By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate knowledge in accessing provincial and tertiary care hospital guidelines and algorithms for management of illnesses in children
• Demonstrate ability to quickly access and apply accurate information on drug dosing and toxicity in children, as well as normal laboratory values for the various ages
  

While on my Pediatric Emergency rotation at BC Children's Hospital, an Emergency doc told me about the resources available to physicians and medical trainees put out by the Children's Hospital, namely clinical practice guidelines and the hospital formulary. While guidelines are debatable in terms of their foundation in evidence, it is always important to know what the standard of care is where you are working as a physician. Certain decision cannot be based in high quality evidence, simply because certain questions have not been asked and studied in rigorous scientific capacity. In these situations, local standards of care can provide guidance to select methods of providing treatment that are conscientious given local realities. Over residency, training in multiple environments and institutions, I have learned how valuable it is to know local resources, guidelines, pathways, and drug formularies, and once I start working in a given location long-term, I plan to become very well-versed in knowing what is available to me.

Key Feature 1: In patients who appear to be obese, make the diagnosis of obesity using a clear definition (i.e., currently body mass index) and inform them of the diagnosis.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 2: In all obese patients, assess for treatable co-morbidities such as hypertension, diabetes, coronary artery disease, sleep apnea, and osteoarthritis, as these are more likely to be present.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 3: In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated thyroid-stimulating hormone testing.
Skill: Clinical Reasoning, Selectivity
Phase: Investigation, Treatment

Key Feature 4: In obese patients, inquire about the effect of obesity on the patient’s personal and social life to better understand its impact on the patient.
Skill: Patient Centered
Phase: History

Key Feature 5: In a patient diagnosed with obesity, establish the patient’s readiness to make changes necessary to lose weight, as advice will differ, and reassess this readiness periodically.
Skill: Patient Centered
Phase: History, Follow-up

Key Feature 6: Advise the obese patient seeking treatment that effective management will require appropriate diet, adequate exercise, and support (independent of any medical or surgical treatment), and facilitate the patient’s access to these as needed and as possible.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 8: In managing childhood obesity, challenge parents to make appropriate family-wide changes in diet and exercise, and to avoid counterproductive interventions (ex: berating or singling out the obese child).
Skill: Clinical Reasoning, Communication
Phase: Treatment

In my first year or residency I did a quality improvement project in my clinic, with the hopes of performing an intervention that would lead to increased screening and diagnosis of overweight and obesity. The intervention was having signage in the office encouraging patients to start a conversation about their weight if they were interested. Of the approximately 300 patients who came through the clinic during the intervention period, 1 patient initiated a conversation about their weight, and this patient had a normal BMI. Although my quality improvement project did not increase the ability to screen for overweight and obesity, it did increase my understanding that screening for overweight and obesity is likely not sensitive unless it is physician-directed, or that at least passive that signage as I had put out was not effective in my current patient population.

I screen patients with an objective measure of overweight and obesity by assessing their BMI along with other interventions during a periodic health assessment. In adults, I also obtain a measure of central adiposity by assessing what their waist circumference is at any given BMI as some patients with a normal BMI may have a large enough waist circumference that they may be at increased risk for cardiovascular disease. As well, some patients with an elevated BMI may have greater risk for cardiovascular disease than this number alone suggests, as people who are "apples" and carry most of their weight around their abdomen and this increases their risk, as opposed to the "pears" that have a more distributed weight. These measurements are objective, and I believe that doing them with all patients helps alleviate the stigma that persists in Western culture regarding having overweight/obesity. That being said, the stigma and the social and psychological consequences are pervasive, so when patients have overweight or obesity, I also perform an assessment of their mental health.

Beyond the negative consequences on mental health, overweight and obesity can occur alongside a slough of comorbidities and an enlist a number of complications. These include hypertension, sleep apnea, polycystic ovarian syndrome, osteoarthritis, gastroesophageal reflux disease, fatty liver disease, a decrease in exercise capacity or ability to perform activities of daily living attributed to excess weight, dyslipidemia, and diabetes mellitus. It is important to assess for and address these other concerns alongside the provision of treatment and management of overweight and obesity. Laboratory investigations are necessary to assess whether of not the weight gain is complicated by new diabetes (fasting blood glucose or hemoglobin A1C), dyslipidemia (lipid panel), or fatty liver disease (ALT), or is a result of hypothyroidism (TSH), which is common enough with a presentation that can be fairly non-specific and so warrants a blood test to be ruled out, in a patient presenting with new-onset overweight/obesity without a previous test of their thyroid function since the onset of overweight/obesity. 

