FAM 551 Family Medicine 2024-2025 PDF

2024-2025  FAM 551 2 Family Medicine FAM 551 Contributors Prof. Marwa Mostafa Ahmed Ass. Prof. Inas Talaat Abd El Hamid Dr. Nadia Mostafa Tawfik  FAM 551 3 Preface Family Medicine i...

2024-2025  FAM 551 2 Family Medicine FAM 551 Contributors Prof. Marwa Mostafa Ahmed Ass. Prof. Inas Talaat Abd El Hamid Dr. Nadia Mostafa Tawfik  FAM 551 3 Preface Family Medicine is an incredibly rewarding specialty that allows physicians to provide comprehensive care to patients while fostering long-term relationships with them. This aspect of continuity of care not only energizes us as physicians but also serves as a cost-effective strategy for delivering healthcare services to the nation. This book aims to equip students with a thorough understanding of the principles that underpin this specialty. It delves into various aspects, including the application of these principles in addressing common medical problems encountered in primary care settings. By providing practical insights and evidence-based approaches, we believe this book will serve as an invaluable tool for our aspiring students. Dr. Marwa Ahmed Head of Family Medicine Department Faculty of Medicine, MTI university  FAM 551 4 Learning objectives By the end of this module, the student should be able to: 1. Recognize the principles of Family Medicine. 2. Identify the referral process in primary care. 3. Recognize the components of successful consultation in primary care. 4. Recognize the role of Family physician in managing common problems throughout the life cycle. 5. Recognize the role of Family physician in managing traveler diarrhea 6. Identify the components of child health maintenance. 7. Identify the components of adolescent health maintenance. 8. Identify the components of adult health maintenance. 9. Identify the components of Geriatric health maintenance. 10.Recognize role of Family physician in managing undifferentiated cases. 11.Recognize the role of family physician in providing health education and behavior modifications. 12.Recognize the role of Family physician in providing health care for common chronic diseases in primary care. 13.Recognize the role of Family physician in in delivering emergency medical care.  FAM 551 5 Table of Contents Introduction to Family Medicine............................................................................................................. 6 Referral in primary care.......................................................................................................................... 9 Consultation skills in primary care....................................................................................................... 11 Family physicians providing care throughout life cycle...................................................................... 16 I. Child Health Maintenance.................................................................................................................. 16 Common child health problems in primary care................................................................................. 24 II. Adolescent Health Maintenance....................................................................................................... 38 Common adolescent health problems in primary care....................................................................... 45 III. Adult Health Maintenance.............................................................................................................. 52 IV. Geriatric Health Maintenance........................................................................................................ 57 Common geriatric health problems in primary care........................................................................... 62 Traveler medicine................................................................................................................................... 74 Role of family physician in promoting women health......................................................................... 77 Role of family physician in manging acute medical problems in PHC.............................................. 97 Role of family physician in managing undifferentiated medical problems..................................... 100 Role of family physician in providing Health education for chronic disease.................................. 102 Role of family physician in behaviour modification.......................................................................... 113 Role of family physician in delivering emergency medical care....................................................... 116 Annex 1.................................................................................................................................................. 120 Integrated Management of newborn and childhood illness (IMCI)................................................ 124................................................................................................................................................................. 124 Annex 2.................................................................................................................................................. 126 Caring for patients with dementia....................................................................................................... 126 References.............................................................................................................................................. 128  FAM 551 6 Introduction to Family Medicine History of Family Medicine The term “general practitioner” was first mentioned by Lancet in 1823. In the two decades following World War II, the number of specialists and sub specialists increased dramatically, while the number of general physicians declined. In 1923, Dr. Francis Peabody (Professor of Medicine at Harvard) called for a rapid return of the general physician who would give comprehensive care. In 1960, the specialty of family medicine was created based on three important committee reports recommendations in USA. In 1972, the World Organization of Family Doctors (WONCA), which is made up of national colleges or organizations concerned with academic aspects of family medicine, was founded. It has over two million family physicians /general practitioners. In 1978, the Declaration of Alma-Ata proposed a set of principles for primary health care. As the new century began, there was a strong sense that medical practices in Egypt were far behind from those of European countries. The need to establish more family medicine departments inside the Egyptian medical schools was much highlighted in both the first and the second Medical Education Conferences in 1976 and 1978 respectively. Family medicine as an academic specialty was first established in The Faculty of Medicine, Suez Canal University. This was followed by the establishment of the family medicine department at Menoufia and Cairo universities. Today, family physicians constitute the fundamental core of the health system worldwide. The new Egyptian Universal Health Insurance Law is introduced through family-oriented primary health care, including family medicine units and centers. The Egyptian Family Medicine Program aims to provide comprehensive and continuous health care to all the population. This is done by developing more than 2500 family medicine units and centers and offering technical and administrative training to family physicians.  