Primary Care Guideline

Screening

• AAA, Cholesterol, and Hypertension Screening

• AAA screening recommended for male aged 65-80 years with a one-time ultrasound, regardless of smoking history

• Cholesterol screening at 40 years old every 5 years, or annually for diabetics

• Hypertension screening advised at every visit

• Cardiovascular Screening

• NO ECG for CAD, AF

• No ABI or OSA screening

• Breast Cancer, Oral Cancer, and Skin Cancer Screening

• Breast cancer screening guidelines by CTFPHC for ages 50-74 include mammography every 2-3 years

• High-risk individuals with specific factors should undergo genetic referral and annual MRI or mammogram

• Oral cancer screening criteria remain unclear

• Skin cancer prevention involves UV exposure minimization, sun protection, and self-examination

• Vitamin Deficiency Screening

• Vitamin deficiency screening recommendations are unclear for individuals at normal risk

• High-risk groups such as those with chronic kidney disease (CKD), hepatic failure, hyperparathyroidism, or obesity should have 25D levels checked

• Endocrine Screening

• Thyroid Ultrasound and TSH Screening

• Thyroid ultrasound indicated for individuals with a family history of medullary thyroid cancer, MEN2, goiter, or specific ethnic backgrounds

• Fine-needle aspiration (FNA) is the preferred procedure for thyroid nodules

• TSH screening recommended for newborns, pregnant, those with risk factors (lipids, sodium, macrocytic anemia, pleural/pericardial effusion)

• Gastrointestinal Screening

• Barrett's, Celiac, and Colorectal Cancer (CRC) Screening

• Barrett's esophagus screening not recommended unless at moderate to high risk

• Celiac disease screening criteria include IgA tissue transglutaminase (ttG) testing for type 1 diabetes mellitus (T1DM) or family history; tested while ON gluten diet

• CRC screening for normal-risk individuals aged 50-74 involves fecal immunochemical test (FIT) or flexible sigmoidoscopy

• Esophageal, Gastric, and Hepatocellular Carcinoma (HCC) Screening

• Esophageal adenocarcinoma screening for patients with confirmed Barrett's esophagus involves specific surveillance intervals based on dysplasia grade

• HCC screening with ultrasound ± alpha-fetoprotein (AFP) every 6 months for individuals with cirrhosis

• Genitourinary Screening

• Bladder Cancer and Cervical Cancer Screening

• Bladder cancer screening not recommended for asymptomatic individuals

• Cervical cancer screening guidelines for Canadian women aged 25-69 include Pap smears

• Endometrial and Ovarian Cancer Screening

• Endometrial cancer screening for postmenopausal women is unclear regarding the efficacy of transvaginal ultrasound (TVUS)

• Ovarian cancer screening not recommended for average-risk individuals; high-risk groups should consider genetic testing and specific exams

• Infectious Disease Screening

• Chlamydia, HSV, HIV, and Syphilis Screening

• Chlamydia screening annually for individuals under 25, sexually active, MSM, or with specific risk factors

• HIV screening for high-risk groups like MSM, IVDU, and sex workers

• HSV serology screening not recommended without active lesions

• Pulmonary and Renal Screening

• COPD and Lung Cancer Screening

• Asymptomatic adults do not require COPD screening; diagnostic spirometry for symptomatic individuals

• Annual low-dose CT screening x 3 for lung cancer in individuals aged 55-74 with a 30 pack-year smoking history

• CKD Screening

• Asymptomatic adults do not need routine CKD screening; annual screening for those on nephrotoxic medications

• Children and Adolescents Screening

• Alcohol Abuse, ADHD, and ASD Screening

• Alcohol abuse screening using CAGE questionnaire

• ADHD evaluation for individuals aged 4-18 with specific symptoms

• ASD screening possible at 18-24 months using tools like MCHAT

• Cholesterol, Depression, and Lead Poisoning Screening

• Cholesterol screening as per guidelines mentioned earlier

• Depression screening in 7-11-year-olds is unclear; use PHQ-A questionnaire

• Lead poisoning screening not recommended for asymptomatic individuals; consider screening for high-risk groups

