient's conviction that fatigue is caused by non-organic factors
HEADACHE
ETIOLOGY
see Neurology Chapter
diagnostically and therapeutically useful to divide into primary and secondary
primary headaches
• migraine, tension type and cluster headaches most common
• usually recurrent and have no organic disease as their cause
secondary headaches
• caused by underlying disease, ranging from sinusitis to subarachnoid hemorrhage
RED FLAGS FOR HEADACHE
headache beginning after 50 years of age: temporal arteritis, mass lesion
sudden onset of headache: SAH, mass lesion (esp. posterior fossa)
increasing in frequency and severity: mass lesion, subdural hematoma, medication overuse
new-onset headache in patient with risk factors for HIV infection or cancer: meningitis
(chronic or carcinomatous), brain abscess (including toxoplasmosis), metastasis
headache with signs of systemic illness (fever, stiff neck, rash): meningitis, encephalitis
systemic infection, collagen vascular disease
focal neurologic signs or symptoms of disease (other than aura): mass lesion, AVM, stroke,
collagen vascular disease
papilledema: mass lesion, pseudotumour cerebri, meningitis
headache subsequent to head trauma: intracranial hemorrhage, subdural hematoma,
epidural hematoma, post-traumatic headache

HEADACHE. . . CONT.
EPISODIC TENSION-TYPE HEADACHE
Diagnostic Criteria
A. at least 10 previous headache episodes fulfilling criteria B through D;
number of days with such headaches: less than 180 days per year
B. headache lasting from 30 minutes to 7 days
C. at least two of the following pain characteristics
1. pressing or tightening (nonpulsating) quality
2. mild or moderate intensity
3. bilateral location
4. no aggravation by walking stairs or similar routine physical activity
D. both of the following:
1. no nausea or vomiting (anorexia may occur)
2. photophobia and phonophobia are absent, or one but not the other is present
Management
acute: acetaminophen 500-1,000 mg q4-6h, NSAIDs, muscle relaxants
preventative: ß-blockers, TCA, education, counselling, stress management, exercise, dietary changes
early follow-up to monitor response
CLUSTER HEADACHE
Diagnostic Criteria
A. at least five attacks fulfilling criteria B through D
B. severe unilateral, supraorbital and/or temporal pain lasting 15 to 180 minutes (untreated)
C. headache associated with at least one of the following on the pain side
1. conjunctival injection
2. lacrimation
3. nasal congestion
4. rhinorrhea
5. forehead and facial sweating
6. miosis
7. ptosis
8. eyelid edema
D. frequency of attacks: one attack every other day to eight attacks per day
Management
acute: oxygen 6 L/min for 15 minutes is 70% effective, nasal lidocaine 4% solution intransally
on ipsilateral side
prevention: methylsergide is treatment of choice, corticosteroids, lithium carbonate,
calcium channel blockers, valproic acid
MIGRAINE HEADACHES
85% are common migraine (without aura)
15% are classical migraine (with aura): transient visual or sensory symptoms lasting 10-30 minutes
between prodrome and headache
Diagnostic Criteria for Migraine Without Aura
A. at least 5 attacks fulfilling criteria B through D
B. each attack, untreated or unsuccessfully treated, lasts 2 to 72 hours
C. at least 2 of the following pain characteristics
1. unilateral location
2. pulsating quality
3. moderate or severe intensity
4. pain aggravated by walking up/down stairs or similar routine physical activity
D. during headache, at least one of the following
1. nausea and/or vomiting
2. photophobia and phonophobia
Diagnostic Criteria for Migraine With Aura
A. at least two attacks fulfilling criterion B
B. at least three of the following characteristics:
1. one or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain
stem dysfunction
2. at least one aura symptom develops gradually over > 4 minutes or two or more symptoms
occur in succession
3. no aura symptom lasts more than 60 minutes
4. headache follows aura, wih a free interval < 60 minutes (headache may also begin before
or simultansously with aura)
auras = visual symptoms like fortification spectra (zig zags), scintillating scotoma (spots)
and teichopsia (flashing lights))

HEADACHE. . . CONT.
Triggers
heredity plus environmental: stress, stress let down, fatigue, increased/decreased sleep, fasting,
caffeine, menstruation, ovulation, OCP, EtOH, food with tyramine (cheese), phenylethylamine (chocolate),
nitrites, MSG, weather changes
Physical Examination/Investigations
primary purpose is to identify causes of secondary headache
vital signs (BP and HR), fundoscopy, cardiovascular assessment, palpation of head and face,
complete neurological exam
investigations only if considered to be ominous in nature
Management
reassurance, lifestyle changes, removal of triggers
pharmacotherapy (indicated if headaches threaten to disrupt the ability to function normally)
• mild attacks (minimal disruption to daily activities)
• ASA, ibuprofen, naproxen, no published studies to show acetaminophen works
• moderate attacks (moderate disruption to daily activities)
• NSAIDs: ibuprofen, naproxen
• selective 5-HT receptor agonist: sumatriptan or other tryptan (PO or SC)
(not concurrently or within 24 h of ergotamine or DHE)
• non-selective 5-HT receptor agonist: DHE (SC, IM or IV), ergotamine
(patient specific, some find side effects outweigh benefits)
• severe attacks (complete disruption to daily activities, impaired efficiency and severe discomfort)
• 1st line: DHE (SC, IM or IV), sumatriptan (PO or SC), metoclopramide (IV preferred),
chlorpromazine (IV or IM), prochlorperazine (IV or IM)
• alternate if above ineffective: ketorolac, dexamethasone
• last resort: meperidine
Table 10. Usual Clinical Features
Tension Headache Common Migraine Classic Migraine Cluster Headache
incidence very common common not common uncommon
age of onset 15-40 10-30 20-40
sex bias more females more females mostly males
family history of headache frequent very frequent infrequent
headache frequency variable, can be daily variable, but “never” daily daily during cluster
stress, fatigue, menstruation

triggers stress or fatigue oral contraceptives, certain foods, alcohol, only during cluster
alcohol, weather changes,
lights, odors
onset during sleep extremely rare not uncommon typical
warning none none visual or none

sensory aura
location bilateral, frontal often unilateral, sometimes bilateral unilateral, orbital, temporal, and malar
or nucho-occipital
severity mild to moderate moderate to severe extremely severe
exacerbators stress or fatigue movement, head jarring, head-low position none

concomitants none nausea, sometimes vomiting, photophobia, unilateral suffusion of eye with ptosis and tearing
sonophobia, etc. stuffing and rhinorrhea of ipsilateral nostril
duration of headache hours to days hours to “all day” - seldom more than two days 20-90 minutes
examination during little distress; sometimes mild to severe distress, severe distress, eye changes as noted above
headache tense tender scalp and neck tenderness of scalp arteries
muscles
Table Source: Usual Clinical Features of Headaches, (Sandoz, Headache, 1992 Edition), by John Edmeads
References
1. Edmeads, J. Headache. 1997 edition
2. Randall-Clinch. C. Evaluation of acute headaches in adults. American Family Physician. Vol 63, no 4, February 15, 2001.