FAM 551 7 Family Medicine Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical, and behavioral sciences. The scope of family medicine encompasses all ages, all genders, each organ system, and every disease entity. There is a need to define both the discipline of general practice/family medicine and the role of the specialist family doctor. The former is required to define the academic foundation and framework on which the discipline is built, and thus to inform the development of education, research, and quality improvement. The latter is needed to translate this academic definition into the reality of the specialist. Principles of Family medicine Access to Care Primary care should be readily available. Access to a quick response to questions is also important. Continuity of Care Seeing the same provider over time helps to enhance continuity of care. However, because no physician can be available all the time, continuity of care can be enhanced by using a comprehensive, shared medical record (continuity of information). Team-based, Comprehensive, Personalized Care A family physician manages without referral between 85% and 90% of patient problems. A wide range of services are provided, including acute care, chronic disease care, preventive care, and care for biomedical and psychosocial problems, and they are tailored to the personal needs and priorities of the patient. This provision of a wide variety of services, covering most patient needs, is termed comprehensiveness of care. It is convenient for the patient, as there is no need to go to multiple providers to get service. Team-based services can include dental services, physical therapy, and a variety of complementary/alternative health providers. Coordination of Care Coordination of care includes being aware of the variety of services available, making appropriate requests for consultation or referral, collecting and interpreting results of studies and specialist visits, and advising when additional care is and is not warranted.  FAM 551 8 Community Orientation Family physicians seek to improve the broader health of the community. In working with patients, they are aware of the many community resources, both formal and informal, that are available to help patients manage their medical and psychosocial needs. Prevention Focus Examples of preventive visits include prenatal care, adult physicals, well baby checkups, well child examinations. Patient Self-empowerment and Self-management Effective chronic illness care requires a partnership in which medical providers help the patient acquire the knowledge, skills, and self-empowerment to manage risk factors, monitor the illness, and make adjustments in their care. Evidence-based Practice Family physicians provide evidence-based practice. This is achieved through the integration of best available evidence, clinical intuition, and knowledge of the patient, family, and community to arrive at the best decisions. Family Orientation Being oriented to the family context is important in medical care because most health behaviors and illness episodes involve some connection with the patient’s social support network. Biopsychosocial, Life-cycle Perspective Effective family physicians view patients from a broad perspective, taking into account physiology, physical illness, emotional health, and the social, occupational, and environmental context within which the person lives. Levels of health care system: Primary Care: is a people-centered rather than disease-centered service that addresses the majority of a person’s health needs throughout their lifetime including physical, mental and social well-being. Secondary Care: is the specialist treatment and support provided by doctors and other health professionals for patients who have been referred to them for specific expert care, most often provided in hospitals. Services are usually based in a hospital or clinic, though some services may be community- based. Tertiary Care: is a level above secondary health care, that has been defined as highly specialized medical care, usually provided over an extended period of time, that involves advanced and complex diagnostics, procedures and treatments performed by medical specialists in state- of-the-art facilities.  FAM 551 9 Referral in primary care Coordination of Care: Family physicians help their patients negotiate the complex health care system by serving as coordinators of care. Through making appropriate requests for consultation or referral, collecting and interpreting results of investigations and specialist visits, and advising when additional care is and is not warranted. It also involves helping patients comprehend what is happening to them, by helping them integrate what are often disparate messages into a coherent whole. Referral System Involves sending a patient to another physician for ongoing management of specific problem and the patient will continue to see the original physician for coordination of total care. Its main goal is to improve the streamline communication among primary care physicians, specialists, and health providers involved in a patient’s care. Referral process 1. The decision is made. 2. Consideration is given to patient’s medical, emotional, cultural & socioeconomic background. 3. Selection of appropriate specialty & appropriate physician in the field. 4. The consultant provides feedback to the family physician. 1- The family physician evaluates the appropriateness of the consultant’s recommendation. 5. The family physician acts on the recommendations. 2- The family physician provides feedback to the consultant regarding the outcome. 3- Evaluation & follow up Types of referrals Routine Emergency Opportunistic Referral letter Patient details (name, location, age & sex). Name of family physician making request & name of the physician being consulted. ▪ Reasons for referral. ▪ Degree of urgency for appointment. ▪ Clinical problem. Important previous history. Findings on physical examination. Findings on investigations. Medication & drug sensitivities. Received medical care Expected outcome & desirable follow up.  FAM 551 10  FAM 551 11 Consultation skills in primary care A successful outcome to the medical consultation depends on a whole array of skills required by the family physician. These skills, which can be collectively termed ‘consulting skills’, include interviewing skills, clinical skills, diagnostic skills, management skills, communication skills, educative skills, therapeutic skills, manual skills and counselling skills. Communication skills, which are fundamental to consulting skills, are the key to the effectiveness of the doctor as a professional, and expertise with these skills is fundamental to the doctor–patient relationship. The purpose of consultation is to bring the relevant knowledge, skills & experience to the benefit of the patient.  FAM 551 12 1. Initiating the session The first physical encounter between patient and clinician sets the scene for the entire medical management to follow. Preparing for the session The pre-consultation period should be used wisely. Always allow for a couple of minutes between patients to end off the earlier consultation, and to get into a neutral mindset before the onset of the following appointment. Establishing Rapport An important part of establishing rapport is to convey a message of respect. Body language should not in any way contradict verbal communication. The clinician should be seated, facing the patient at a comfortable distance, leaning slightly forward and making good eye contact. The use of other non-verbal cues such as applicable gestures/greeting (for example, a handshake) and making the patient comfortable, sends a welcoming and accepting message. Clinicians who communicate in a warm, empathic, and reassuring way improve patient satisfaction and adherence. Identifying the need for the consultation Start the clinical questioning with an open-ended general enquiry (“How can I help today?”). Open-ended questions provide an opportunity for the patient to disclose his/her complaints. Where closed-ended questions lead to yes-no answering, open-ended questions generally yield longer, more comprehensive answers. Open-ended questions may be followed by closed-end questions only if the clinician needs more clarity on certain detail. But take care not to interrupt the patient by asking clarification questions too soon. A common pitfall to avoid is to interrupt a patient in the early minutes of the interview (The golden moment). After the patient has completed the initial problem statement, the clinician can provide a summary of what is understood. 