• Newborns and Infants Screening

• Anemia, Critical Congenital Heart, and DDH Screening

• Anemia screening for high-risk infants; universal hemoglobin testing at 12 months

• Critical congenital heart screening using pulse oximetry (right hand, left/right foot)

• Developmental dysplasia of the hip (DDH) screening with specific maneuvers

○ Consider imaging for Breech or positive family history

○ DDH U/S: 6 weeks to 6 months

○ DDH Hip X-ray: ≥ 4 months

○ Ortho: positive Ortolani, persistent Barlow

○ Ortolani Test: Positive result indicates hip dislocation, characterized by limited abduction.

○ Universal screening with ultrasound (U/S) is not recommended.

○ Ultrasound is advised for infants at high risk between 6 weeks to 6 months, based on factors such as breech position, family history, parental concern, clinical instability, and lower extremity swaddling history.

○ Hip X-ray is recommended after 4 months for high-risk infants with a normal physical exam or positive physical exam findings.

○ If a hip is found to be unstable on physical examination (positive Ortolani test), referral to orthopedics is necessary, and imaging may not be immediately required.

○ Approximately 90% of infants with a positive examination result resolve without intervention.

○ Positive Barlow test results should prompt re-examination, and if the condition does not resolve, referral to orthopedics is warranted.

○ It's advised not to swaddle infants with hips extended and adducted to prevent hip dysplasia or dislocation.

• Growth Abnormality, Hearing, and Hemoglobinopathy Screening

• Use WHO growth charts for infants under 24 months

• Universal newborn hearing screening OAE (otoacoustic emission) by 1 month if positive do ABR (auditory brainstem response) by 3 months

• Universal screening for sickle cell disease, PKU, metabolic disease, and thyroid in newborns

• Adults, Pregnant Women, and Elderly Screening

• Dementia, Falls, and Family Violence Screening

• Dementia screening in adults is unclear regarding the efficacy of screening tools

• Annual falls assessment in the elderly

• Family violence screening for women of reproductive age

• Osteoporosis, Vision Impairment, and Pre-eclampsia Screening

• Osteoporosis screening for individuals over 65 years (earlier if risk factors like steroids) using DXA or ultrasound calcaneus

• Vision impairment screening in older adults is unclear; consider baseline at 40 years old

• Pre-eclampsia screening involves blood pressure monitoring and specific criteria

Prevention

• Cardiovascular Disorders

• Prevention and Management

• ASA not recommended for primary prevention of ACS and CVA due to gastrointestinal bleeding and hemorrhagic stroke risk

• Diet recommendations for individuals aged 18 and above include limiting saturated fat to less than 7%, cholesterol intake to less than 300mg per day, 1% dairy fat consumption, and trans fat intake to less than 1%

• Statin therapy is recommended for individuals aged 18 and above LDL > 5, DM aged 40 years or older, or individuals aged 30 with DM for 15 years

• Hypertension (HTN) management guidelines suggest a blood pressure goal of 140/90 mmHg for individuals aged 18 and above

• Smoking cessation is advised, with special caution for women smokers regarding the discontinuation of oral contraceptive pills (OCP)

• Stroke prevention strategies include reducing risk factors, avoiding ASA for primary prevention, and focusing more on rhythm control for atrial fibrillation (AF) with lenient rate control at heart rates below 110 beats per minute

• Atrial Fibrillation (AF) and Stroke Prevention

• For AF with stroke prevention, there is a shift towards rhythm control

• In AF with mechanical valve, warfarin with INR range is 2-3 or 2.5-3.5, with INR monitoring weekly initially and then monthly

• Nonvalvular AF PCI and CHADS score greater than 2 should receive Clopidogrel and oral anticoagulant (OAC) but no ASA

• Nonvalvular AF with CHADS score greater than 2 or history of CVA/TIA is recommended to receive Warfarin with INR 2-3 or direct oral anticoagulants (DOAC)