In terms of the treatment and management of obesity, society has drilled it into us that it is typically a consequence of poor lifestyle choices. That if we only ate less and exercised more, overweight and obesity would not be an issue. The emphasis on personal behaviours neglects the reality of just how complicated the innate pathways wiring our brain and endocrine systems are, encouraging weight gain and fighting efforts to lose weight, and this perspective does not take into account the societal structures that promote and reinforce weight gain. Yes, personal lifestyle choices can make a difference, mostly by improving health and wellbeing rather than necessarily dropping numbers on the scale overly significantly (wide range of results here). It is important for us to encourage one another to adopt healthier behaviours whenever possible without compromising quality of life, with the intent of actually enhancing it. We all have a role in adopting healthy behaviours in families and other community and societal units, while at the same time avoiding behaviours that stigmatise people who have excess weight. The more we see it as a personal consequence, the further from the truth I believe it is, and the less effective will be the call to action. The impact of any given intervention on quality of life is individualistic as well, and the individual has to find proposed behaviour changes tolerable and worth it to be motivated to continue the behaviours long-term. As a family doctor, my role in this matter is to assist the patient in moving from ambivalence to action when it is something they truly want (aka motivational interviewing for healthy lifestyle changes), as well as promoting the best interests of the community. I am a firm believer that we need to strengthen our communities with healthy public policy.

Unfortunately, no matter how motivated one is, once an individual has acquired enough weight such that they meet the criteria for overweight or obesity, healthy lifestyle behaviours alone are typically not sufficient to treat overweight and obesity so as to achieve a normal weight. On the flip side, there are medications and surgical treatments that are highly effective. While these treatment modalities do not replace the need for healthy lifestyle behaviours, they do make significant differences in the morbidity and mortality of patients with overweight and obesity. I am of the opinion that many physicians are not offering these treatments to patients frequently enough, probably as a consequence of a lack of discussion about weight with patients altogether. Fortunately, there are people who have started organisations such as Obesity Canada that seek to change this discourse. As the issue continues to be a growing concern as rates of overweight and obesity continue to increase, I suspect that eventually overweight and obesity will be managed much more effectively as the chronic disease process that it is.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate skill in the procedures relative to pediatrics

My approach to peripheral venous access, be it for an adult, child, or infant, is derived from Procedures Consult: Intravenous cannulation. This procedure is done both to obtain blood for investigations or to infuse IV fluids. It can be life-saving, and so contraindications (abnormal overlying skin, abnormality of the extremity, and infusions of substances that can be damaging to veins) really are relative contraindications. For these contraindications, it may warrant a poke in a central vessel instead.

Equipment

• Gloves (nonsterile is fine)
  
• Antiseptic solution (chlorhexidine is ideal)
  
• Rubber elastic tourniquet
  
• Local anesthesia (optional, ex: 1% lidocaine with 25-gauge needle and small [1-3 mL] syringe)
• IV catheter (usually 22-gauge is appropriate)
• Supplies for phlebotomy if needed (ex: 5-10 mL syringes or vacuum bottles, specimen bottles)
• IV fluid or saline "lock" setup with saline flush
• IV tubing (for infusion)
• Cotton balls or gauze (for bleeding)
• Sterile dressing

Procedure

1. Obtain informed consent
2. Position the patient supine or in a supported position (one that would be safe to faint in!)
3. Universal body fluid precautions
4. Organize equipment within reach, and prep/ensure all equipment is not defective (ex: set up IV tubing, pre-flush saline locks)
5. Place the tourniquet 5 to 10 cm proximal to the anticipated venipuncture site
   
6. Find your vein (consider favouring nondominant extremity, distal vein depending on needle/IV gauge, avoid over joint, ideally engorged)
   
7. Cleanse skin (don't re-palpate!)
   
8. Local anesthesia (if doing it, this is your moment - 0.5 mL is all that is required)
   
9. Apply traction distal to vein with thumb of your nondominant hand
   
10. Insert needle with thumb and middle finger of dominant hand, 15 degrees from surface of skin for a teensy vessel, up to 45 degrees for a massive vessel
    
11. Observe for flash of blood, then stop
    
12. Lower angle of needle to less than 15 degrees and advance 1-2 mm
    
13. Then, using index finger of dominant hand, advance catheter further over needle without also advancing needle
    
14. Release traction and use nondominant hand to tamponade skin overlying catheter insertion point, then remove the needle and activate safety (needle retraction) device
    
15. Obtain blood samples as needed, then release the tourniquet, then the needle, then cover site with bandage and apply pressure for 5 min and label any samples. Alternatively, attach IV tubing and secure catheter to patient ("U" shape position to decrease tension on tubing at site of insertion). Check all the connections and be sure everything is working right, from the bag to the skin.

Key Feature 1: Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (ex: sepsis, pyelonephritis, impacted infected stones).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Investigation

Key Feature 2: Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (ex: ultrasound).
Skill: Clinical Reasoning
Phase: Investigation

Key Feature 3: In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (ex: pregnancy, immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy).
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Urinary tract infections are extremely common, and most of the time they aren't complicated. When someone presents to my clinic with symptoms in keeping with a UTI (dysuria, urinary frequency and urgency +/- hematuria +/- suprapubic pain), it's my job to ensure that they don't have symptoms and signs suggesting a more complicated picture. The following features on clinical assessment take a UTI from simple to complicated:

• The patient has constitutional symptoms or  is febrile on exam
• The patient has flank pain or costovertebral tenderness

All patients with features suggesting a complicated UTI warrant referral to the nearest ED for further workup. Beyond routine and microscopic urinalysis as well as urine culture and sensitivity, blood cultures are warranted if you are thinking about possible sepsis. In terms of imaging, if you are thinking about pyelonephritis, obtain a CT abdo/pelvis with contrast, and if you are thinking about infected kidney stones, obtain a non-contrast CT abdo/pelvis. If you wish to avoid contrast and have the option, consider starting with a renal ultrasound instead. 