2. Gathering Information Information gathering involves further exploration of the patient’s problem from the biomedical perspective and the patient’s perspective. During this part of the interview, the clinician gains as much information as possible to formulate a well-supported clinical hypothesis. A shift from a ‘disease model’ to a ‘biopsychosocial model’ in the patient interview is integral for a comprehensive clinical picture. The term "biopsychosocial” refers to a combination of a biomedical  FAM 551 13 investigation, understanding social background and context, and regarding a person’s potential psychological connections to their illness. A psychosocial approach “tells the patient’s illness story” and explains and predicts the individual’s experience and response to illness. Skills Necessary for Gaining Biopsychosocial Information Active Listening Active listening puts patients at ease, signals interest from the clinician’s side and thereby facilitates disclosure of information without feeling pressured. It involves both verbal and non-verbal behavior. The clinician should allow the patient to talk without interrupting and leave space for the patient to think before answering. Explore Patient Perceptions and Concerns, and Setting the Agenda Empathy is defined as the cognitive understanding of a patient’s experiences, concerns and perspectives, and the ability to communicate this understanding in order to help alleviate any form of suffering or discomfort. An empathic clinician creates a space where a patient feels comfortable to disclose sensitive information without fearing judgement or a breach of confidentiality. The clinician also needs to thoroughly understand the patient’s ideas, concerns and expectations regarding the presenting condition. Expectations can include aspects such as the exploration of alternative treatment options, diagnostic clarity, reassurance and verification, or even the opportunity to voice frustration and anger. Explore the Impact of Symptoms on the Patient’s Life Functional impairment is a major threat to many patients, especially if their regular income or normal functioning is at stake. Clinicians need to explore the extent of the functional impairment due to the presenting condition, but also how this impairment affects the patient on an emotional and psychological level. 3. Physical examination A thorough and effective physical examination is considered an art that is important for proper diagnosis and builds the patient-physician relationship. Signposting involves informing the patient of what you are about to say or do to help them feel less anxious and give them a sense of control. This is achieved by providing a concise summary of the last step and the following step of the assessment.  FAM 551 14 4. Explanation and planning Providing Feedback to the Patient A practical way to provide this feedback in a logical, quickly remembered manner by using the mnemonic DCEPT: D – Diagnosis C – Cause of condition E – Expected further course of the condition P – Prognosis T – Treatment options Evidence-based methods to convey information and enhance optimal understanding and recall: Chunk and check: Deliver information in small quantities and then stop to ensure the patient understands before continuing to the next bit of information. Use clear words and avoid medical jargon when explaining diagnosis, prognosis, and treatment options. Repeat and summarize information where applicable. Ask the patient to repeat applicable instructions, advice, or summary of information. Personalize patient management plans rather than providing generic written protocols. Shared Decision Making Shared decision-making is “a collaborative process that involves a person and their healthcare professional working together to reach a joint decision about care.” The clinician shares with the patient all alternatives in treatment options, including possible benefits and harms of each option, while considering the patient’s values, preferences and circumstances. Shared decision-making relies on evidence-based practice, the clinical expertise of the health care professional, and patient-specific conditions and settings. 5. Closing the Session Closing provides the clinician with a final opportunity to Safety-netting: making sure ensure proper comprehension and commitment from the the patient understands how patient. and when to seek medical Closing is divided into two parts including contracting help if their condition with the patient regarding the next steps of treatment, as worsens or does not follow well as safety netting this is followed by a brief the expected path. clarification and summary.  FAM 551 15 Breaking bad news ▪ One of the most important skills is the ability to “break bad news” to patients and families. ▪ Breaking bad news is a complex task that can be managed successfully if it is done correctly. ▪ A mental strategy for not only conveying the information, but also dealing with emotion, the family, and the plan for further care and support can be more easily planned when a relationship has previously been established with the patient. SPIKES protocol The SPIKES protocol is a six-step framework designed to help healthcare professionals deliver bad news effectively while maintaining empathy and understanding. 1. Setting: Prepare a private and comfortable environment for the conversation. Sit down, make sure patient data is available, and involve significant others if needed. Establish rapport and ensure there are no interruptions during the discussion. 2. Perception: Assess what the patient already knows about their condition. Listen carefully to understand their level of comprehension and avoid confronting denial at this stage, as it can be a protective mechanism for the patient. 3. Invitation: Ask the patient how much detail they wish to know about their condition or treatment. Respect their preference to receive or avoid certain information and offer to answer more questions later if they decide to know more. 4. Knowledge: Share medical facts in a clear and understandable manner, tailoring the information to the patient’s background and emotional state. Present information in small, manageable chunks and check for understanding throughout the conversation. Start with positive aspects when possible. 5.Emotions: Respond to the patient’s emotional reactions with empathy. Identify their emotions, explore their feelings, and offer support by connecting their feelings to the situation. Use empathetic phrases to acknowledge their distress and provide comfort. 6. Strategy and summary: Conclude by discussing the next steps in the treatment plan, performing further tests, or addressing symptoms. Ensure the patient feels supported by reassuring them that you will continue to provide care and guidance and confirm that they will be safe after the discussion.  FAM 551 16 Family physicians providing care throughout life cycle The primary care clinician follows their patient throughout their medical journey, building a partnership to collaboratively discuss, plan for, and achieve one’s optimal health. Capitalizing on the rapport, trust, and partnership built, clinicians can focus efforts on clearly and transparently discussing the patient’s health and goals for care. Using evidence-based guidelines like the USPSTF gives the clinician the power and the knowledge to help guide the conversation as well as the overall care of the patient throughout the continuum, striving for optimal health in the physical as well as psychosocial domains. The utilization of sensitive and specific screening tools can serve to guide the decision-making process and the formulation of differential diagnoses. Screenings are utilized to help identify early-stage disease processes where early identification and treatment have been demonstrated to improve outcomes. Safety, risk, cost-effectiveness, and predictive value need to be considered when deciding which screenings are to be conducted in which populations. I. Child Health Maintenance The pediatric well-child examination provides an opportunity Stages of growth and development for parents, especially first-time parents, to ask questions about, Prenatal and for the physician to address specific concerns regarding, their child. 