• For nonvalvular AF at low risk (CHADS 0 or 1), the management may involve no treatment, ASA, or OAC based on individual factors

• Venous Thromboembolism (VTE) and Prevention

• Hospitalized VTE risk assessment can be done using Padua Prediction Score or IMPROVE score

• Treatment of VTE involves using LMWH or Fondaparinux over unfractionated heparin (UFH)

• In the intensive care unit (ICU), LMWH is preferred over UFH

• Prophylaxis for VTE should NOT include direct oral anticoagulants (DOACs) in hospitalized patients, and long-distance travelers may benefit from compression stockings or LMWH

• Low Back Pain and Breast Cancer Prevention

• Low Back Pain Management

• Treatment for low back pain includes exercise and education

• Breast Cancer Prevention Strategies

• Lifestyle modifications such as exercise, healthy diet, and limiting alcohol consumption are recommended for breast cancer prevention

• Additional preventive measures include breastfeeding, avoiding chest radiation (Hodgkin), and considering hormonal therapy (e.g., tamoxifen - estrogen agonist for pre and post-menopausal, raloxifene or anastrozole (both are postmenopausal only)) for vasomotor symptoms

• Gout Prevention and Management

• NSAIDs or colchicine are recommended for up to 6 months after the first gout attack

• Urate-lowering therapy like allopurinol is not indicated for the first gout attack but may be considered for recurrent attacks or in the presence of tophi

• Oral Cancer, Osteoporosis, and Pressure Ulcers

• Oral Cancer Risk Factors

• Risk factors for oral cancer include tobacco use, alcohol consumption, betel nut chewing, sun exposure, and infection with HPV 16/18

• Osteoporosis Management

• Preventive measures for osteoporosis include weight-bearing exercises, fall prevention strategies, reducing central nervous system medications, addressing vitamin D deficiency, and avoiding tobacco and excessive alcohol consumption

• Recommended daily intake includes 1200mg of calcium and 600 IU of vitamin D, with pharmacotherapy indicated for T-scores below -2.5

• Pressure Ulcers and Skin Cancer Prevention

• Strategies for preventing pressure ulcers involve reducing pressure points, maintaining skin moisture, proper hydration and nutrition, and avoiding compression stockings in individuals with arterial disease

• Skin cancer prevention includes sunscreen use, minimizing UV exposure, and avoiding tanning beds

• Endocrine and Metabolic Disorders

• Diabetes Mellitus (DM) Management

• Management of DM includes dietary modifications, regular exercise, weight loss, annual monitoring, flu vaccination, pneumococcal vaccination, and consideration of aspirin therapy for individuals with a Framingham Risk Score (FRS) greater than 10%

• Hormone Replacement Therapy (HRT) in Postmenopausal Women

• HRT is not recommended for the prevention of osteoporosis, coronary artery disease (CAD), breast cancer, or cognitive decline in postmenopausal women (even for hysterectomy patients if they still have ovaries)

• Consider HRT for those with ovaries removed (premature menopause) for vasomotor symptoms

• Gastrointestinal Disorders

• Colorectal Cancer (CRC) and Esophageal Cancer (Eos CA)

• Risk factors for CRC include high cholesterol, alcohol consumption, high-fat diet, tobacco use, obesity, and being overweight

• Eosophageal cancer risk factors differ based on the type (adenocarcinoma or squamous cell carcinoma) and include GERD, smoking, alcohol consumption, achalasia, obesity, and diets high in starch but low in fruits and vegetables

• Gastric Cancer and Hepatocellular Carcinoma (HCC)

• Gastric cancer risk factors include consumption of smoked foods, salty foods, obesity, physical inactivity, and infection with H. pylori

• HCC risk factors encompass viral infections (HBV, HCV), alcohol consumption, non-alcoholic steatohepatitis (NASH), primary biliary cholangitis (PBC), Wilson disease, and exposure to aflatoxin

• Genitourinary Disorders

• Cervical Cancer and Endometrial Cancer

• Preventive measures for cervical cancer include HPV vaccination, tobacco cessation, reducing oral contraceptive pill (OCP) use, regular Pap screening