Speaking of renal ultrasound, besides its utility in looking for pyelonephritis or nephrolithiasis, it is also useful to look for urinary tract malformations in pediatric patients when indicated. As in the adult population, UTIs are much more common in females as their urethral tract is much shorter and they are therefore at greater risk of bacteria finding their way up and into the bladder. However, recurrent UTIs in prepubertal females are not common, and any UTIs in prepubertal males are unusual. UpToDate recommends obtaining renal and bladder ultrasonography if the following indications are met: 

• Children younger than two years of age with a first febrile UTI
• Children of any age with recurrent febrile UTIs
• Children of any age with a UTI who have a family history of renal or urologic disease, poor growth, or hypertension
• Children who do not respond as expected to appropriate antimicrobial therapy

As well, for any children with suspected UTI, obtain urinalysis as well as urine culture and sensitivity (by catheter for children who are not toilet-trained).

Children should also be sent for a voiding cystourethrogram to look for vesicoureteral reflux if the following indications are met: 

• Children of any age with two or more febrile UTIs, or
• Children of any age with a first febrile UTI and:
  • Any anomalies on renal ultrasound, or
  • The combination of temperature ≥39°C and a pathogen other than E. coli, or
  • Poor growth or hypertension 

So now I've singled out two groups to be weary of with suspected UTI: those who have features suggestive of a complicated UTI and children with suspected UTI. Other groups that require special considerations, and the considerations they warrant, are as follows. Note that any patients with a suspected complicated UTI, recurrent UTI, or any features below warrant at the very least a urinalysis and urine culture & sensitivity.

• Women who are pregnant: Although standard of care is not to test for cure after a course of antibiotics if the patient improves symptomatically, doing so with culture and sensitivity is recommended in women who are pregnant. Any infection in pregnancy poses risk of infection in the developing child, and high temperature (ex: from hot weather, hot tubs, hot yoga, or fever) can be teratogenic. 
• Patients who are immunocompromised: Although these patients may present with signs and symptoms of uncomplicated UTI, it is important to follow these patients closely if they are being treated for an uncomplicated UTI to ensure they improve as expected. If there is any doubt as to whether there is a smidge of complication to the UTI, it is best to err on the side of caution and treat them with suspicion for a complicated UTI.
• Neonates: If they have a UTI, they are at increased risk for bacteremia, so any neonate with a suspected UTI should be sent to the ED for blood cultures. If ill-appearing or febrile, an LP is also warranted. Treatment is with parenteral antibiotics. All neonates diagnosed with UTI also warrant at least a renal ultrasound as far as imaging is concerned. 
• Young men: As mentioned above, UTIs are more uncommon in boys, as they are in men of all ages. All males of any age with suspected UTI warrant at least a urinalysis and urine culture & sensitivity. If they have a tender prostate on examination, they should be treated for prostatitis rather than acute uncomplicated cystitis.
• Elderly men with BPH: Enlargement of the prostate can result in urinary retention, and urinary retention increases the risk for UTI. In elderly men with a UTI, obtain a genitourinary ultrasound to rule out urinary obstruction as a contributing factor.

Key Feature 5: When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 6a: In menopausal or perimenopausal women: Specifically inquire about the use of natural or herbal products.
Skill: Clinical Reasoning, Selectivity
Phase: History

Key Feature 6b: In menopausal or perimenopausal women: Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions.
Skill: Clinical Reasoning
​Phase: Treatment

Hormone replacement therapy used to scare people. Older studies showed there was a significantly greater risk of adverse cardiovascular outcomes for women at risk, but the women looked at in these studies were quite far along past the menopausal transition - in their 70s or so. Newer evidence has shifted current thinking, and with the advent of the estrogen patch to further decrease risk, many women are now candidates who were previously shunned from the benefits of hormone replacement therapy for the treatment of distressing menopausal symptoms. There are still some reasons, however, for which hormone replacement therapy is contraindicated, or for which symptoms are too mild to be considered worth it for the patient to start this treatment, or for women who do not want to assume the risks of hormone therapy that do exist even if relatively small, and women should be assisted to understand the other effective options that are available for the treatment of bothersome hot flashes and vulvovaginal atrophy. Explaining the other options that are available to treat menopausal symptoms is also indicated in obtaining good informed consent for hormone therapy, so women know there are other options to consider even if they present to clinic thinking this is what they want.

Below is the information I've amassed about non-hormonal therapy treatment options per UpToDate:

For women with mild hot flashes:

• "Women with mild flashes (hot flashes that do not interfere with usual activities) usually do not need pharmacotherapy. Instead, simple behavioral measures, such as lowering room temperature, using fans, dressing in layers of clothing that can be easily shed, and avoiding triggers (such as spicy foods, anxiety, warm drinks, caffeine, alcohol, stress, sudden ambient temp change), can help reduce the number of hot flashes."
• "Other potential options may include weight loss, cognitive behavioral therapy (CBT), vitamin E, and hypnosis."