1. Embryonic period (first 8 weeks) 2. Fetal period (9-40 weeks) It allows the physician to assess the child's growth and Postnatal development in a systematic fashion and to perform an 1. Neonatal period (first 28 days) appropriate physical examination. It also allows for a review of 2. Infant (till 2 years) both acute and chronic medical conditions. 3. Early childhood 2-6 years 4. Late childhood (6-10) When performed at recommended time intervals, it gives the opportunity to provide age-appropriate immunizations, 5. Adolescent (10-19) screening tests, and anticipatory guidance. Finally, it supports the development of a good doctor-patient-family relationship, which can promote health and serve as an effective tool in the management of illness. A comprehensive history should be obtained at the initial visit, with more focused, history obtained at subsequent encounters: ▪ The initial history should include an opportunity for the parent to raise any questions or concerns that the parent may have. ▪ Past Medical History: A complete past medical history should be obtained. This should start with a detailed prenatal and pregnancy history, including the duration of the pregnancy, any complications of pregnancy, the type of delivery performed, the child’s birth weight, and any neonatal problems. Any significant chronic or acute illnesses should be recorded. The use of any  FAM 551 17 medications, both prescription and over the counter, should be reviewed. Old medical records should be obtained if available. ▪ Growth charts, immunization records, results of screening tests, and other valuable information that can assist with the child’s assessment can often be found and reduce the unnecessary duplication of previously performed interventions. ▪ Family History: A detailed family history, including information (when available) on both maternal and paternal relatives, should be obtained. ▪ A thorough social history is critical in pediatric care; information such as the parents’ education levels, relationships, religious beliefs, use of substances (tobacco and drugs), and socioeconomic factors can provide significant insight into the health and development of the child. Newborn assessment in primary health care The care begins just after the birth with routine management of the newborn, which involves a physical examination, eye care, and routine disease prevention and screening. All newborns must be antibiotic drops in each eye to prevent ophthalmia neonatorum. Growth monitoring: A newborn with birthweight 65 with increased risk of fall and for patients at ↑ risk. ▪ Balance, gait, & strength training; at least 12 weeks duration with 30–90-min sessions occurring 1 to 3 times/week ▪ Examples: OTAGO exercise program (https://www.youtube.com/watch?reload=9&v=RmZO_EPoB4k ) 3. Treatment of osteoporosis 4. Patients at ↑ risk: Treatment varies by cause of fall. May include the use of assistive devices (walker, cane), replacement of high-risk medication or ophthalmology referral.  FAM 551 64 Osteoporosis The National Osteoporosis Foundation defines osteoporosis as a chronic, progressive disease characterized by low bone mass, microarchitecture deterioration of bone tissue and bone fragility with a consequent increase in fracture risk. Osteoporosis can be prevented, diagnosed, & treated. Screening plays critical role in ↓ disease burden, as disease is clinically silent until falls occur. Primary osteoporosis occurs with advanced age. While secondary osteoporosis result from medications, endocrinopathy and systemic diseases. Fragility fracture: Bone fracture caused by low-trauma activity which presumably would not occur without underlying bone weakness. It is usually pathognomonic for osteoporosis. Major osteoporotic fractures usually affect hip, spine, proximal humerus, or forearm. Disease burden: Hip fracture is major source of ↑ mortality and dependency in elderly. It increases the risk of future fracture. Screening of osteoporosis The USPSTF recommends screening for osteoporosis by Bone mineral density testing using dual-energy x-ray absorptiometry (DEXA) for women of 65 years and older and those younger than 65 years with risk for fracture. WHO classification of bone mineral density (BMD) based on standard deviation (SD) difference between a patient's BMD and that of a young adult reference population (T-score). ▪ Normal: T-score ≥–1 ▪ Osteopenia: T-score between –1 & –2.5 ▪ Osteoporosis: T-score ≤–2.5 (For postmenopausal and ≥50) Risk factors of osteoporosis ▪ Increasing age ▪ Low weight ▪ Heredity and race (parent with hip fracture; White or Asian race) ▪ Female gender ▪ Inactive lifestyle ▪ Tobacco use ▪ Low calcium intake ▪ OP may be secondary to many disease states (metastatic lesions, multiple myeloma, immobilization, weight loss, renal or hepatic failure, intestinal malabsorption, renal calcium loss, and excesses of cortisol, parathormone, or thyroxine).  FAM 551 65 ▪ Other risk factors: o Gonadal hormone deficiency (gonadal failure, surgical or natural menopause, oligomenorrhea (5 to 7 cm Body mass index lower than 20 About 60% of women with spinal compression fractures are unaware of their occurrence. Laboratory Studies: ▪ Basic evaluation: Complete blood count (CBC), electrolytes, creatinine, serum 25-OH-vitamin D, thyroid-stimulating hormone, liver function tests, phosphate, and calcium are normal, but alkaline phosphatase may be temporarily elevated following a fracture. ▪ Other tests. In otherwise unexplained cases, consider testing urinary calcium (normally 50 to 250 mg per day), parathyroid hormone. Imaging: DEXA scanning can be used in diagnosing OP and in monitoring progress in treatment. ▪ There is no firm evidence for how often DXA should be repeated, either for primary screening or for monitoring treatment. ▪ However, the US Preventive Services Task Force recommends waiting at least 2 years between DXAs to adequately assess change. Evaluation of fracture risk All pts should be assessed for presence of risk factors. If present → fracture risk assessment tool (FRAX) and DEXA scan should be done  FAM 551 66 Determining fracture risk: ▪ FRAX estimates 10 y risk of hip fracture and major osteoporotic fracture. ▪ It is available at frax.shef.ac.uk/FRAX/ Differential Diagnosis of Fracture: ▪ Consider metastatic lesions, multiple myeloma, osteomalacia, infections (Pott disease), pathologic fractures from Paget disease, or bone tumors. Alcoholism should always be considered, particularly when OP occurs in young people or middle-aged men, and it causes more fractures than predicted by bone density. ▪ Many of these conditions can be excluded by history and physical examination Management of osteoporosis Nonpharmacologic therapy: Indicated for all patients with ↓ BMD or fragility fracture. A balanced diet rich in vitamin D, calcium, protein, vegetables, and fruits Make sure that calcium intake for postmenopausal women is 1200 mg/day. If cannot achieve it through diet, then need to take calcium supplements. Vitamin D supplementation 1000 IU per day Weight-bearing exercise (walking, running, dancing, aerobic exercise, sports, weight lifting as appropriate) has skeletal, cardiovascular, muscular, and emotional benefits for all age groups. Reasonable goal: 30 to 60 minutes, 4 to 6 times per week. Smoking cessation Discourage unnecessary weight loss Fall prevention in those at ↑ risk of falls. Pharmacologic therapy: Indicated in all pts with osteoporosis (including history of fragility fracture) or osteopenia and (10 y risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% per FRAX algorithm). ▪ Bisphosphonates: Oral bisphosphonates are first-line pharmacologic therapy. It ↓ incidence of hip & vertebral fractures. Oral bisphosphonates should be taken only with water and a wait of at least 30 minutes before reclining or ingesting other medication or food. ▪ Denosumab: Consider if patient has chronic kidney disease or can’t tolerate bisphosphonates. ▪ Hormonal replacement therapy (HRT): Estrogen therapy, with or without a progestin, has been shown to prevent postmenopausal bone loss. The use of these agents for osteoporosis is no longer generally recommended in otherwise healthy postmenopausal women and if used, should be started at the lowest possible dose for the shortest time period possible. ▪ Others: e.g., teriparatide (prescribed by endocrinologist).  FAM 551 67 Polypharmacy Definition: Polypharmacy is defined as taking more than five medications and is an independent risk factor for both delirium and falls Complications: Increase adverse drug reactions Increase drug interactions Decrease adherence Increase hospitalization increase medical cost Increase cognitive impairment, falls, urinary incontinence and delirium Decrease function and quality of life. Increase mortality Causes of Polypharmacy Patient Physician 1- Multiple comorbidities 1- Presuming that patients expect prescription of 2- Multiple physicians medications (Ignore nonpharmacological strategies) 3- Reluctant to discontinue medications 2- Prescribing drugs without sufficient assessment 4- Self medications 3- Unclear instructions 5- Underreporting of medicines or symptoms 4- No regular review of medication list which may be drug induced 5- Treating S/E with other drugs 6- Lack of knowledge about geriatric clinical pharmacology Steps for appropriate prescribing ▪ Step 1: Define the patient’s problem (Diagnosis) ▪ Step 2: Specify the therapeutic objective ▪ Step 3: Verify the suitability of treatment (Efficacy- S/E – Drug interaction – contraindications – Function & QoL- Barriers to drug adherence) ▪ Step 4: Give information, instructions & warning (Effect (Why & when)- S/E (what & how ) – How long- When to stop ) ▪ Step 5: Using tools that are available to guide clinicians in the choice of medications for older adults. Like the Beers criteria to identify potentially harmful medications; an updated list is available through the American Geriatrics Society. The tool is available here: (http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf).  FAM 551 68 Major Neurocognitive Disorders (Dementia) As the aging population grows, so will the number of dementia cases and the burden to the family and caregivers. According to current estimates, more than 55 million people worldwide are living with dementia, which is expected to increase over the next 35 years. In Egypt, the prevalence of dementia among adults aged 50 and older ranges from 2.01% to 5.07%. Definition, types & risk factors Dementia is an umbrella term for several diseases affecting memory, other cognitive abilities and behavior that interfere significantly with a person’s ability to maintain their activities of daily living. Although age is the strongest known risk factor for dementia, it is not a normal part of ageing. Types of dementia include Alzheimer disease, Vascular dementia, Frontotemporal dementia, Lewy body dementia (LBD), and mixed dementia. Risk factors for dementia include older age (the greatest risk factor), family history of dementia; personal history of cardiovascular disease, cerebrovascular disease, diabetes, or midlife obesity; use of anticholinergic medications; apolipoprotein E4 genotype; and lower education level. Diagnostic criteria: According to The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V): Major neurocognitive disorder requires demonstration of significant cognitive decline in at least one of the following cognitive domains: complex attention, executive function, language, learning and memory, perceptual-motor, or social cognition. This decline must be based on both subjective and objective findings and interfere with instrumental activities of daily living.  FAM 551 69 Evaluation of suspected dementia Initial History and Physical Examination ▪ History should include the input of a reliable informantion (e.g., family members, close friends, caregivers). ▪ Onset, course and duration of symptoms (Rapid onset and progression of symptoms (weeks to months) should prompt a specialty referral) ▪ Instrumental activities of daily living (which are usually affected in early dementia) ▪ Basic activities of daily living (which are usually affected later). ▪ Medication history (especially that may affect cognition). ▪ Evaluation for cardiac risk factors. Although physical examination findings are usually normal in patients with dementia, they can assist in identifying potentially reversible causes of cognitive decline, such as hypothyroidism, vitamin deficiencies, depression, neurosyphilis, intracranial tumors, and normal-pressure hydrocephalus. Screening Tests for Cognitive Impairment Mini-Cog The Mini-Cog test takes approximately three minutes to administer and has minimal to no language or education bias. The patient is instructed to repeat three unrelated words, perform a clock drawing test, and then recall the three words. Cognitive Tests for Patients Who Screen Positive on Initial Testing The following brief cognitive tests have limited sensitivity and specificity, particularly in patients with high intelligence and education levels. Physicians should consider referral for neuropsychiatric evaluation if a patient has normal findings on brief cognitive tests, but cognitive impairment is still strongly suspected. ▪ Mini-Mental State Examination (MMSE): There is a nomogram that establishes cutoff scores depending on the patient's age and education. ▪ The Montreal Cognitive Assessment (MOCA): has excellent sensitivity for detecting mild neurocognitive disorder. Diagnostic Evaluation Screening for depression using Geriatric Depression Scale. In patients with depression and dementia, treatment for depression should be initiated first. Pseudodementia, or depression causing cognitive impairment, is diagnosed if the impairment resolves with treatment of the depression.  FAM 551 70 Laboratory evaluation The standard laboratory evaluation for patients with cognitive impairment includes testing for anemia, hypothyroidism, vitamin B12 deficiency, diabetes, and liver and kidney disease. Other testing should be based on patient history or physical examination findings. Neuroimaging Routine structural neuroimaging in patients with suspected dementia is recommended by the American Academy of Neurology. Magnetic resonance imaging (MRI) without contrast media is the preferred imaging test to exclude other intracranial abnormalities, such as stroke, subdural hematoma, normal- pressure hydrocephalus, or treatable mass. Management of Dementia Nonpharmacological approaches: ▪ Lifestyle modifications to optimize cognitive function: include optimizing sleep, eating an anti- inflammatory diet, adequate exercise, treating hearing or vision loss, minimizing stress, and maintaining normal blood sugar, cholesterol, and blood pressure levels. ▪ Supportive care, memory training, physical exercise programs, and mental and social stimulation must be employed in symptom control. Pharmacological approaches: FDA-approved medications to improve cognitive function include cholinesterase inhibitors and memantine. Cholinesterase inhibitors include donepezil, galantamine, and rivastigmine. Supporting families and caregivers: ▪ Patients and their families should be counseled about the disease and its consequences. They should be provided with all the necessary information about what to expect and how to react. ▪ Coaching caregivers on skills that help them to deal with patients with dementia (Annex 2)  FAM 551 71 Prevention of dementia Dementia should be differentiated from Delirium Delirium History ▪ Determining the acuity of the “change in mental status” is the essential first step. ▪ Medications and alcohol use should be reviewed in detail. Physical Examination ▪ The examination should focus on whether delirium is present using the Confusion Assessment Method (CAM) which is the standard screening tool for delirium. ▪ The comprehensive examination, guided by the history and context, should focus on the likely cause(s) of the delirium. Confusion Assessment Method (CAM) For delirium to be identified, both features #1 and #2 must be present plus either #3 or #4. 