HYPERTENSION
EPIDEMIOLOGY
most common outpatient diagnosis (20% of population)
estimated 50% undiagnosed and only 16% have adequate HTN control
risk factors: family history, age, male, obesity, and alcohol/tobacco use
DEFINITION
Table 11. Classification of Blood Pressure
dBP (mmHg)
< 90 normal BP
90 - 104 mild hypertension
105 - 114 moderate hypertension
> 115 severe hypertension
sBP when dBP < 90 mmHg
< 140 normal BP
140 - 159 borderline isolated systolic hypertension
> 160 isolated systolic hypertension
Accelerated Hypertension
significant recent increase in BP over previous hypertensive levels associated with evidence of
vascular damage on fundoscopy but without papilloedema
Malignant Hypertension
sufficient elevation in BP to cause papilloedema and other manifestations of vascular damage
(retinal hemorrhages, bulging discs, mental status changes, increasing creatinine)
not defined by absolute level of BP, but often requires BP of at least 200/140
develops in about 1% of hypertensive patients
Isolated Systolic HTN
sBP > 160 mmHg, dBP < 90 mm Hg
associated with progressive reduction in vascular compliance
risk factor for CVD and IHD
usually begins 5th decade; up to 11% of 75 year olds
ETIOLOGY(see Nephrology Chapter)
essential (primary) hypertension (90%)
• undetermined cause
renal hypertension (5%)
• renal parenchymal disease (3%)
• renovascular hypertension (< 2%)
endocrine (4-5%)
• oral contraceptives (4%)
• primary hyperaldosteronism (0.5%)
• pheochromocytoma (0.2%)
• Cushing’s syndrome (< 0.2%)
• hyperparathyroidism (< 0.2%)
coarctation of the aorta (0.2%)
enzymatic defects
neurological disorders
drug-induced hypertension (e.g. prolonged corticosteroid use)
hypercalcemia from any cause
watch for labile, "white coat" hypertension
DIAGNOSTIC EVALUATION
average of 2 readings where sBP >140 and/or dBP > 90 on three separate visits over 6 months
if BP > 140/90, but < 180/105 at initial visit, four other visits over 6 months necessary to diagnose HTN (B)
patients with target-organ damage can be diagnosed as hypertensive at/after visit 3 (B)
patients presenting as a hypertensive urgency are diagnosed as hypertensive at their initial visit (D)

HYPERTENSION. . . CONT.
Elevated BP at 1st visit
2 more readings at same visit and arrange

3 further visits over 6 months
Search for Target Organ Damage
Review Medical Record AND Diagnostic Tests

Prior to Visit 3
Assess Risk Factors Ask Examine * urinalysis

* age * Hx angina or MI? * cardiovascular * CBC
* male gender * Hx TIA/stroke? system * serum creatinine
* postmenopausal * Hx of peripheral * respiratory system * K+ , Na+
* smoking vascular insufficiency? * neurological exam * fasting serum glucose
* high cholesterol * Hx renal disease? * include fundoscopy * fasting total cholesterol,
* glucose intolerance * Exogenous causes: for retinopathy HDL, LDL, TGs
* LVH > excess EtOH? * standard 12 lead ECG
> OCP? * consider CXR
> conj. estrogens?
> NSAIDs?
BP < 140/90 mmHg on

Last Diagnostic Visit?
YE (< 130/80 for those with DM) NO
S
Target Organ Damage?
Lifestyle modification and/or
NO YE pharmacological therapy
F/U yearly F/U q 4-6 mos
S
Figure 4. Approach to Hypertension
Adapted from: The Canadian Hypertension Society, 1999.
suspect secondary causes and consider further investigations if

• onset of HTN before age 30 or after age 60
• HTN refractory to treatment
• accelerated or malignant hypertension
• suspicious clinical situation
• presence of paroxysmal headache, palpitations and diaphoresis may suggest
pheochromocytoma
• presence of renal bruits may indicate renovascular hypertension
• presence of hypokalemia and hypernatremia may suggest hyperaldosteronism
THERAPEUTIC CONSIDERATIONS
General Considerations
target BP should be < 140/90
• < 130/80 for those with DM
• correction need not be rapid
referral is indicated for cases of refractory hypertension, suspected secondary cause or worsening
renal failure
hospitalization is indicated for malignant hypertension
follow-up
• nonpharmacological
• q 3-6 months
• pharmacological
• q 1 month until 2 BP readings < target
• more often for symptomatic HTN, severe HTN, antihypertensive drug intolerance, target organ
damage
• q 3-6 months once at target BP
Nonpharmacological therapy
smoking cessation
alcohol restriction (C) to low risk drinking guidelines (see Alcohol section)
salt restriction (B) to maximum of 90-130 mmol (3-7 g) per day
saturated fat intake reduction
weight reduction (B) if BMI > 25 (at least 4.5 kg)
regular aerobic exercise (B); moderate intensity, 50-60 min, 3-4x/week
behavioural therapies (B) (see Stress Management section)
potassium/calcium supplements (B) NOT recommended above suggested daily dietary intake
(60 mmol for potassium)
Indications For Pharmacological Therapy
< 60 years of age
• average dBP > 100 mmHg (A) or sBP > 160 mmHg (B)
• average dBP > 90 mmHg with hypertensive target organ damage, diabetes mellitus, renal
disease or cardiovascular disease (A – C)
• average dBP > 90 mmHg with independent cardiovascular risk factors (i.e. family history) (B – D)
> 60 years of age
• average dBP > 105 mmHg (A) or sBP > 160 mmHg (B)
• average dBP > 90 mmHg with hypertensive target organ damage, diabetes mellitus,
renal disease or cardiovascular disease (A – C)
• average dBP > 90 mmHg with independent cardiovascular risk factors (i.e. family history) (B – D)
Reference: McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can J Cardiol 2001 May;
17(5):543-59.
Pharmacological Therapy
patients under 60 years old
• initially: monotherapy with thiazide diuretic (low dose: < 50 mg/d HCTZ) (A), a beta-adrenergic
antagonist (B), an ACE inhibitor (B) or a long acting dihydropyridine CCB (B)
• if partial response: substitute another drug from the above group
• if still not controlled: try other classes of anti-hypertensives in monotherapy or in combination and
search for reasons for poor response to therapy (i.e. noncompliance) (D)
• alpha-blockers are not recommended as first-line agents (A)
patients over 60 years old
• initially: low-dose thiazide diuretic (A), a long-acting dihydropyridine CCB (A) or an ACE inhibitor (B)
• if partial response: substitute another drug from the above group
• avoid hypokalemia in patients taking thiazides
• beta-adrenergic blockers (A) and alpha-blockers (A) are not
recommended as first-line agents for uncomplicated hypertension
• if partial response to monotherapy: combination therapy (D)
• if still not controlled: try other classes of anti-hypertensives (D)
Reference: McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can J Cardiol 2001. May;
17(5):543-59.
for patients with complicated hypertension (those with co-morbidities): choose antihypertensive
agent based on the individual patient (see Figure 5 and Table 12)
Home BP Monitoring
consider if patient is
• suspected to be noncompliant (B)
• has diabetes mellitus (D)
• suspected of having “white-coat hypertension”
consider elevated if home BP > 135/85 (B)
only monitoring devices that have met Association for Medical Instrumentation
OR British Hypertension Society standards should be used (D)
patients should be provided with adequate training (D)
accuracy of home BP monitoring device must be checked regularly against a mercury-column
sphygmomanometer (D)
Ambulatory BP Monitoring
consider for treated patients suspected of having the following symptoms (B)
• “white-coat hypertension” (office induced increased BP)
• symptoms suggestive of hypotension
• fluctuating BP readings
• apparent resistance to drug therapy
only devices that have been validated independently using established protocols should be used (A)
any decision to withhold drug therapy based on ambulatory BP should take into account normal
values for 24 hrs (B), awake ambulating BP and changes in nocturnal BP (A)
Factors Adversely Affecting Prognosis
presence of additional modifiable risk factors
presence of uncontrollable risk factors
• early age of onset, male sex, family history
evidence of target organ damage
malignant hypertension
Reference: Feldman RD, Campbell N, Larochelle P, Bolli P, Burgess ED, Carruthers SG, et. al. 1999 Canadian recommendations for the management of hypertension.
CMAJ 1999;161 (12 Suppl).