For women with moderate to severe hot flashes:

• "The agents most commonly used include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs. These drugs are also often tried in women who experience recurrent hot flashes after stopping hormone therapy. Our choice of drug depends upon whether the patient is taking tamoxifen, the pattern of hot flashes, and the presence of a mood disorder or sleep problem." SSRIs tend to be first line because they have as much evidence for effectiveness as anything else and because by and large they have the least number and severity of side effects.

For women with vulvovaginal atrophy:

• "Vaginal atrophy (also referred to as vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis) caused by estrogen loss often results in vaginal complaints (ex: dryness, burning, dyspareunia) that cause distress in menopausal women. Urinary frequency and recurrent bladder infections may also occur. (...) As first line therapy for symptoms of vaginal atrophy, we suggest regular use of vaginal moisturizing agents supplemented by water-based lubricants during vaginal intercourse rather than treatment with hormonal agents." So the first-line therapy for this symptom specifically, in the absence to treat other symptoms of menopause, is not even hormone therapy anyway! 

Many women who are bothered by the symptoms secondary to menopause may already be trying their own alternative herbs remedies. It is important to ask about this, as there are a lot of natural remedies that women use. Furthermore, if something is strong enough to have an impact on symptoms, it's certainly possible to be having side effects and it's worth keeping on your radar as their physician, as for any patients in general who take herbal supplements. Like fad diets, there is no shortage of herbal remedies purported to treat symptoms and disease processes. Sometimes the evidence is in favour of them, sometimes it is not, and sometimes it is inconclusive. While training to learn the basics of Family Medicine and the number of medications and all of their possible side effects and risks, recommended dosages and drug interactions, I simply cannot prioritize taking on the vast compendium of herbal therapies out there in the ether. However, it is my duty to look things up as patients inquire or confide in me that they are using them, and then to counsel them on what is known based on the evidence that is available. Although I can't be expected to be aware of treatments that are uncommon and that I don't personally prescribe or recommend, helping patients to make choices that are as informed as possible, while taking into account their values and preferences, is always my role as their family physician.

Key Feature 1: Assess osteoporosis risk of all adult patients as part of their periodic health examination.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 2: Use bone mineral density testing judiciously (ex: don’t test everybody, follow a guideline).
Skill: Selectivity, Professionalism
Phase: Investigation, Follow-up

Key Feature 3:  Counsel all patients about primary prevention of osteoporosis (i.e., dietary calcium, physical activity, smoking cessation), especially those at higher risk (ex: young female athletes, patients with eating disorders).
Skill: Clinical Reasoning, Communication
Phase: Treatment

Key Feature 5: In patients with osteoporosis, avoid prescribing medications that may increase the risk of falls.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

Key Feature 6: Provide advice and counseling about fracture prevention to older men, as they too are at risk for osteoporosis.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

Key Feature 7: Treat patients with established osteoporosis regardless of their gender (ex: use bisphosphonates in men).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

In previous blog posts I have made reference to periodic health assessment tools that I use with young kids (Rourke Baby Record) and older kids and adolescents (Greig Health Record). However, I have not yet made mention of the periodic health assessment tool I use for adult patients, which is the Preventive Care Checklist by the College of Family Physicians of Canada. It prompts me to consider screening for osteoporosis with all of my adult patients, with recommendations of when and when not bone mineral testing is indicated. Regardless of whether or not someone is at more  or less risk of developing osteoporosis, the Checklist prompts me to counsel all patients on what they can do to prevent osteoporosis, which includes recommending a sufficient dietary intake of calcium and vitamin D, encouraging sufficient physical activity, and broaching smoking cessation, as indicated. Although some people are certainly at much more risk of developing osteoporosis than others, with risk factors outlined as part of the indications for obtaining a bone mineral density scan, it is a common disease that affects many people later in life, and one in which an ounce of prevention can result in a pound of cure. Recommending evidence-based measures to protect health and promote quality of life is one of the most important jobs of the Family Doctor, and the Checklist is a way of streamlining this process and thereby promoting health for all Canadians.  

If a patient is diagnosed with osteoporosis there are now multiple pharmacological treatment options to choose from. First line pharmacotherapy is usually an oral bisphosphonate. It's also important to be sure that what we are prescribing for other reasons is not further eroding bone integrity wherever possible, along with ensuring our prescriptions are not increasing the risk of falls, which can lead to falls and unfortunate fractures that significantly impair quality of life and that are associated with significant increases in mortality. This fact sheet put out by the CDC provides a list of the common medications that increase the risk of falls. 

Menopause

Key Feature 1: In any woman of menopausal age, screen for symptoms of menopause and (ex: hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes).
Skill: Clinical Reasoning, Patient Centered
Phase: History, Hypothesis generation

Key Feature 2: In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.)
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 3: In a patient with atypical symptoms of menopause (ex: weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause.
Skill: Selectivity
​Phase: Hypothesis generation, History

Key Feature 4: In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 7: In a menopausal or perimenopausal women, provide counselling about preventive health measures (ex: osteoporosis testing, mammography).
Skill: Clinical Reasoning
Phase: Treatment

Osteoporosis

Key Feature 4: In menopausal or perimenopausal women, provide advice about fracture prevention that includes improving their physical fitness, reducing alcohol, smoking cessation, risks of physical abuse, and environmental factors that may contribute to falls (ex: don’t stop at suggesting calcium and vitamin D).
Skill: Clinical Reasoning, Communication
Phase: Treatment, Hypothesis generation

