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FM30 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Management
Table 16. Management of Erectile Dysfunction
Nonpharmacologic
Lifestyle changes
(alcohol, smoking, exercise) Relationship/sexual counselling Vacuum devices
Pharmacologic
Oral agents
Suppository
Male urethral suppository for erection (MUSE) Injections
Surgical
Implants Vascular repair Realignment
• pharmacologictreatment
■ phosphodiesterase type 5 inhibitors
■ α-adrenergic blockers (e.g. yohimbine)
■ serotonin antagonist and reuptake inhibitor (e.g. trazodone)
■ testosterone – currently only indicated in patients presenting with hypogonadism and testosterone
deficiency (note: breast/prostate cancer are absolute contraindications)
Table 17. Phosphodiesterase Type 5 Inhibitors
Examples
sildenafil (Viagra®)
tadalafil (Cialis®) vardenafil (Levitra®)
Fatigue
Epidemiology
Dosing (1 dose/d)
25-100 mg/dose
5-20 mg/dose 2.5-20 mg/dose
Specifics
Take 0.5-4 h prior to intercourse May last 24 h
Effects may last 36 h
Take 1 h prior to intercourse
Side Effects
Flushing, headache, indigestion
As above As above
Contraindications
Not to be used in patients taking nitrates
As above As above
Fatigue Red Flags
• Fever
• Weight loss
• Night sweats
• Neurological deficits • Ill-appearing
• 25%ofofficevisitstofamilyphysicians ■ peaks in ages 20-40
■ F:M=3-4:1
• 50%haveassociatedpsychologicalcomplaints/problems,especiallyif<6moduration
Differential Diagnosis
Table 18. Differential Diagnosis of Fatigue: PS VINDICATE
P Psychogenic
Physiologic
S Sleep disturbance Sedentary
V Vascular
I Infectious N Neoplastic
Nutrition
Neurogenic
D Drugs
I Idiopathic
C Chronic illnesses A Autoimmune
T Toxin
E Endocrine
Common causes are in bold
Investigations
Depression, life stresses, anxiety disorder, chronic fatigue syndrome, fibromyalgia Pregnancy, caregiving demands (young children, elderly)
Obstructive sleep apnea, sleep disorder, poor sleep hygiene, BPH, shift work, pain Unhealthy/sedentary lifestyle
Stroke
Viral (e.g. mononucleosis, hepatitis, HIV), bacterial (e.g. TB), fungal, parasitic
Any malignancy
Anemia (Fe2+ deficiency, B12 deficiency)
Myasthenia gravis, multiple sclerosis, Parkinson’s disease
β-blockers, antihistamines, anticholinergics, benzodiazepines, antiepileptics, antidepressants
CHF, lung diseases (e.g. COPD, sarcoidosis), renal failure, chronic liver disease SLE, RA, mixed connective tissue disease, polymyalgia rheumatica Substance abuse (e.g. alcohol), heavy metal
Hypothyroidism, DM, Cushing’s syndrome, adrenal insufficiency, pregnancy
• psychosocialcausesarecommon,sousuallyminimalinvestigationiswarranted
• physicalcausesoffatigueusuallyhaveassociatedsymptoms/signsthatcanbeelicitedfromafocused
history and physical exam
• investigationsareguidedbyhistoryandphysicalexamandmayinclude:
■ CBC and differential, electrolytes, BUN, Cr, ESR, glucose, TSH, ferritin, vitamin B12, serum protein electrophoresis, Bence-Jones protein, albumin, AST, ALT, ALP, bilirubin, calcium, phosphate, ANA, β-hCG
■ urinalysis, CXR, ECG
■ additional tests: serologies (Lyme disease, hepatitis B and C screen, HIV, ANA) and Mantoux skin
tests