1. Acute change in mental status with a fluctuating course 2. Inattention (reduced ability to sustain attention and follow conversations) 3. Disorganized thinking (problems with memory, orientation, or language) 4. Altered level of consciousness (hypervigilance, drowsiness, or stupor)  FAM 551 72 Laboratory and Imaging Delirium is a clinical diagnosis. Tests investigate the cause(s) of the delirium. ▪ Order tests based on history, vitals, and physical and neurologic examinations. ▪ Search for infections. ▪ A reasonable diagnostic workup would include complete blood count, electrolytes, urea, creatinine, glucose, calcium, magnesium, liver function tests, thyroid stimulation hormone, chest x-ray, urinalysis, electrocardiogram, and blood cultures. Causes of delirium Almost any medical illness, intoxication, or medication can cause delirium. It is often multifactorial, and each potential cause should be investigated. The most common causes include: ▪ Infections (think PUS—Pneumonia, Urinary, Skin). ▪ Medications (Even long-standing medications can contribute to delirium and should be evaluated.) ▪ Dehydration and electrolyte abnormalities Prevention ▪ Primary prevention of delirium is probably the most effective treatment strategy by targeting risk factors. ▪ Proactive geriatric consultation in patients undergoing surgeries like surgery for hip fracture. Treatment ▪ Identification and treatment of the underlying cause(s) while maintaining safety and preventing complications. ▪ There are no pharmacological agents approved by the US Food and Drug Administration (FDA) for delirium treatment. Furthermore, there is little evidence for both the off-label use, and the dosing of pharmacological agents for delirium treatment.  FAM 551 73 Insomnia With increasing age, less sleep is needed (approximately 1hr less than young adults), circadian rhythm is less marked, and sleep becomes more fragmented with greater difficulty getting to sleep. Insomnia can be very distressing and is associated with increased morbidity and mortality. Around 25 % of elderly people have chronic insomnia — even higher rates with psychiatric and medical conditions. Sleep history What time do you go to bed? After you lie down, how long does it take you to fall asleep? Do you leave the television or radio on as you are attempting to fall asleep? Do you take night caffeine, alcohol or have exercise? After falling asleep, what time do you first wake up? What awakens you? (pain? Urge to urinate?) How long does it take you to return to sleep after waking up? What time do you get out of bed in the morning? Feeling fresh? Do you nap during the day? First ensure that underlying causes are looked for and treated: Pain at night Nocturnal urinary frequency, e.g., due to polyuria Comorbidities, e.g., orthopnea, esophageal reflux, Parkinson’s disease Depression/anxiety; very common and use of an antidepressant will improve sleep much better than a hypnotic. Drugs: corticosteroids, omeprazole, phenytoin, amiodarone, sulfasalazine atorvastatin, ramipril, as well as psychiatric drugs can cause insomnia. The following non-pharmacological interventions (sleep hygiene) can be tried: Reduce or stop daytime napping. Avoid caffeine and heavy meals. Use a bedtime routine. Ensure dark, quiet, and comfortable environment. Try warm milky drinks. Manage expectations — older people will rarely sleep as much or well as younger people.  FAM 551 74 Traveler medicine Travel is associated with potential morbidity and even mortality from infectious sources, modes of transportation, environmental exposures, and adverse medical outcomes from illnesses independent of travel. Pre-travel consultation This consultation typically occurs 4–6 weeks before departure, though it can be done closer to travel if necessary Key Components of Pre-Travel Consultation: ▪ Determine the patient’s health status (e.g., infants, elderly, pregnant women, or those with chronic illnesses or underlying medical conditions). ▪ Identify potential medical needs (e.g., allergy to vaccine components, medication use, immunosuppression). ▪ Evaluate the patient’s travel itinerary (e.g., planned destinations, climate and altitude, rural vs. urban environment, duration of stay, accommodations, purpose of travel). ▪ Vaccination and Preventive Medications: Discuss necessary vaccinations and preventive medications (e.g., malaria prophylaxis) based on the destination’s risks Health education Food: Advise patients that fruits are safe only when peeled and that vegetables need to be fully cooked. Unpasteurized dairy products and inadequately cooked fish or meat should be avoided. Water: Counsel patients to avoid ice cubes and that water is safe only after it has been boiled Insect repellents: Advise travelers to use at least 20% DEET on clothing and exposed skin to prevent mosquito-borne infections such as malaria, yellow fever, and dengue fever. Protection with DEET lasts for several hours but is mitigated by swimming, washing, sweating, wiping, and rain. Travelers may also choose to treat clothing and bed netting with permethrin, which can effectively repel mosquitoes for more than a week, even with washing. Medications: Advise travelers to bring adequate supplies of regularly used medications, since equivalent drugs may not be available at their destinations. Air travel —Prolonged immobilization during flight may cause venous thrombosis in individuals with preexisting thrombotic or venous disease. All airline travelers should maintain hydration and periodically move their lower extremities to minimize stasis and reduce the risk of venous thrombosis; use of compression stockings and avoidance of restrictive clothing may also be helpful. Travelers with upper respiratory tract infections, differential air pressures between blocked eustachian tubes or sinuses and the cabin may develop on ascent or descent and impair hearing or cause pain in the ears or sinuses. Symptoms can be relieved by the use of decongestants. Jet lag ensues, which manifests as impaired alertness during the desired wake time and/or difficulty sleeping during the allotted time for sleep at the destination.  FAM 551 75 Traveling during pregnancy Most airlines allow women to fly up to 37 weeks of gestation, although individual policies may vary. Commercial airline travel is generally safe for women with uncomplicated pregnancies Women with complicated pregnancies that may be exacerbated by flight conditions or require emergency care should avoid air travel. Immunizations ▪ Routine or standard immunizations: Review childhood immunization programs and age- appropriate updates, regardless of travel. ▪ Required immunizations (obligatory): Offer yellow fever vaccine for travel to certain parts of sub-Saharan Africa and tropical South America. Offer the meningococcal vaccine for travel to Saudi Arabia during the Hajj (required by the Saudi Arabian government). COVID-19 vaccine should be offered. ▪ Recommended immunizations: Offer HAV, HBV, typhoid fever, meningococcal meningitis, Japanese encephalitis, rabies, and tick-borne encephalitis, depending on the trip-related risk and exposure to such diseases Traveler diarrhea Approximately 40%–60% of travelers to developing countries develop diarrhea. Prevention ▪ Traditional advice (e.g., avoiding food from street stands, tap water, raw foods, and ice). Hand washing reduces risk by 30%; alcohol-based hand sanitizer also significantly reduces risk. ▪ Prophylactic antibiotics are not routinely recommended. ▪ For patients at particularly high risk, taking bismuth subsalicylate (Pepto-Bismol; two tablets four times daily for the duration of the trip) reduces risk by 50% to 65%. Symptoms/Exam Patients may present with malaise, anorexia, nausea, vomiting, and abdominal cramps, followed by sudden onset of watery diarrhea 4–14 days after arrival, with symptoms lasting 1–5 days. Management ▪ Replace fluids: The 1° and most important treatment! Replete both fluid volume and electrolytes. ▪ Give antibiotics for those presenting with moderate to severe diarrhea characterized by more than 4 unformed stools daily; fever; or blood, pus, or mucus in the stool. ▪ Do not use antimotility agents for mild to moderate cases; use only in severe cases in conjunction with antibiotics. ▪ You may use bismuth subsalicylate, which has antisecretory and antimicrobial properties, to ↓ stool frequency and shorten the duration of illness (15 mL or 2 tablets every 30 minutes for up to 8 doses). ▪ Advise patients to seek medical care in the presence of high fever, severe abdominal pain, bloody diarrhea, or vomiting, and when antibiotics have not been helpful.  