Women have reached menopause once they've gone a whole year without having a menstrual period. The average age at which women start to go through the menopausal transition - when the changes secondary to fluctuating estrogen levels begin to occur - is on average around 47 years. This natural cluster bomb of erratic menstrual cycles and hot flashes, with a domino effect of other symptoms such as poor sleep, difficulty concentrating, and decreased mood, is a natural process, not a disease, although for some women it may certainly feel like something is very wrong. Indeed, there is a range of severity of menopausal symptoms that affect different women differently, and for those who are suffering, there are ways that modern medicine can help to alleviate some of the distress. So that is why we are trained to ask about the menopausal transition. Asking may lead to disclosure of symptoms a woman may perceive as par for the course that in fact don't have to be. Imagine shooting 18 holes carrying your own bag vs hopping in a golf cart. You still have to get through it, but it doesn't have to be such an arduous process. You may get your ball stuck in a few sandpits on the way, but with the right pitching wedge, you can avoid a lot of unnecessary frustration.

Besides the utility of knowing about menopausal symptoms in order to reduce these and improve quality of life in the here and now, knowing that a women is perimenopausal is useful in order to practice preventative medicine. When it comes to screening for disease, although some women are candidates for screening interventions just based on age alone and not menopausal status [ex: mammography, colorectal cancer screening, screening for diabetes], screening guidelines for osteoporosis include candidacy for bone mineral density based on menopausal status. It's also an opportunity to discuss with the patient that the menopausal transition increases their risk for osteoporosis, and that there are lifestyle interventions that can reduce their risk, including supplementation with vitamin D (approximately 800 units daily) and calcium (aiming for 1200 mg daily, no more than 500 mg from supplementation), regular exercise aiming to include resistance training at least 2-3 times per week, and avoiding excess substance use (tobacco cessation, no more than one drink of alcohol daily).

It is not uncommon to hear women present to clinic asking to have their hormones tested to see if they're going through menopause. However, in a women who is older than 45 years old with the symptoms of menopause, testing is simply unnecessary. At least in a women with symptoms that are classic menopausal symptoms, without atypical features, the chances of the symptoms being attributed to some other endocrine disturbance is just so small, probably like getting a whole in one on the first time playing a course. As well, not only is it unnecessary, it may be downright misleading. Hormones, especially early in the menopausal transition, fluctuate immensely, such that if a hormone level is in the normal range for a premenopausal woman, this absolutely doesn't rule out menopause. So hormones can be ordered, but in a women who is of the right age and with the classic presentation, testing for them adds little value, wastes a lot of money on the grand scheme of things, and is time better spent delving into the options to actually improve the symptoms that are causing the burden in the first place. If a women is presenting with features not quite in keeping with menopause, and in whom you do think you should investigate for the possibility of other things going on, FSH can be ordered to look for evidence of menopause. If FSH is >15, it suggests the patient is indeed in the menopausal transition. This doesn't mean something else isn't going on. As well, if the FSH is <15, this doesn't necessarily exclude menopause since the FSH level can be pretty all over the place earlier on in the menopausal transition. So, it is something that can be used to help with figuring out in a patient who presents with atypical features of menopause, but by no means is it a definitive diagnostic test.

To be confident at reassuring women that their symptoms are truly normal menopausal symptoms, it takes knowing the spectrum of normal in menopause. Classic symptoms of menopause are as follows, in order of usual appearance:

• Erratic menstrual cycles (typically first becoming shorter and heavier, and later becoming more spaced out)
• Hot flashes
• Sleep disturbance
• Difficulty concentrating
• Decreased mood
• Joint aches and pains
• Decreased libido
• Vaginal dryness
• Urinary incontinence

Knowing the above normal symptoms, you can then know that pretty well everything that isn't a logical extension of the above symptoms are something to inquire further about. For example, weight loss and bloody stools are not logical consequences of the above set of typical features, so these complaints should be approached just as they would be in anyone regardless of their menopausal status. Furthermore, any extreme case of the normal menopausal symptoms may warrant consideration of a differential diagnosis that includes other processes that lead to the same outcome, ones that deserve investigation as they ought not be missed. For example, in a  woman who states she is consistently hot rather than just during episodic hot flashes followed by a normal body temperature, check her temperature with a thermometer. Maybe she has a fever. Night sweats in someone with risk factors for TB may warrant screening for tuberculosis. And with a women who is sexually active and without contraception who has missed her period, always consider the need to check to see if she could be pregnant. There are many other possible zebras, so having a good grasp of normal will strengthen your ability to recognize when a presentation isn't.

In a women who indeed is having menopausal symptoms, we know that hormone replacement therapy works to treat the hot flashes and other sequelae. But what are the risks? Cardiovascular, breast cancer, and clotting. UpToDate provides a table to assess the cardiovascular risks and whether the risk of HRT outweighs the benefits:

To assess breast cancer risk, check out this tool: https://bcrisktool.cancer.gov

And last but not least, consider whether a patient has other risk factors (apart from HRT if initiated) for developing a blood clot, according to the following table from UpToDate. If so, it is best to provide transdermal HRT.

Key Feature 1: In addressing eye complaints, always assess visual acuity using history, physical examination, or the Snellen chart, as appropriate.
Skill: Clinical Reasoning
Phase: History, Physical

Key Feature 2a: In a patient with a red eye, distinguish between serious causes (ex: keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Take an appropriate history (ex: photophobia, changes in vision, history of trauma).
Skill: Clinical Reasoning
Phase: History

Key Feature 2b: In a patient with a red eye, distinguish between serious causes (ex: keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Do a focused physical examination (ex: pupil size, and visual acuity, slit lamp, fluorescein).
Skill: Clinical Reasoning
Phase: History

Key Feature 2c: In a patient with a red eye, distinguish between serious causes (ex: keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Do appropriate investigations (ex: erythrocyte sedimentation rate measurement, tonometry).
Skill: Clinical Reasoning
Phase: Investigation

Key Feature 2d: In a patient with a red eye, distinguish between serious causes (ex: keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Refer the patient appropriately (if unsure of the diagnosis or if further work-up is needed).
Skill: Clinical Reasoning
​Phase: Referral

Key Feature 3: In patients presenting with an ocular foreign body sensation, correctly diagnose an intraocular foreign body by clarifying the mechanism of injury (ex: high speed, metal on metal, no glasses) and investigating (ex: with computed tomography, X- ray examination) when necessary.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4: In patients presenting with an ocular foreign body sensation, evert the eyelids to rule out the presence of a conjunctival foreign body.
Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills
Phase: Hypothesis generation, Physical

Key Feature 5: In neonates with conjunctivitis (not just blocked lacrimal glands or ‘‘gunky’’ eyes), look for a systemic cause and treat it appropriately (i.e., with antibiotics).
Skill: Clinical Reasoning
​Phase: Hypothesis generation, Treatment

Key Feature 6: In patients with conjunctivitis, distinguish by history and physical examination between allergic and infectious causes (viral or bacterial).
Skill: Clinical Reasoning
Phase: Diagnosis, History

Key Feature 7: In patients who have bacterial conjunctivitis and use contact lenses, provide treatment with antibiotics that cover for Pseudomonas.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 8: Use steroid treatment only when indicated (ex: to treat iritis; avoid with keratitis and conjunctivitis).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 9: In patients with iritis, consider and look for underlying systemic causes (ex: Crohn’s disease, lupus, ankylosing spondylitis).
Skill: Clinical Reasoning
Phase: Hypothesis generation

A common presenting concern in primary care is that of a red eye, which has a decent differential diagnosis. As for most presenting complaints, it's important to take a history that pertains to the presentation, including any inciting factors (ex: trauma) that may have contributed to the concern. Following the history comes the physical exam, which always includes testing visual acuity, inspecting the eyes, and assessing pupillary reactivity to light. In an emergency department setting, a slit lamp examination may also be done +/- using fluorescein to assess for corneal abnormalities, but in the primary care office the penlight can be used in place of the slit lamp to visualize the anterior portion of the eye at least. This can help assess for corneal abnormalities, but if you have a high index of suspicion, it is best to refer the patient to the ED to be examined with the slit lamp anyway. 

The standard of care for assessing visual acuity is the Snellen chart. If there isn't a Snellen chart anywhere nearby, you can simply have the patient read objects both near and far to check their near- and far-sighted vision, respectively, each eye at a time. And, if triaging patients over the phone, the best thing you can do is to ask the patient if there is a change in their vision and have them test it as you guide them to do so. Make sure they are wearing corrective glasses if they usually need them to read near or far. And bottom line really is that you should assess visual acuity as best as is feasible, and document your findings, no matter the eye concern.

As a primary care provider, after having done my focused history and physical exam, it is in fact quite simple to assess for whether or not a red eye is something I can treat right then and there, or if the patient's presentation warrants urgent referral to an Ophthalmologist. The 4 criteria that tell me I can manage the concern are:

1. Vision is unaffected
2. There is no objective foreign body sensation or photophobia
   1. An objective foreign body sensation means the patient cannot spontaneously keep their eye open in a brightly or dimly lit room, versus the subjective sensation as though it feels like there is something in the eye or that light bothers them, but still they can tolerate keeping their eye open without significant distress. An objective foreign body sensation warrants detailed historical assessment for the mechanism of injury, inspecting the eye and flipping the lid to look for an obvious and easily removable foreign body, +/- referring the patient to the emergency department for urgent assessment. 
   2. Photophobia means the patient cannot spontaneously keep their eye open in a brightly lit room, but that they can spontaneously keep their eye open in a dimly lit room. This suggests iritis, which itself is due to another (autoimmune) cause that requires further assessment. Firstly, the patient ought to be referred to an Ophthalmologist to confirm there is indeed true anterior uveitis. The treatment for autoimmune conditions is often immune-modulator therapy, such as topical steroids for the eye. Steroids are not without consequence, so having a complete Ophthalmology assessment prior to the initiation of steroids is a good eye-dea.
3. There is no corneal opacity, hypopyon, or hyphema (the latter two being a layer of white or red blood cells in the anterior chamber of the eye)
4. The pupil is reactive to light

Sometimes further investigations needs to be done, depending on the eye complaint. However, in the setting of a red eye, the concerns that would prompt me to further investigate would be ones for which I would be sending the patient for more urgent care anyway. The only exception to this would be in a patient who presents with risk factors or an atypical presentation of what would otherwise likely be benign disease. When it comes to a seemingly benign eye complaint that doesn't respond to basic management, a referral to Ophthalmology is also warranted.