• High parity and HPV positivity increase cervical cancer risk

• Endometrial cancer risk factors involve unopposed estrogen exposure, obesity, tamoxifen use, nulliparity, and endometrial hyperplasia

• Preventive strategies for endometrial cancer including combined estrogen-progestin oral contraceptives, weight management, and increasing parity

• Ovarian Cancer and Prostate Cancer

• Ovarian cancer risk factors include postmenopausal unopposed estrogen use, genetic predisposition (BRCA testing), elevated BMI, and tall stature, with preventive options like oral contraceptives, tubal ligation, breastfeeding, and prophylactic bilateral salpingo-oophorectomy (BSO)

• Prostate cancer risk factors include family history, African descent, and the use of finasteride or dutasteride for risk reduction

• Newborn and Infants, Older Adults, and Pregnancy

• Newborn and Infants Care

• Sudden Infant Death Syndrome (SIDS) prevention strategies include placing infants on their back to sleep, avoiding soft bedding, ensuring a firm sleeping surface, room-sharing without bed-sharing, eliminating tobacco and alcohol exposure, preventing overheating, and discouraging stomach or side sleeping

• Management of gonorrhea ophthalmia neonatorum varies by country, with Canada recommending against routine prophylaxis and the USA suggesting erythromycin ointment

• Older Adults Health and Pregnancy Care

• Elderly driving assessments should consider dementia, history of motor vehicle accidents, Mini-Mental State Examination (MMSE) scores, alcohol use, and medications

• Falls prevention in the elderly involves modifying home hazards, conducting multifactorial assessments, recommending vitamin D supplementation, strength and balance training, and reducing psychotropic medications

• Hormone replacement therapy (HRT) in postmenopausal women may

○ ↓ hip fracture risk, ↓ CRC

○ ↑ breast cancer risk, VTE risk, cholecystitis risk, and dementia risk

○ No effect coronary artery disease (CAD) risk

• Pregnancy considerations include vaginal birth after cesarean (VBAC) safety, risk calculators for cesarean section (C/S) rates, and management of women in labor requiring cesarean section or induction

• Pregnancy Preventive Care

VBAC (Vaginal Birth After Cesarean)

• Considered "safe and appropriate for most" with a success rate of 75%.

• Approximately 80% of women who had a previous Cesarean section (C/S) undergo repeat C/S.

• It's advisable to choose a facility that offers Trial of Labor After Cesarean (TOLAC) services.

• Planned Vaginal Birth After Cesarean (PVBAC) is an option for eligible candidates.

Women in Labor - Cesarean Section (CS)

• Induction of labor should only be performed for medical reasons, as it increases the risk of complications.

• There is an increased risk of uterine rupture or abnormal implantation in women who undergo induction.

GBS (Group B Streptococcus)

• Rectal swab for GBS is typically performed at 35 to 37 weeks in Canada.

• Intrapartum antibiotic prophylaxis (IAP) is recommended for women with a current positive GBS culture, GBS bacteriuria during pregnancy, or a history of GBS infection in a newborn.

• IAP should not be administered for C/S with intact membranes and before the onset of labor.

• Penicillin G is the first-line antibiotic for IAP, with alternatives such as amoxicillin, cefazolin (if non-anaphylactic allergy), clindamycin or vancomycin (if truly penicillin-allergic).

Other Pregnancy-Related Recommendations

• Folate supplementation (0.4-0.8 mg) is recommended for women of childbearing age or planning pregnancy to prevent neural tube defects (NTDs).

• High-risk factors for pre-eclampsia include diabetes mellitus (DM), chronic hypertension, personal history of pre-eclampsia, multifetal gestation, and autoimmune disorders.

• Aspirin (ASA) is recommended at 12 weeks for women with one or more risk factors for pre-eclampsia.

• Progesterone can be offered at 16-24 weeks to prevent preterm birth, regardless of cervical length.

• Cervical cerclage may be considered for women with a short cervix (<2.5 cm) before 24 weeks of gestation.