FAM 551 76 Malaria ▪ Initial manifestations of the disease (common to all malaria species) are similar to flu-like symptoms ▪ The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness followed by shivering and then fever and sweating Prevention –Clothing –Insect repellant –Mosquito netting Chemoprophylaxis Travelers to endemic regions should receive malaria prophylaxis. The choice of prophylactic medication should be based on whether the patient is going to an area with chloroquine-sensitive or chloroquine-resistant malaria. Available chemoprophylaxis includes: Atovaquone/ proguanil (Malarone) Daily dosing. Begin 1 – 2 days before travel, daily during travel, and for 7 days after leaving. Good for last-minute travelers and short trips Chloroquine (Plaquenil) Weekly dosing. Begin 1 – 2 weeks before travel, once/week during travel, and for 4 weeks after leaving. Good choice for long trips because it is taken only weekly Doxycycline Daily dosing. Begin 1 – 2 days before travel, daily during travel, and for 4 weeks after leaving. Good for last-minute travelers Mefloquine Weekly dosing. Begin 1 – 2 weeks before travel, weekly during travel, and for 4 weeks after leaving. Good choice for long trips because it is taken only weekly Primaquine Daily dosing. Begin 1 – 2 days prior to travel, daily during travel, and for 7 days after leaving Good for last-minute travelers and short trips Chemoprophylaxis for pregnant females: Chloroquine and mefloquine.  FAM 551 77 Role of family physician in promoting women health Women experience unique and complex health problems during each stage of life. Family physicians play an essential role in responding to the unique health needs through advanced age and during life transitions from puberty and reproduction to menopause. This can be achieved through providing appropriate preventive and curative services. Evaluation of the patient with breast disease The three most common presenting problems related to the female breast are breast pain, nipple discharge, and a palpable mass. A woman with one or more of these problems is often concerned whether it represents a malignancy. This concern may be openly stated but is often left unspoken. History: ▪ Mass: Timing of appearance, duration, changes in size/character, associated pain, fluctuations, association with menstrual cycle (suggests cyst); ▪ History of prior cyst at site; review family history for breast Cancer ▪ Reproductive history ▪ Menstrual history Examination: ▪ The key point in examining a woman with breast disease is to look for signs suggestive of breast malignancy, such as a mass, skin changes, or bloody nipple discharge. ▪ The four breast quadrants, subareolar areas, axillae, and supraclavicular and infraclavicular areas should be systematically examined with all positions, including the woman both lying and sitting with her hands on her hips and then above her head. ▪ Check for skin changes, the symmetry and contour of the breasts, nipples position, scars, dimpling, edema, erythema, skin retraction, ulceration or crusting of the nipple, and changes in skin color. ▪ Check for enlarged or tender lymph nodes like supraclavicular, axillary, or infraclavicular. ▪ Describe and comment on breast masses. ▪ Check for any discharge from the nipple. Suspected characteristics of a malignant mass ▪ Single lesion ▪ Any asymmetry ▪ Hard, fixed/immobile ▪ Skin dimpling ▪ Irregular border ▪ Bloody nipple discharge ▪ Size greater than 2 cm ▪ Lymphadenopathy  FAM 551 78 Investigations Triple-test evaluation, including clinical breast examination (CBE), ultrasound imaging, and tissue sampling via fine-needle aspiration (FNA) The choice of imaging modality is based on age: ▪ Women under 30 years of age should undergo ultrasound because it is more accurate than mammography for that age group. ▪ Women between 30 and older should undergo mammogram. Ultrasound can be used to detect breast cysts. A definitive diagnosis of breast carcinoma requires a breast biopsy. Three main types of biopsy are commonly performed: ▪ Fine-needle aspiration (FNA) ▪ Core-needle biopsy ▪ Excisional biopsy. A cystic lesion or lesion of uncertain nature may be aspirated both diagnostically and therapeutically. The U.S. Food and Drug Administration requires that all mammography reports be accompanied by aBreast Imaging Reporting and Data System (BI-RADS) categorization to direct management. Management Communication: Breast masses are source of anxiety for clinicians and patients; be open about potential for false / results; encourage patients to follow up promptly with persistent concerns; establish a plan for follow up and discussion of test results; document discussion/plan.  FAM 551 79 Common causes of breast mass Fibroadenoma ▪ The most common solid tumor in young women ▪ Physical examination. A well-defined, rubbery, mobile, nontender, 1 to 5 cm mass can generally be palpated. The usual location is in an upper quadrant. ▪ Diagnostic procedures. Aspiration of the mass should be attempted. A fine-needle biopsy may be diagnostic. Mammography is not usually helpful. ▪ Management. It can be managed with core biopsy and short term (3 to 6 months) follow-up with U/S and breast examination. Excisional biopsy is both diagnostic and curative. Breast cysts ▪ Cysts may be solitary or multiple and may be difficult to differentiate from solid masses on physical exam. ▪ Cystic disease is most common in premenopausal women older than 40 years. ▪ Ultrasound may be used to establish diagnosis and guide aspiration. ▪ Management: Aspiration and clinical follow-up ▪ Cysts should be surgically biopsied if they contain bloody fluid, fail to resolve completely after drainage, or recur after 4 to 6 weeks. Fibrocystic Breast Disease ▪ Fibrocystic changes are the most common benign condition of the breast, occurring to some extent in most, if not all, women. ▪ Changes are most common in women 35 to 45 years old and are rare in postmenopausal women. ▪ The pain is generally bilateral, located in the upper outer quadrants, begins a few days prior to menstruation, diminishes with the onset of menses, and may be associated with an increase in breast size. ▪ Family history is common. ▪ To assess for possible menstrual changes, it may be helpful to repeat the examination with the patient at another point in her cycle. ▪ Mammography and ultrasonography should be used to evaluate a mass in a patient with fibrocystic condition. ▪ Fine-needle aspiration (FNA) cytology may be used. ▪ Treatment is focused on the predominant symptom or sign, be it a mass or pain.  