Among the diagnoses that primary care physicians can make and proceed to treat without referral to Ophthalmology is conjunctivitis, be it of allergic, viral, or bacterial etiology. The cardinal features, of these three types of conjunctivitis, respectively, are mucoserous discharge with pruritus, mucoserous discharge in the setting of an upper respiratory tract infection and without pruritus, and mucopurulent discharge all day. The treatment varies depending on the type, but first-line is typically topical treatment(s). If a diagnosis of bacterial conjunctivitis is made, it is important to determine whether or not the patient wears contact lenses. If so, they are at risk for Pseudomonas conjunctivitis, and the topical antibiotic therapy that is chosen should cover for this organism.

An exception to using topical antibiotic therapy as the first-line treatment for bacterial conjunctivitis is in the setting of neonatal bacterial conjunctivitis, in which case one should always have suspicion that this could be part of a systemic infection. According to UpToDate, "C. trachomatis should be suspected in an infant less than one month of age with conjunctivitis if there is the possibility of exposure to the organism, specifically if the mother has a history of untreated C. trachomatis infection, or no prenatal care. If there has been no prenatal care or a maternal history of Neisseria gonorrhoeae (N. gonorrhoeae), the exudate also should be examined with Gram stain and cultured using selective medium to detect N. gonorrhoeae." If there is a high enough clinical suspicion of swabbing for the ocular discharge for Chlamydia and Gonorrhea, the neonate should be sent to a pediatric ED as empiric therapy is with IV antibiotics.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Screen for and have an approach to caring for patients with concurrent substance use and mental health disorders
  

Crisis

Key Feature 10: Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
Skill: Professionalism
Phase: Treatment

​Substance Use

Key Feature 1: In all patients, and especially in high-risk groups (ex: mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).
Skill: Clinical Reasoning
Phase: History

Key Feature 2a: In intravenous drug users: Screen for blood-borne illnesses (ex: human
immunodeficiency virus infection, hepatitis).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Investigation

Key Feature 2b: In intravenous drug users: Offer relevant vaccinations.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 5: Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (ex: alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients).

Key Feature 7: In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 8: In substance users or abusers, routinely determine willingness to stop or decrease use.
Skill: Patient Centered
Phase: History, Treatment

Key Feature 9: In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (ex: poverty, crime, sexually transmitted infections, mental illness) and long-term complications (ex: cirrhosis).
Skill: 
Phase: 

Asking about substance use is something I do routinely when gathering a medical history, with all patients, but re-inquire more frequently if a patient's circumstances have  changed or they have increased risk (ex: stressors, psychiatric illness, family history of addictions). I ask about alcohol use, tobacco use, or any other substances such as marijuana, stimulants such as cocaine or crystal meth, or sedatives such as benzodiazepines or opioids. If a patient endorses using any substances, I then attempt to quantify how much of each that they use. If they endorse anything other than alcohol or tobacco, I also ask if they have ever injected any substances, which comes with a whole other set of health risks aside from a potential substance use disorder. Namely they are at risk for certain blood-borne illnesses and so I recommend screening (bloodwork for HIV, hepatitis B, and hepatitis C) and vaccinations accordingly (hepatitis A and B).

Most illicit substances can be harmful to the body. So, when patients endorse any substance use, it prompts me to assess for the presence of substance abuse. Alcohol is a bit of an exception, in that culturally and medically it is not harmful in (very) low quantities, but in high quantities contributes immensely to chronic disease. That being said, with alcohol I assess for the presence of alcohol abuse when the quantity of drinking suggests it is not low risk, defined as no more than 4 drinks on any given day or more than 14 drinks on any given week for men under 65 years old, and defined as no more than 3 drinks on any given day or more than 7 drinks on any given week for all others. Conversely, when patients present with any of the many symptoms that could be attributed to use or withdrawal of substances, I ask about substance use as it is in the differential diagnosis. More times than not it can often be a cause or can aggravate of patient's complaints. It can also be a reason for why patients aren't getting better as expected once treatment forgiven disease has been started. Substance use has such extensive ramifications that not asking about it could be considered a form of neglect. 

Once a patient has screened positive for alcohol (i.e., not low risk alcohol consumption), tobacco, or any other substance use, I then ask them for permission to explore a little bit more about their use of the substance(s). (Note that this may not occur on the same medical encounter depending on whether there are other/unrelated acute medical issues that need to be addressed more urgently.) If a patient is open to it, I then take a history to assess for the substance use disorder(s) that may apply to them, per the DSM V. If they meet the diagnostic criteria for a substance use disorder, I explain this to them and solicit their thoughts about this, which helps me as part of the treatment of substance use disorders that is front and central is motivational interviewing and gauging where patients are at with respect to the Stages of Change (precontemplation, contemplation, preparation, action, or maintenance). The diagnostic criteria for alcohol use disorder, a common substance use disorder, are as follows: 