• Various measures to prevent surgical site infections, manage venous thromboembolism (VTE), and discourage tobacco use during pregnancy are outlined.

• Behavioral Health

• Psychiatric and Substance Use Disorders

• Routine laboratory tests or CT scans are not recommended for psychiatric evaluations

• Alcohol use disorder management involves thiamine prophylaxis, pancreatic enzyme supplementation, assessment for psychiatric comorbidities, and medications like naltrexone and acamprosate

• Anxiety management according to NICE 2018 guidelines includes cognitive-behavioral therapy (CBT) or sertraline, with avoidance of benzodiazepines and antipsychotics

• Attention-deficit/hyperactivity disorder (ADHD) treatment starts with behavioral interventions and may progress to medications like methylphenidate, lisdexamfetamine, or dexamfetamine, while avoiding guanfacine, clonidine, and atypical antipsychotics

• Autism spectrum disorder may present with regression of social and language skills

• Depression treatment with SSRIs may increase suicidality by 1-2%

• Eating disorder management is multidisciplinary and includes bone mineral density monitoring and dental care

Chapter 19 - ID

• Intravascular Catheter:

• Prefer PICC for IV >6 days.

• Choose peripheral over central if it works.

• Upper extremity preferred; avoid femoral vein for central access.

• Nontunnelled CVC in subclavian > IJV or femoral for reduced infection risk.

• Use ultrasound guidance.

• Remove unneeded catheters promptly.

• Replace emergent catheters within 48 hrs.

• C Difficile:

• Implement contact precautions.

• Endocarditis Prevention:

• Prioritize oral hygiene over antibiotics before dental procedures.

• Antibiotics not recommended for MVP, rheumatic heart disease, or most congenital conditions (despite increased IE risk).

• Consider antibiotics for gingival or periapical issues.

• Mitral stenosis from rheumatic heart disease should be on long-term antistreptococcal prophylaxis.

• Avoid tattoos in cardiac conditions.

• Conduct preoperative dental evaluation before cardiac valve replacement or repair.

• Influenza Chemoprophylaxis and Immunization:

• Use inhaled zanamivir or oral oseltamivir for chemoprophylaxis.

• Influenza vaccination preferred for those unable to be vaccinated.

• Vaccine recommended for ages >6 months.

• Live attenuated vaccine (LAIV) contraindicated for <2 years, severe febrile illness, immunodeficiency.

• Egg allergy not a contraindication.

• GBS within 6 weeks of influenza is a contraindication.

• Zoster: > 50 years

Chapter 20 - Renal

• AKI:

• Use isotonic crystalloids over colloids for volume expansion.

• Employ volume expansion in specific cases (e.g., GFR <40, CHF, renal transplant, >75 years).

• Do NOT use diuretics unless volume overload is present.

• Avoid dopamine and vasopressors.

• Unclear evidence for NAC to prevent contrast-induced nephropathy.

Chapter 21 - Children and Adolescents

• Asthma:

• Avoid smoking, vaginal delivery, excessive acetaminophen, and broad-spectrum antibiotics.

• Minimize maternal obesity and maternal intake of allergens.

• Allergen avoidance not effective for primary prevention of asthma.

• Atherosclerotic CVD in Children:

• Increase omega-3 intake and decrease sugar consumption.

• Encourage physical exercise.

• Consult a lipid specialist for very elevated lipid levels.

• Concussion:

• Consider discontinuing sports participation if chronic neurological defects persist or repeat concussions occur.

• Dental Caries (Up to 5 years):

• Clean infant gums daily with a soft, damp cloth.

• Apply fluoride varnish upon primary tooth eruption.

• Supplement oral fluoride if deficient.

• Fluoride mouthwash decreases caries risk by 25% for children under 16 years.

• Otitis Media:

• Avoid prophylactic antibiotics.

• Encourage exclusive breastfeeding for 6 months.

• Eliminate tobacco exposure.

• Vaccinate against pneumococcal and influenza infections.

Other: