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FM20 Family Medicine
Common Presenting Problems Toronto Notes 2019 Concussion/Mild Traumatic Brain Injury
• seeNeurosurgery,NS32andEmergencyMedicine,ER8
• ausefultoolfortheassessmentofindividualsandathleteswithconcussionistheSportConcussion
Assessment Tool, 5th edition (SCAT5), Br J Sports Med 2017;0:1-8
Contraception
• seeGynecology,GY15
EMERGENCY CONTRACEPTION
• hormonalEC(Yuzpe®orPlanB®,usually2dosestaken12hapart)orpost-coitalcopperIUDinsertion
• hormonalECiseffectiveiftakenwithin72hofunprotectedintercourse(reduceschanceofpregnancy
by 75-85%), most effective if taken within 24 h, does not affect an established pregnancy
• copperIUDsinsertedwithin5dofunprotectedintercoursearesignificantlymoreeffectivethan
hormonal EC (reduces chance of pregnancy by ~99%)
• pregnancytestshouldbeperformedifnomenstrualbleedingwithin21dofeithertreatment
• advanceprovisionofhormonalECincreasestheuseofECwithoutdecreasingtheuseofregular
contraception
• pharmacistsacrossCanadacandispensePlanB®OTC
Cough
History and Physical
• duration(chronic-8wk),onset,frequency,quality(dryvs.productive),sputumcharacteristics, provoking/relieving factors, recent changes
• associatedsymptoms:fever,dyspnea,hemoptysis,wheezing,chestpain,orthopnea,PND,rhinitis, reflux, post-nasal drip
• constitutionalsymptoms:fever,chills,fatigue,nightsweats
• riskfactors:smoking,occupation,exposure,familyhistoryoflungCAorotherCA,TBstatus,recent
travel
• medications(e.g.ACEI,β-blockers),allergies
• PMH:lung(asthma,COPD,CF),heart(CHF,MI,arrhythmias),chronicillness,GI(reflux)
• vitals including O2 saturation, respiratory exam, HEENT and precordial exam
Investigations
• guidedbyfindingsonhistoryandphysical
■ consider throat swab, CXR, PFTs, upper GI series, sputum culture test for acid-fast bacilli (if TB is
suspected)
Dementia (Major Neurocognitive Disorder)
• seePsychiatry,PS21
Epidemiology
• 15%ofCanadians≥65yrarelivingwithdementia;riskfordementiadoublesevery5yearsafterage65
• prevalenceofdepressionindementiais20-60%;majordepressiondecreasesasdementiaseverity
increases; vascular and mixed dementias have a higher prevalence of depression
• leadingtypesofdementia:Alzheimer’s(40-50%),Mixed(20-25%),Lewy-Body(5-15%),Vascular(5-
10%), Frontotemporal (5-10%)
Investigations
• history,physicalexam,MMSE,MOCA(bestscreeningtest),dementiaquickscreen(seesidebar)
• investigationsarecompletedtoexcludereversiblecausesofdementiaandshouldbeselectedbasedon
the clinical circumstances
• CBC, liver enzymes, TSH, renal function tests, serum electrolytes, serum calcium, serum glucose,
vitamin B12, folate, VDRL, HIV, head CT
Management
• treatandpreventreversiblecauses
• provide orientation cues (e.g. calendars, clocks) and optimize vision and hearing
• familyeducation,counselling,andsupport(respiteprograms,grouphomes)
• pharmacologictherapy:N-methyl-d-aspartatereceptorantagonistsandcholinesteraseinhibitorsslow
rate of cognitive decline; low-dose neuroleptics and antidepressants can be used to treat behavioural
and emotional symptoms
• 20%ofpatientsdevelopclinicaldepression,mostcommonlyseeninvasculardementia
Differential Diagnosis
Common Causes
• Upper airway cough syndrome (post-nasal drip)
• Asthma/COPD
• GERD
• Non-asthmatic eosinophilic bronchitis
Other Causes
• ACEI
• Aspiration
• Bronchiectasis
• Cystic fibrosis
• Chronic interstitial lung disease
• CHF
• Lung/laryngeal cancer
• Pertussis
• Psychogenic
• Restrictive lung disease
• TB, atypical mycobacterium, and other
chronic lung infections
Dementia Quick Screen = Mini Cog + Animal Naming
• 3 simple tests, takes about 2 min
• Use when suspect mild cognitive
impairment or when patient is at high risk
• Mini Cog = 3-word recall + clock drawing
• Clock Drawing – including numbers and
hands so time shows 10 min past 11 (normal = correct number/hand placing, or only minor spacing problems)
• 0 word recall = impairment, 1-2 words and clock drawing abnormal = impairment, 3-word recall = normal.
• Naming animals in 1 min (normal = >15 in one min)
• Interpretation: If all 3 results within normal range, cognitive impairment unlikely
• Return for further evaluation if: • <15 animals named
• 0-1 words recalled
• Clock Drawing Abnormal