Once it is clear that a patient has a substance use disorder, whether they agree or disagree, and regardless of where they are motivated for change, it is important to screen them for the many comorbid issues and long-term complications that frequently travel with those who abuse substances. In the midst of the opioid crisis, this includes death by overdose. This really means getting a good social history and being aware of the evidence-based recommendations for screening for people who use particular substances. (For people who use illicit opioids this includes screening for risk factors for overdose and death, including whether the patient uses alone and whether they have a take-home naloxone kit and know how to use it to help those around them who are also using, or to have with them for someone to use on them if needed.) It can be extremely challenging to screen for social and medical issues in patients with substance use disorders as they often present infrequently for medical attention, or else in times of acute crisis. It is important that health care providers be able to respond medically (ex: providing rescue naloxone in a patient with an acute overdose, referring patients with comorbid mental health disorders to see a psychiatrist) and socially (ex: by understanding what community resources are available and that the patient may benefit from accessing). There may be no better example of the need for primary care physicians to practice opportunistic medicine.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Manage common paediatric problems in an office setting

Key Feature 1: Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).
Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills
Phase: Diagnosis, Physical

Key Feature 2: Include pain referred from other sources in the differential diagnosis of an earache (ex: tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 3: Consider serious causes in the differential diagnosis of an earache (ex: tumours, temporal arteritis, mastoiditis).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 4: In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (ex: through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (ex: reassessment in 48 hours).
Skill: Selectivity, Communication
Phase: Treatment

Key Feature 5: Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)
Skill: Selectivity, Professionalism
Phase: Treatment

Key Feature 6: In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 7: In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 8: Test children with recurrent ear infections for hearing loss.
Skill: Clinical Reasoning
Phase: Investigation

According to the UpToDate article Evaluation of earache in children, "The diagnosis of acute otitis media (AOM) requires bulging of the tympanic membrane or other signs of acute inflammation and middle ear effusion. The importance of accurate diagnosis is crucial to avoidance of unnecessary treatment." Thus, if the view of the tympanic membrane is obstructed, one cannot make a diagnosis of acute otitis media. If there is cerumen impaction, this must first be disimpacted so that the tympanic membrane can be visualized. This can be done using cerumenolytics, +/- irrigation, +/- mechanical removal. And then, when the tympanic membrane is visualized, it is important to look for signs of inflammation suggestive of AOM. The most specific finding is a bulging membrane, which bulges from the increased quantity of inflammatory fluid in the middle ear space. Although a red tympanic membrane can be in keeping with an AOM, there other reasons that can cause the eardrum to become red (such as fever and crying, which are both common findings in children who are being brought in for assessment of possible ear infection but that may very well be occurring for reasons other than an ear infection). This means that a red eardrum in isolation is not a sufficient finding on otoscopy to make a diagnosis of AOM, and other sources of infection should be sought in a child with a fever.

Although the most common reason for a child to present with ear pain is AOM, there is a big differential for ear pain that must be considered. My general DDx for ear pain is as follows:

1. External ear pain 
   1. Infections 
      1. Otitis externa (ex: fungal, bacterial) 
      2. Auricular cellulitis 
      3. Perichondritis
      4. External canal abscess 
   2. Trauma (ex: frostbite, piercings) 
   3. Other (ex: foreign body, cerumen impaction) 
2. Middle and inner ear pain 
   1. Infections or inflammation 
      1. Acute otitis media 
      2. Serous otitis media 
      3. Mastoiditis 
      4. Myringitis
   2. Trauma (ex: perforation, barotrauma) 
   3. Neoplasms 
3. Referred pain 
   1. Infections (ex: sinusitis, dental disease) 
   2. Trigeminal neuralgia 
   3. Other (ex: temporomandibular joint dysfunction, thyroiditis) 

If a patient does indeed have evidence of AOM then a decision needs to be made about whether or not to prescribe antibiotics. UpToDate recommends that children less than 2 years old with evidence of AOM on examination be given antibiotics, while being more conservative about antibiotic prescribing in children 2 years and up. They suggest that antibiotics in this latter age group should be prescribed based on the presence of any of the following features:

• Toxic appearance
• Persistent otalgia for >48 hours
• Temperature ≥39°C in the past 48 hours
• Bilateral AOM
• Otorrhea
• Uncertain access to follow-up

In on other words, initial observation may be appropriate in a child 2 years of age or older with evidence of AOM on exam, if the caretakers are reliable to follow-up if indicated (for any of the above-listed features).

First-line treatment for AOM, according to Bugs & Drugs, is penicillin 40 mg/kg/d PO divided TID for 5-10 days in an otherwise healthy child, or 1 g PO TID x 5 days in an otherwise healthy adult (an uncommon disease process in adults). And whether or not antibiotics are prescribed, it is recommended that the ear pain be treated with oral ibuprofen or acetaminophen. 

If a child has recurrent AOM (defined as at least 3 episodes in 6 months or at least 4 episode in 12 months) with middle ear effusions, consider sending them to see an ENT Surgeon in consideration of tympanostomy tube insertion. The reason this would be done would be to prevent hearing loss and subsequent delay in language development in the child. If there are concerns about hearing loss that is ongoing after an AOM has been treated, consider that there may be persistent otitis media with effusion, and send the child for audiometry testing. If this is remarkable, an ENT referral would also be warranted.