able 12. macologic eatment of Hypertension with Co-existing
Condition or Risk Recommended native Not
Ischemic Heart
• Angina/Recent Myocardial ß-blockers, ACE ++ antagonists, eg.
and
CMAJ. 1999; 161 (12 suppl.).

Congestive Heart ACE hydralazine + isosorbide
(thiazide diuretics AII
additive
FM30 – Family Medicine

Peripheral ascular
as for uncomplicated as for uncomplicated ß-blockers (with severe
low dose - ß-blockers without
ACE AII
ß-blockers with ++ antagonists

centrally acting
Diabetes
ACE AII-receptor high dose
ACE inhibitors, ß- -blockers, centrally acting

(with autonomic
With Systolic
low dose
dihydropyridine
2+
antagonist
potassium sparing +
diuretics for patients on ß-
Adapted from: Feldman RD, Campbell N, Larochelle P. et al. 1999. Canadia recommendations for the management of hypertension.
thiazides, but
hyperuricemia is not
labetolol, pindolol, ACE

++ antagonists
(BP > 169/90)
labetalol,
low dose ß-
ACE
Renal ACE inhibitors, dihydropyridine ++ antagonists
diuretics as additive
ISA=intrinsic sympathomimetic
MCCQE 2006 Review Notes

Co-Existing Medical Conditions

and/or Target Organ Damage
Inadequate response or
adverse effects
Partial Partial
Response Response
Not Controlled or
Adverse Effects
Figure 5. Pharmacological Treatment of Hypertension

Adapted from: The Canadian Hypertension Society, 1999.
LOW BACK PAIN

see Orthopedics and Neurosurgery Chapters
DEFINITION
activity intolerance due to lower back or back-related leg symptoms
acute if < 3 month duration
ETIOLOGY
50% of working-age adults, of whom 20% seek medical care
4-5% of primary care visits (lifetime prevalence 90%)
largest WSIB category
most common cause of chronic disability for persons < 45 years old
90% resolve in 6 weeks, 5% become chronic
DIFFERENTIAL DIAGNOSIS
98% mechanical cause (e.g. soft tissue injury, disc injury, spondylosis, spondylolisthesis, fracture, stenosis)
systemic disorder (e.g. malignancy, infection, ostoporosis)
neurologic cause (e.g. myopathy, neuropathy)
referred pain (e.g. perforated ulcer, pyelonephritis, ectopic pregnancy, AAA, hip disorder)
HISTORY
symptoms (pain, numbness, weakness, stiffness), duration, onset
impact on daily function (how long can you sit, stand, walk)
LOW BACK PAIN. . . CONT.
PHYSICAL EXAMINATION
inspection of spine: curvature, posture
palpation: paraspinal, bony tenderness
ROM of back: flexion, extension, lateral flexion, rotation
straight leg raise, femoral stretch (positive if pain at < 70 degrees, aggravated by dorsiflexion of ankle),
crossover pain (straight raise of well limb elicits pain in leg with sciatica)
neurologic exam (muscle strength, circumferential measurement (significant if difference is > 2 cm),
reflexes, sensory exam)
INVESTIGATIONS
routine testing (labs, plain films) not recommended during first month of activity limitation,
except when red flag is noted or physiologic evidence of tissue insult or neurologic dysfunction
CBC, ESR, urinalysis (infection, tumor)
bone scan (infection, tumor, occult fracture)
CT, MRI (neural, soft tissue damage)
MANAGEMENT
provide reassurance and education if no underlying serious condition
• 90% of low back pain will recover spontaneously in 6 weeks
recommend comfort measures
• > 4 days bed rest has potentially debilitating effects and no proven efficacy
• activity alterations to avoid back irritation (lift objects close to body, use soft support placed
at small of back, armrests when sitting)
• encourage return to normal activities as soon as possible
• encourage low-stress aerobic exercise (condition trunk muscles after 2 weeks)
pharmacological
• NSAIDs
• acetaminophen
• NOT muscle relaxants or opiods (poor tolerance, drowsiness)
physical methods
• manipulation of low back during first month of symptoms without radiculopathy
• NO proven efficacy of traction, massage, heat or cold, U/S, cutaneous laser treatment, TENS,
needle acupuncture, injection procedures (with corticosteroids, lidocaine, opiods)
if no improvement after one month of conservative therapy consider further investigations
order x-rays and appropriate labs in presence of any Red Flags
consider surgery when there is clinical evidence of nerve root irritation or neurological deficit after
one month of conservative therapy
RED FLAGS
BACK PAIN
• B: bowel or bladder dysfunction
• A: anesthesia (saddle)
• C: constitutional symptoms/malignancy
• K: chronic disease
• P: paresthesias
• A: age > 50
• I: IV drug use
• N: neuromotor deficits
surgical emergencies
• cauda equina syndrome: fecal incontinence, urinary retention, saddle anesthesia, decreased anal tone
• abdominal aortic aneurysm: pulsatile abdominal mass
medical conditions
• neoplastic (primary, metastatic)
• infectious (osteomyelitis, tuberculosis)
• inflammatory(seronegative spondyloarthropathies)
• metabolic (osteoporosis with fractures, osteomalacia, Paget's disease)
• visceral (prostatitis, endometriosis, pyelonephritis, pancreatitis)
Reference: Acute Low Back Problems Guideline Panel. Acute Low Back Problems in Adults: Assessment and Treatment. American Family Physician
Feb 1, 1995; 52(2): 469-484

MENOPAUSE/HRT
EPIDEMIOLOGY
Canadian female life span = 81.2 years
mean age of menopause = 51.4 years
a woman will spend over 1/3 of her life in menopause
risk of CAD and osteoporosis increases dramatically after menopause
CONTRAINDICATIONS TO HRT
A: acute liver disease/chronically impaired liver
B: bleeding (undiagnosed vaginal)
C: cancer (breast or uterus)
D: DVT (acute vascular thrombosis or thromboembolic disease)
MANAGEMENT
encourage physical exercise and vitamin D/calcium supplements
routine use of HRT still controversial
examples of HRT routines
• cyclic estrogen + progesterone
• continuous estrogen + progesterone
• estrogen ring
• estrogen gel
• raloxifene (SERM)
OBESITY
DEFINITION
obesity is an excess of body fat
body mass index (BMI) = kg/m2 (WHO Classification)
• normal range: 20-25
• overweight: 25-30
• obese: 30-40
• morbidly obese: > 40
BMI has a correlation of 0.7-0.8 with body fat content in adults
waist-hip ratio (WHR) = circumference of the waist divided by the circumference of the hips
• may be a better predictor of the sequelae associated obesity than BMI (central adiposity)
• men > 1.0, women > 0.8, shown to predict complications from
obesity, independent of BMI
EPIDEMIOLOGY
close to 50% of adult Canadians are overweight and ~20% obese
increasing prevalence of childhood obesity in many countries, including Canada and U.S.
(prevalence doubled in the U.S. in the last 20 years)
1/3 of obese individuals binge eat
only 10-15% of population consume < 30% fat
DIAGNOSIS
complete diet history: include past attempts to lose weight, successes, obstacles, goals
calculate BMI and waist-hip ratio (see above)
assess patient's self-image
• does patient feel underweight, overweight, or normal?
• does patient feel that weight interferes with health? with activities?
• screen for eating disorders (see Psychiatry Chapter)
personal/family history of obesity/nutrition problems
• strong genetic component (70-80% risk with 2 obese parents)
review of systems: include sleep habits, apneic spells, OTC medication (e.g. laxatives)
physical exam
• directed at pertinent positives from review of systems
• respiratory capacity
• weight bearing joints
INVESTIGATIONS
discretionary
• fasting fractionated lipid profile
• sleep study
• exercise tolerance testing

OBESITY . . . CONT.
MANAGEMENT
success in weight control occurs when > 50% of weight loss is maintained at one year
• discuss nutrition-related problems
• heart disease, obesity, hypertension, osteoporosis, anemia, dental decay, cancer, gastrointestinal
disorders, respiratory compromise, high lipids, diabetes, sleep apnea, osteoarthritis
use Canada's Food Guide as a teaching guide
counselling on diet (when applicable); stress weight maintenance if currently in healthy weight range
• discourage fad diets: no long-term benefits
• there is no ideal weight, but rather a range of healthy weights
Treatment Approaches
behaviour modification
• very effective, low side effects
• daily records of foods eaten (eating slower and less)
• change environment, preparation styles, etc.
• lose about 0.5 kg/week
• rewards when goal achieved (not food!)
• positive self-affirmation
exercise
• associated with long-term weight maintenance
• 50-60 minutes, 3 times per week
group support
• Weight Watchers, Overeaters Anonymous
• uses behaviour modification
• high attrition rates (up to 80%)
pharmacological
• sibutramine (Meridia), appetite suppressant; inhibits NE and 5-HT reuptake; not associated with
primary pulmonary HTN or heart valve abnormalities
• orlistat (Xenical), reduces fat absorption; pancreatic lipase inhibitor
surgery
vertical band gastroplasty and gastric bypass
NATURAL HISTORY
obesity is a chronic problem, refractory to most treatments
after 5 years, < 30% of patients maintain > 25% of lost weight
complications of obesity include
• higher incidence of adult-onset diabetes, hypertension, hypercholesterolemia
• increased risk of certain cancers (colon, rectum, prostate, gallbladder, biliary tract, breast, cervix,
endometrium, ovary), cholelithiasis, obstructive sleep apnea, venous thromboembolism,
and osteoarthritis
• lower quality of life by limiting mobility and physical endurance, through social, academic,
and job discrimination
OSTEOARTHRITIS
see Rheumatology Chapter
DEFINITION
condition of synovial joints characterized by focal cartilage loss and an accompanying reparative
bone response
ETIOLOGY
most common joint disease, affects 10-12% of population
age > 65, almost everyone shows signs based on x-ray, but only 33% of these will be symptomatic
age < 45, more frequent in males; age > 55, more frequent in females
primary OA is mostly related to aging (wear-and-tear phenomenon)
causes of secondary OA include obesity, repeated trauma or surgery to joint structures, congenital
abnormalities, gout, diabetes, and other hormone disorders
PATHOPHYSIOLOGY
disease primarily affects cartilage
• progressive breakdown of articular cartilage that lines joint surfaces
• dense, smooth surface bone formation at base of cartilage lesion and formation of osteophytes
at joint margins
multi-factorial disease process (biochemical, biomechanical, inflammatory, immunologic)
SIGNS AND SYMPTOMS
pain with weight bearing, improved with rest
early morning stiffness or gelling
tender to palpation, bony enlargement, crepitus, limitation of movement
pseudolaxity of collateral ligaments develops with degeneration of cartilage
usually affects distal joints of hands and feet, spine, and large weight-bearing joints (hips, knees)
OSTEOARHTRITIS . . . CONT.
INVESTIGATIONS
there are no laboratory tests for the diagnosis of OA
radiographic features:
• joint space narrowing
• subchondral sclerosis
• subchondral cyst formation
• heterotopic ossification (marginal osteophytes)
MANAGEMENT
goals: relieve pain, preserve joint motion and function, prevent further injury and wear of cartilage
biomechanical factors: weight loss, use of canes/crutches, correct postural abnormalities, proper shoe
support, exercise (OT/PT)
pain control
• first choice: acetaminophen 500 mg tid titrated to a maximum dose of 1 g qid
(OA is not an inflammatory disorder)
• then NSAIDs, Naprosyn 500 mg bid or ibuprofen 600 mg qid (does not alter natural course of OA)
• topical analgesics (capsaicin, methylsalicylate creams)
• opiod analgesics in acute flare (codeine)
• then corticosteroid (intra-articular injection may be helpful in acute flares, oral/parenteral therapy
not indicated)
surgery, joint arthroplasty may relieve pain, stabilize joints, improve function; total joint arthroplasty
successful for the knee and hip
chondrocyte harvesting, expansion in vitro, and reimplantation is being investigated
Reference: Ontario Treatment Guidelines for Osteoarthritis, Rheumatoid Arthritis, and Acute Musculoskeletal Injury, June 2000. Ontario Musculoskeletal Therapeutics
Review Panel
OTITIS MEDIA (ACUTE)

see Otolaryngology Chapter
DEFINITION
sudden onset of inflammation of the middle ear associated with an effusion and one or more of the
following: pain, fever, irritability
EPIDEMIOLOGY
most common diagnosis in pediatric age group
most common reason for treatment with antibiotics
peak incidence 6 months to 2 years old
HISTORY
fever, otalgia, ear pulling, otorrhea
vomiting, anorexia, diarrhea, irritability, lethargy
recent URI
PHYSICAL EXAMINATION/DIAGNOSIS
E.M.I.L.Y. Method of TM Examination
E = Where is the Erythema? (be aware of normal areas of erythema
and tympanic flush when child crying)
M = Are the long and short processes of the Malleus visualized?
Is the pars flaccida bulging?
I = Use I nsufflation to detect mobility of tympanic membrane.
L = Is the Light reflex fully visible?
Y = Check the colour on/behind the TM ( Yellow)
ETIOLOGY
bacterial: S. pneumoniae(34%), H. influenza(24%), M. catarrhalis (13%)
viral: RSV, CMV, rhinovirus
MANAGEMENT
antibiotics (treat for 10 days)
• 1st line: amoxicillin, TMP-SMX
• 2nd line: amoxicillin/clavulinate, cephalosporins
• symptoms should resolve within 72 hours
controversy over antibiotic use
• trend exists toward a decrease in antibiotic use
• studies show that 60% of children are pain free within 24 hours of presentation without antibiotic use
• children receiving antibiotics have almost twice the amount of vomiting, diarrhea, and rashes
bacterial and viral vaccines currently being developed

SEXUALLY TRANSMITTED DISEASES
HISTORY
Sexual History
sexually active? types of activities? (oral, anal and/or vaginal intercourse)
at what age did you become sexually active?
sex with men, women or both?
while traveling, were you sexually active with strangers? which countries?
number of partners in the past life/year/month/week? duration of involvement with each?
problems related to sexual activity (dyspareunia, premature ejaculation, obtaining/maintaining an
erection, reaching orgasm, lubrication, premature ejaculation, not interested, being forced)
STD History
are you aware of STDs? ever had one? ever been tested?
contraception history
symptoms such as genital burning, itching, discharge, sores, vesicles
associated symptoms such as fever, arthralgia, lymphadenopathy
last PAP test and results
have you discussed this with your partner?
PATIENTS AT RISK
sexually active males and females < 25 y.o.
most at risk
• contact to known case of STD
• street involved and/or substance use
• unprotected sex
• new or > 2 partners in past 6 mos
• previous STD
ORGANISMS
bacteria:
Chlamydia trachomatis, Neisseria gonorrhoeae
viruses: HSV, HIV, hepatitis A virus, hepatitis B virus, hepatitis C virus (especially IV drug users), syphilis
PREVENTION
counsel regarding the risks of HIV (homosexuality is not a risk factor, unprotected sex and especially
anal sex are risk factors), hepatitis and other STDs
counsel about sexual practices; abstinence, condoms (male/female), immunization against hepatitis A and B
urinate after sexual contact
DIAGNOSIS/INVESTIGATIONS
PHE recommends screening in high risk groups for:
• HIV (A recommendation)
• Gonorrhea(A recommendation)
• Chlamydia (B recommendation)
examine for ulcer/papules
test for HSV if lesions
serology for VDRL, hepatitis B
Females
Males
if mucopurulent discharge and/or presence of dysuria AND/OR Gram stain shows > 4 leukocytes
per oil immersion, test for Gonorrheaand Chlamydia, screen for other STDs
• if > 4 leukocytes per oil immersion field and presence of Gram negative intracellular diplococci,
then treat for Gonorrheaand Chlamydia
• if > 4 leukocytes per oil immersion and NO intracellular diplococci treat only for Chlamydia
• evaluate and treat partners immediately if tests are positive for patient
• follow-up visit: repeat the diagnostic test if symptoms and signs persist
• if abnormalities persist consider other diagnosis (i.e. non-infectious causes, non-bacterial prostatitis)
if clear discharge AND < 4 leukocytes per oil immersion field
• test for Gonorrheaand Chlamydia
• screen for other STDs
• treat depending on result
• evaluate and treat partners of positive cases
• follow-up visit as above
MANAGEMENT
an STD patient is not considered treated until the management of their partner(s) is(are) ensured
Gonorrhea: cefixime 8 mg/kg po x 1 dose (max. 400 mg)
Chlamydia: azithromycin 10-15 mg/kg po x 1 dose (max.1 g)
cefixime and azithromycin preferred for contact management, even in absence of positive tests
and symptoms
genital herpes: 1st episode: acyclovir 400 mg tid 5-7 days; recurrent episode with prodrome:
acyclovir 400 mg tid x 5 days; chronic suppresive therapy: acyclovir 400 mg bid po
syphilis: benzathine penicillin G 2.4 to 7.2 million U im
bacterial vaginosis: metronidazole 500 mg po bid x 7 days
yeast: OTC topical treatment, imidazole or fluconazole 150 mg po single dose
T. vaginalis: metronidazole 2 g po single dose

