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Toronto Notes 2019 Common Presenting Problems
• providecommunityresources
■ safety planning includes ensuring that there is access to an exit in the home, establishing a safe place
to go and having money, clothes, keys, medications, important documents, and other emergency
items prepared should the patient need to leave quickly
■ shelter or helpline number with legal advocacy and counselling services ■ involve social workers or domestic violence advocates
• appointmentforfollow-uptoassesswhetherconditionisbetterorworse • reassurepatientshe/heisnottoblameandthattheassaultisacrime
■ goal is to convey the message that “As your doctor, I am concerned for your safety” and “Your partner has a problem that he/she needs help with” and “I want to help you”
■ reporting suspected or known child abuse is mandatory
■ spousal abuse is a criminal act, but not reportable without the woman’s/man’s permission • DOCUMENTallevidenceofabuse-relatedvisitsformedico-legalpurposes
ELDER ABUSE
• seeGeriatricMedicine,GM9
Dyspepsia
• seeGastroenterology,G10
Definition and Clinical Features
• definedasepigastricpainordiscomfort
• canbeassociatedwithfullness,belching,bloating,heartburn,foodintolerance,N/V
Epidemiology
• annualincidence1-2%,prevalence20-40%
Etiology
• common: functional, PUD, GERD, gastritis
• others:cholelithiasis,irritablebowelsyndrome,esophagealorgastriccancer,pancreatitis,pancreatic
cancer, Zollinger-Ellison syndrome, and abdominal angina
History
• symptomsmaynotbeusefulinfindingcause
• associatedwitheating,anorexia,N/V,alcohol,NSAIDuse
• redflags:vomiting,bleeding/anemia,abdominalmass,dysphagia(VBAD)
Investigations and Management
• fornewonsetdyspepsia,testforH.pyloriusingtheureabreathtestorserology
• upperendoscopy(preferred),upperGIseries(notinpatientswithalarmsymptoms)
• lifestylemodifications:decreasecaffeineandalcoholintake,avoidcitrusfood,smallerandmore
frequent meals, avoid supine position right after meals, smoking cessation • pharmacologictreatment
■ gastric acid suppression: H2 blockers, PPI’s; both are effective for PUD and GERD
■ prokinetics: e.g. Metoclopramide; effective for functional dyspepsia
• H. pylori eradication
• donotkeeppatientsonPPIwithoutatleast1trialoffthemedicationperyear
(https://choosingwiselycanada.org/perspective/ppi-toolkit/) • for non-responders, gastroscopy should be considered
Dyspnea
• seeRespirology,R3andEmergencyMedicine,ER26 Definition
• uncomfortable,abnormalawarenessofbreathing
History and Physical Exam
• history
■ cough, sputum, hemoptysis, wheezing, chest pain, palpitations, dizziness, edema, SOB ■ constitutional symptoms
■ history of asthma, allergies, eczema, ASA/NSAID sensitivity, nasal polyps
■ smoking, recreational drugs, medications
■ occupational exposure, environmental exposure (e.g. pets, allergens, smoke)
■ travel and birth place
■ FHx of atopy
■ previous CXR or PFTs
• physicalexam:vitals,respiratory,precordial,HEENT,signsofanemia/liverfailure/heartfailure
Family Medicine FM27
Dyspepsia Red Flags
• Weight Loss
• Dysphagia
• Persistent vomiting
• GI bleeding (hematemesis, hematochezia,
melena)
• Onset age >50
H. pylori Eradication
Take the following 10 day treatment
1) PPI 1 tablet 2x/d for 10 d and
2) Amoxicillin 1 g twice a day for 5 d (day 1-5) Followed by
3) Clarithromycin 500 mg 2x/d (day 6-10) and 4) Metronidazole 500 mg 2x/d (day 6-10)
Differential Diagnosis of Dyspnea
Pulmonary
• COPD
• Asthma
• Restrictive lung disease • Pneumothorax
• Congenital lung disease • PE
Cardiac
• CHF
• CAD
• MI (recent or past) • Cardiomyopathy • Valve dysfunction • Pericarditis
• Arrhythmia
• Hypertrophy
Mixed/Other
• Deconditioning
• Trauma
• Pain
• Neuromuscular
• Metabolic condition
• Functional: anxiety, panic attack,
hyperventilation