SKIN LESIONS
see Dermatology Chapter
ETIOLOGY
60% of all cutaneous diagnoses are seen by non-dermatologists
comprises 7% of office visits to family physicians
Top 10 Diagnoses by Family Physicians
dermatitis
• contact/irritant dermatitis
• pruritic, inflammatory reaction that progresses from erythema to vesiculobullous exanthem
• caused by a delayed cellular (type IV) hypersensitivity mechanism
• Tx: symptomatic care (cool water, moisturizing lotion), antihistamines/acetaminophen/ibuprofen
for pruritus
• xerotic eczema (winter itch)
• occurs in the winter and in the elderly on the legs, arms, and hands
• characterized by dry, cracked, fissured skin and pruritus
• Tx: avoid overbathing with soap, room humidifiers, tepid water baths with oils with
application of moisturizing cream after drying, medium-potency corticosteroids applied
BID until eczema clears, topical alpha-hydroxy acids (such as glycolic acid or lactic acid)
• stasis dermatitis
• chronic dermatitis of the lower legs in people with chronic venous insufficiency
• mild pruritus, pain (if an ulcer is present), aching discomfort in the limb, swelling of the ankle,
nocturnal cramps
• atopic dermatitis (infantile eczema)
• see Pediatrics Chapter
pyoderma
viral wart
Tinea (unguis – nails, pedis – foot, cruris – perineum, corporis – body, capitis – scalp)
epidermoid cyst
Candida
acne vulgaris
benign tumors
dermatosis, NOS
actinic keratosis
SLEEP PROBLEMS
DEFINITION
most often characterized by one of three complaints:
• insomnia – inability to initiate sleep or inability to maintain sleep, such as frequent nighttime
or early-morning wakenings
• excessive daytime sleepiness
• parasomnias – unusual occurrences during sleep
insomnia affects 1/3 of population at some time, persistent in 10%
ETIOLOGY
primary sleep disorders
• obstructive sleep apnea, insomnia, restless legs syndrome, narcolepsy
secondary causes
• medical/surgical (COPD, asthma, CHF, hyperthyroidism, chronic pain)
• drugs (EtOH, caffeine, nicotine, beta-agonists, thyroxin, steroids, theophylline)
• psychiatric disorders
• lifestyle factors (shift work)
HISTORY
take thorough sleep history from patient and bed partner
• onset and persistence of symptoms, including any changes over weekends/vacations
• chief sleep symptom (initial insomnia, waking at night)
• medical, job, or stress-inducing events at time of onset and whether these factors have persisted
• presence of medical or psychiatric conditions that could affect sleep
• collateral from bed partner (snoring, movements, apneic episodes, sleep paralysis)
• impact of sleep complaint on patient’s quality of life
• sleep hygiene (regularity of sleep time, sleep environment, use of stimulants such as caffeine, etc.)
• family history of sleep disorders
• treatments attempted and their effectiveness
• drug and alcohol use

SLEEP PROBLEMS . . . CONT.
PHYSICAL EXAMINATION/INVESTIGATIONS
keep sleep log, which tracks time in bed, time asleep, wakenings, etc.
address specific medical problems (CBC with differential, TSH)
sleep study referral if primary cause is suspected (for nighttime polysomnogram or daytime
multiple sleep latency test)
MANAGEMENT
treat and manage any suspected medical cause
promote good sleep hygiene (avoid caffeine, nicotine, EtOH; exercise regularly; use bed only for sex,
sleep, sickness; comfortable sleep environment; go to bed when drowsy)
patients can develop tolerances or dependencies to many of the medicines; pharmacological
interventions should be used for the short term
drug therapies may be periodically changed; patients may take "drug holidays" for one or two weeks
once or twice each year
STRESS-INDUCED INSOMNIA
majority of cases
may persist well beyond the event that brought the onset of the condition
person reacts to the insomnia with fear or anxiety around bedtime or with a change in sleep hygiene
can progress to a chronic disorder (psychophysiological insomnia)
Treatment
improve sleep hygiene (do not use bed for viewing television, eating, or other wakeful activities),
avoid daytime naps, do not lie awake in bed for long periods, avoid caffeine or alcohol
biofeedback and other self-control techniques, including restriction of wakeful time in bed, may be effective
hypnotic agents and TCAs may be appropriate as short-term treatment
PERIODIC LIMB MOVEMENTS OF SLEEP (PLMS)

AND RESTLESS LEG SYNDROME
RLS characterized by an uncomfortable feeling usually in the calves that is relieved by activities such
as walking
RLS is a waking disorder that is almost always accompanied by nighttime PLMS
PLMS (also known as nocturnal myoclonus) is characterized by frequent leg or arm jerks during sleep,
and may occur in the absence of RLS
PLMS sufferers may complain of insomnia or EDS but be unaware of their limb jerks
diagnosis: confirmed by polysomnography
treatment: clonazepam, temazepam
CIRCADIAN RHYTHM DISORDERS
result either from an internal "clock" that is not in sync with society's sleep-wake cycle, or from difficulty
in readjusting the internal clock to changes such as a rapid change in time zones (jet lag)
• e.g. non-24-hour sleep-wake cycle, shift work disorder
treatment: sleep hygiene, "chronotherapy" (sleep is progressively phase delayed until bedtime is at an
acceptable time), bright-light exposure, antidepressants, benzodiazepines, opioids, melatonin(?)
PARASOMNIAS
abnormal occurrences during sleep
may or may not result in complaints of insomnia or EDS
sleepwalking and night terrors (periods of apparently intense anxiety often accompanied by loud cries;
occur while the individual is still asleep and are not associated with specific dreams)
• often seen in children
• usually outgrow the disorder, but may require psychotherapeutic treatment
sleep paralysis
• normally associated with narcolepsy, can occur in non-narcoleptic patients
• can usually be left untreated, but does respond to low dosages of TCAs
EXCESSIVE DAYTIME SLEEPINESS (EDS)
chronic sleep deprivation – may not be getting enough sleep
narcolepsy
• clinical presentation: EDS and unusually early episodes of REM phase during sleep, cataplexy,
sleep paralysis, and hypnagogic hallucinations
• family history is likely
• confirmed by sleep study
• treatment: optimal sleep hygiene and scheduled daytime naps, CNS stimulants for EDS,
anticholinergics and antidepressants (trazadone) for cataplexy
obstructive sleep apnea
• objective indices of severity elicited by polysomnography should include a high index of
respiratory disturbances per hour, repetitive episodes of hypoxemia, and an abnormally
shortened sleep latency
• treatment: oral/dental appliances, CPAP, surgical intervention

SMOKING
EPIDEMIOLOGY
70% of smokers see a physician each year
70% of smokers report that they want to quit and have made one serious attempt to quit
single most preventable cause of death
responsible for 80% of lung cancers, COPD, cardiovascular disease
highest prevalence among ages 25-34
15% of smokers smoke > 25 cigarettes/day
see Community Health Chapter for Stages of Change
HISTORY
smoking habits: amount, duration, frequency, time of day
gain from smoking (e.g. weight loss, decreased anxiety, social relationships)
personal concerns about smoking and quitting
foreseen benefits from quitting
interest in quitting (a person will only quit if they are willing)
previous attempts and results
medical situation: cough, SOB, asthma, COPD, HTN
social situation: other smokers in family/social network
nicotine dependence
preoccupation or compulsion to use
impairment or loss of control over use
continued use despite negative consequences
minimization or denial of problems associated with use
MANAGEMENT
enhance motivation to quit
• relevance: medical conditions, family/social situation
• smoking risks
• short-term – SOB, asthma exacerbation, impotence, infertility
• long-term – heart attacks, strokes, lung cancer, COPD, other cancers
• environmental – increased risk in spouse/children of lung CA, SIDS, asthma,
respiratory infections
• rewards: improved health, better-tasting food, saving money, good
example to children, freedom from addiction
relapse prevention
• highest relapse rate within 3 months of quitting
• minimal practice – congratulate, encourage abstinence on each visit; review benefits, problems
• prescriptive interventions – address problems with weight gain, negative mood,
withdrawal symptoms, and lack of support; offer recommendations
• anticipate problems
self-help materials
• remove ashtrays/lighters
• increase high fibre snacks/gum
• increase aerobic exercise
• self-reward
Nicotine Gum
indications: patient preference, failure with nicotine patch, contraindication to patch
relative contraindications: pregnancy, cardiovascular diseases, mouth soreness, dyspepsia
dosage: 2 mg (< 30 pieces/day), 4 mg (< 20 pieces/day if failed 2 mg treatment or highly dependent
on nicotine); 1 piece q1-2 hours for 1-3 months
abstain from smoking
acidic beverages (soft drinks, coffee, juice) interfere with absorption and should be avoided 15 minutes
before and during chewing
chew until “peppery” taste emerges, then “park” between gum and cheek to facilitate nicotine absorption
(chew-park intermittently for 30 minutes)
Nicotine Patch
preferable for routine clinical use compared to gum
continuous self-regulated amount of nicotine
decreases craving and/or withdrawal
will not replace immediate effects of smoking habit or pleasure
indications: nicotine dependent, high motivation to quit smoking
contraindications: smoking while on patch
relative contraindications: pregnancy, skin reaction, cardiovascular diseases
duration of treatment: 4-12 weeks usually adequate
dose: 21 mg/d X 6 weeks, then 14 mg/d X 2 weeks, then 7 mg/d X 2 weeks

SMOKING . . . CONT.
Bupropion (Zyban/Wellbutrin)
acts on dopaminergic (reward) and noradrenergic (withdrawal) pathways
contraindications: seizure disorder, alcoholism, eating disorder, recent MAOI use, current pregnancy;
caution if using SSRI (reduction of seizure threshold)
dose: 150 mg bid x 1-10 wks; may vary with amount the patients smokes
patient continues to smoke for first week of treatment and then completely stops
(therapeutic levels reached in one week)
recommend abstinence from alcohol due to risk of toxic levels with liver dysfunction
side effects: headache, insomnia, dry mouth, weight gain
follow-up: set firm dates
continue to monitor/support, do not give up if failed
PROGNOSIS
most relapses occur in first year
most try > 5 times before quitting
Reference: AHCPR Smoking Cessation Guidline (in JAMA 1996, vol. 275(16):1270-1280)
SORE THROAT
ETIOLOGY
Viral
most common cause, often mimics bacterial infection
occurs year round
more common in preschool children and those with nasal symptoms
Adenovirus
• primarily summer months, lasts 5 days
• pharyngitis, rhinitis, conjunctivitis, fever
Coxsackie virus
• primarly late summer, early fall
• sudden onset fever, pharyngitis, dysphagia, vomiting
• appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharyx
• ulcers are pale gray, several mm in diameter, have surrounding erythema, may appear on hands
and feet (hand, foot and mouth disease)
Herpes simplex virus
• like coxsackie virus but ulcers are fewer and larger
EBV (infectious mononucleosis)
• pharyngitis, tonsilar exudate, fever, lymphadenopathy, fatigue, rash
Mycoplasma pneumoniae
• nonexudative pharyngitis, fever, headache, malaise progressing to cough, pneumonia
Bacterial
Group A ß-hemolytic Streptococci (GABHS)
• most common bacterial cause
• most prevalent between 5-17 years old and in winter months
• four classic symptoms
• fever
• tonsillar or pharyngeal exudate
• swollen, tender anterior cervical nodes
• absence of cough
• complications
• rheumatic fever
• glomerulonephritis
• suppurative complications (abscess, sinusitis, otitis media, pneumonia, cervical adenitis)
• meningitis
• impetigo
• spread of disease to others
• Note: incidence of glomerulonephritis is not decreased with antibiotic treatment
• see Table 13 for approach to diagnosis and management of GABHS
• some feel laboratory confirmation should be done in: children from 5-15 years, those with
previous rheumatic heart disease, family members of individuals with previous rheumatic
heart disease and young adults in closed communities (i.e. military recruits, college students, etc.)
others: Neisseria gonorrhoeae, Chlamydia, Candida, Corynebacterium diphtheriae

SORE THROAT . . . CONT.
INVESTIGATIONS AND MANAGEMENT
Suspected GABHS
gold standard for diagnosis is throat culture (refer to Table 13 for indications for throat culture)
rapid test for streptococcal antigen only 50-90% sensitive but 95% specific
• if rapid test positive, treat patient
• if rapid test negative, take culture and call the patient, if culture
positive start antibiotics
no increased incidence of rheumatic fever with 48 hour delay in treatment
Penicillin V is drug of choice; erythromycin if penicillin allergic
follow-up throat culture for GABHS after antibiotic therapy only
recommended for patients with history of rheumatic fever, patients whose
family member has history of acute rheumatic fever, suspected strep carrier
Suspected Viral Pharyngitis
symptomatic therapy for viral pharyngitis: acetaminophen/NSAIDs for fever and muscle aches, decongestants
Table 13. SORE THROAT SCORE (Approach to diagnosis and management of GABHS)*
POINTS
Is COUGH ABSENT? 1
Is there a HISTORY OF FEVER OVER 38ºC (101ºF)? 1
Is there TONSILLAR EXUDATE? 1
Are there SWOLLEN, TENDER ANTERIOR NODES? 1
Age 3-14 years 1
Age 15-44 years 0
Age > 45 years –1
In communities with moderate levels of strep infection
(10% to 20% of sore throats):
SCORE
0 1 2 3 4
Chance that patient 2-3% 3-7% 8-16% 19-34% 41-61%
has strep throat
Suggested action No culture Culture all, treat only Culture all, treat with
or antibiotic if culture is positive penicillin on clinical grounds1
1
Clinical grounds include a high fever or other indicators that the patient is clinically unwell and is
presenting early in the the course of the illness. If the patient is allergic to penicillin, use erythromycin.
* Limitations:
* This score is not applicable to patients less than 15 years of age.
* If an outbreak or epidemic of illness caused by GAS is occuring in any community, the score
is invalid and should not be used.
Adapted from: Centor RM et al., Med Decis Making 1981; 1: 239-246;
McIsaac WI, White D, Tannenbaum D, Low DE, CMAJ 1998; 158(1):75-83.

REFERENCES
Anti-infective Guidelines for Community-acquired Infections:2nd edition. Ontario Anti-infective Review Panel. Toronto, Canada. 1997.
Canadian Asthma Guidelines Quick Reference Tool. CMAJ, 1999;161 (11 Suppl).
Canadian recommendations for the management of hypertension. CMAJ 1999;161(12).
Gonzales R, Bartlett JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis:
background. Ann Emerg Med. 2001 Jun;37(6):720-7.
Gray J. Therapeutic Choices: 3rd Edition. Canadian Pharmacists Association, 2000.
Guidelines for the Diagnosis and Pharmacological Treatment of Depression: 1st edition revised. Toronto, ON; CANMAT, 1999.
Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease (COPD). Canadian Respiratory Review Panel. 1998.
Herbert FL. Et. Al. Diagnostic pearls for 10 common problems.

Patient Care Canada , 1995;6(1):28-50.
Marshall KG. Mosby’s Family Practice Sourcebook: Evidence-Based Emphasis. Harcourt Brace & Co., Canada, 2001.
McAlister FA, Levine M, Zarnke KB et.al. The 2000 Canadian recommendations for the management of hypertension: Part one. Can J
Cardiol 2001 May; 17(5):543-59.
Ontario Drug Therapy Guidelines for Stable Ischemic Heart Disease in Primary Care. Ontario Program for Optimal Therapeutics. June
2000.
Ontario Drug Therapy Guidelines for Chronic heart Failure in Primary Care. Ontario Program for Optimal Therapeutics. Queen’s
Printer of Ontario, June 2000.
Ontario Guidelines for Peptic Ulcer Disease and Gastroesophageal Reflux. Ontario GI Therapy Review panel. Queen’s Printer of
Ontario, June 2000.
Ontario Guidelines for the Pharmacotherapeutic Management of Diabetes Mellitus. Ontario Program for Optimal Therapeutics.
Queen’s Printer of Ontario, June 2000.
Ontario Guidelines for the Prevention and Treatment of Osteoporosis. Ontario Program for Optimal Therapeutics. Queen’s Printer of
Ontario, June 2000.
Ontario Guidelines for the Management of Anxiety Disorders in Primary Care. Anxiety Review Panel. Queen’s Printer of Ontario,
Sept. 2000.
Ontario Treatment Guidelines for Osteoarthritis, Rheumatoid Arthritis, and Acute Musculoskeletal Injury. Ontario Musculoskeletal
Therapeutics Review Panel. Queen’s Printer of Ontario, June 2000.
Panagiotou L, Rourke LL, Rourke JTB, Wakefield JG, Winfield D. Evidence-based well-baby care. Part 1: Overview of the next genera-
tion of the Rourke Baby Record.Canadian Family Physician , March 1998;44:558-567.

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FAMILY MEDICINE

FOUR PRINCIPLES OF FAMILY MEDICINE .. 3 DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

MCCQE 2006 Review Notes Family Medicine – FM1

HYPERTENSION (HTN) . . . . . . . . . . . . . . . . . . . . 27 SEXUALLY TRANSMITTED

OSTEOARTHRITIS (OA) . . . . . . . . . . . . . . . . . . . . 34 SORE THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

OTITIS MEDIA (OM) (ACUTE) . . . . . . . . . . . . . . 35

FM2 – Family Medicine MCCQE 2006 Review Notes

PATIENT-CENTRED CLINICAL METHOD

ADULT PERIODIC HEALTH EXAM

Table 1. Classification of Recommendations

B fair evidence supporting inclusion of the maneuver

C poor evidence regarding the inclusion or exclusion of the

D fair evidence supporting exclusion of the maneuver

E good evidence supporting exclusion of the maneuver

ADULT PERIODIC HEALTH EXAM

MCCQE 2006 Review Notes Family Medicine – FM3

FM4 – Family Medicine MCCQE 2006 Review Notes

MCCQE 2006 Review Notes Family Medicine – FM5

Table 2. Target Heart Rate

END OF LIFE CARE

FM6 – Family Medicine MCCQE 2006 Review Notes

Table 3. Common Herbal Medications

MCCQE 2006 Review Notes Family Medicine – FM7

FM8 – Family Medicine MCCQE 2006 Review Notes

Table 4. Distinguishing Problem Drinking from Severe

Clinical Feature Problem Drinking Alcohol Dependence

MCCQE 2006 Review Notes Family Medicine – FM9

TREATMENT (see Psychiatry Chapter)

FM10 – Family Medicine MCCQE 2006 Review Notes

Figure 1. Differentiating Anxiety Disorders

ACUTE EXACERTABIONS OF CHRONIC BRONCHITIS (A.E.C.B.)

FM12 – Family Medicine MCCQE 2006 Review Notes

Table 6. Differential Diagnosis of Chest Pain

Pulmonary GI MSK/Neuro. Psychologic

Angina Pneumonia GERD Arthritis Anxiety

ISCHEMIC HEART DISEASE

MCCQE 2006 Review Notes Family Medicine – FM13

beta-blocker for all post MIpatients

Figure 2. Treatment Algorithm for Stable Ischemic Heart Disease

COMMON COLD (ACUTE RHINITIS)

FM14 – Family Medicine MCCQE 2006 Review Notes

MCCQE 2006 Review Notes Family Medicine – FM15

FM16 – Family Medicine MCCQE 2006 Review Notes

MCCQE 2006 Review Notes Family Medicine – FM17

Etiology: • tumour • tumour • VBI • decreased visual

FM18 – Family Medicine MCCQE 2006 Review Notes

Table 7. Differentiating COPD from Asthma

Age of Onset usually in 6th decade any age

Evolution slow, cumulative disabling pattern episodic

History of Allergy infrequent over 50% patients

Chest X-ray often normal often normal or episodic hyperinflation;

FM20 – Family Medicine MCCQE 2006 Review Notes

Table 8. Etiology, Signs and Symptoms of Dysuria

MCCQE 2006 Review Notes Family Medicine – FM21

FM22 – Family Medicine MCCQE 2006 Review Notes

Appropriate assessment for presence of anxiety Yes

Appropriate assessment of current life stresses and Yes

Hemoglobin test No • presence of symptoms, e.g. pallor, tachycardia,

WBC count No • fever or other evidence of infection

Erythrocyte sedimentation rate No • evidence of inflammatory arthritis

Electrolytes No • taking meds known to affect electrolytes,

Glucose No • history of GDM (women)

Other investigations • as indicated by history and physical

CHRONIC FATIGUE SYNDROME(myalgic encephalomyelitis)