FAM 551 80 Breast pain ▪ Mastalgia is a symptom complex of breast pain and tenderness, with or without nodularity. ▪ Mastalgia is either cyclic or noncyclic, and the management depends on this categorization. ▪ Reassurance, after appropriate evaluation, that the pain is not due to cancer will be sufficient for most women; roughly 15% will require additional treatment ▪ Mastalgia is the second most common breast symptom leading to medical evaluation in the primary care setting. ▪ Although pain is often mild, up to 11% of women experience severe pain, and more than one- third of these patients report adverse effects on sleep and sexual activity. Cyclic mastalgia: It accounts for two-thirds of all breast pain cases and is most common in women in their 20s and 30s. Cyclic pain tends to be diffuse and bilateral, and often radiates to the axilla. Noncyclic mastalgia: Noncyclic mastalgia has no temporal association with menses and may be focal or diffuse. Patients are usually older and often presenting in their 30s or 40s. Symptoms resolve spontaneously in nearly one- half of affected women. Noncyclic pain is thought to be: ▪ Medication use (oral contraceptives, hormone therapy, some psychotropic agents, and some cardiovascular agents), ▪ Breast trauma, infection, benign tumors, and ligamentous pain from pendulous breasts. ▪ Pain may also be referred from extramammary cardiopulmonary or gastrointestinal sources or inflammatory musculoskeletal conditions. Evaluation of mastalgia History taking ▪ Pain profile (location, quality, severity, laterality, and temporal relation to menses), ▪ Medication history, ▪ Musculoskeletal triggers, ▪ Impact on daily function, ▪ Family history of breast cancer. Clinical Breast Examination (As discussed before.) ▪ A palpable breast mass requires imaging and biopsy. ▪ In women with breast pain and no identifiable mass, the clinician may recommend imaging based on mastalgia characterization and patient age.  FAM 551 81 Investigations (Diagnostic imaging) ▪ Diagnostic imaging is not needed in patients with cyclic mastalgia if routine screening mammography is up to date and physical examination findings are normal. ▪ Noncyclic/focal mastalgia should trigger diagnostic imaging because of its rare but occasional ▪ association with underlying malignancy. ▪ Imaging may also identify a benign, treatable cause of noncyclic/focal pain. ▪ The risk of malignancy in patients with breast pain after normal CBE and mammography findings is approximately 0.5%. Management ▪ Spontaneous resolution of breast pain is common, ▪ But mastalgia can be chronic, necessitating a stepwise approach to management. ▪ Reassuring women with cyclic mastalgia that they are at low risk of breast cancer and lifestyle modifications have been shown to reduce symptoms. ▪ Topical nonsteroidal anti-inflammatory drugs such as diclofenac are the first-line pharmacologic treatment for cyclic and noncyclic mastalgia. ▪ Natural remedies such as vitamin e and evening primrose oil are commonly used despite limited data supporting their effectiveness. ▪ In instances of severe and refractory pain, referral to a subspecialist should be considered.  FAM 551 82 Nipple Discharge Nipple discharge is a common symptom among women of reproductive age, with most women experiencing at least one episode. Although nipple discharge is predominantly physiologic or due to a benign etiology, an underlying malignancy is identified in up to 21% of patients with pathologic discharge who undergo biopsy. The initial workup includes a comprehensive history and physical examination. Physiologic discharge ▪ Physiological discharge is generally bilateral, multiductal, negative for blood (regardless of color), and is associated with nipple stimulation or breast compression. ▪ If the history, physical examination findings, and routine screening mammography are consistent with physiological discharge, no additional imaging is indicated. Avoidance of nipple expression may accelerate resolution. ▪ The presence of spontaneous bilateral lactation outside of pregnancy and the postpartum period is termed galactorrhea. Elevated prolactin levels may be due to: hypothalamic or Galactorrhea is commonly caused by hyperprolactinemia. pituitary lesions (tumors or ▪ All patients with true galactorrhea should do pregnancy test to infiltrative disorders), systemic rule out pregnancy, measurement of prolactin and thyroid- disease (hypothyroidism or stimulating hormone levels. renal insufficiency), or ▪ A comprehensive medication review should be performed to dopamine-inhibiting rule out iatrogenic causes of galactorrhea. medications. Pathologic discharge ▪ Pathological discharge is generally spontaneous and unilateral and originates from a single duct opening on a nipple. ▪ It may be bloody, serous, serosanguineous, or watery. ▪ The differential diagnosis includes: intraductal papilloma, ductal ectasia, breast carcinoma ▪ If discharge is deemed pathologic, age-appropriate diagnostic imaging with mammography and/or ultrasonography is indicated.  FAM 551 83  FAM 551 84 Premarital Screening Premarital screening is a legally required assessment that tests the couple to-be as they plan to get married. It does not test against all diseases and therefore does not guarantee having normal children. Initial visit Ordered routine Investigations: 1. Complete Blood Count. 2. Blood Group (ABO & Rh Typing). 3. Fasting blood sugar. 4. Urine analysis. 5. Chest X ray 6. Rubella Abs, Toxoplasmosis Abs for female 7. Semen analysis for male 8. HBs Ag. 9. Anti-HCV Ab 10. Special investigation if needed in some cases (e.g., Hemoglobin electrophoresis, karyotyping, hormonal profile) Follow-Up Visit Always have a glance on the results before calling in the patients to be sure that the setting is ready for breaking any bad news if needed. Moreover, whenever a partner has an abnormal result, try your best to interview them alone first instead of having both partners together. Folate supplementation Decrease risk of neural tube defect (open spina bifda, anencephaly, encephalocele) recommend 0.4mg (400 micrograms) daily from when pregnancy is being planned until 13wk gestation. Recommend 5mg daily if: ▪ Previous child had neural tube defect ▪ Maternal/paternal history or other family history of neural tube defect ▪ Mother has coeliac disease, DM, BMI >30kg/m, or is taking anticonvulsants Other supplements Vitamin D: Consider 10 micrograms (400IU)/d, particularly if poor diet and limited exposure to sunlight Preconception visit ▪ A preconception visit can be used to maximize the expectant parents’ health, safety, and well- being before conception, and to maximize fetal health in the early months of pregnancy. ▪ The consultation ideally occurs 3 to 6 months before conception and covers health promotion, risk assessment, and medical intervention. ▪ Opportunities for informal preconception guidance include well-woman exams, Pap smears, visits for contraception or a negative pregnancy test, and follow-up visits after poor birth outcomes  FAM 551 85 Antenatal care ▪ Prenatal care likely benefits both maternal and infant health by encouraging long-term health maintenance and increasing the likelihood that infants receive timely care. ▪ Family physicians’ knowledge, scope of practice, and comprehensive training makes them uniquely suited to provide prenatal care for women and their families. ▪ Bonds formed during maternity care often translate into lifelong relationships with families. ▪ The goals of prenatal care are confirming the pregnancy, assessing and modifying risk, screening for and managing conditions that arise, and providing patient education and support. Initial prenatal visit: basic components. ▪ History of current pregnancy: assessment of gestation age and symptoms ▪ Prior obstetrical history ▪ Gynecologic history ▪ Past medical history; chronic illnesses, surgeries, medications, allergies, immunizations ▪ Social history: alcohol, drugs, tobacco, occupation, home situation ▪ Screen for depression and intimate-partner violence ▪ Family/genetic history: ethnic background, genetic and congenital defects ▪ Physical exam: general and pelvic with attention to uterine size ▪ Routine investigations ▪ Risk assessment ▪ Patient education Subsequent visits ▪ Should ask about warning symptoms: ✓ Vaginal bleeding ✓ Leakage of fluid per vagina ✓ Persistent vomiting ✓ Severe persistent headache, blurring of vision, marked swelling of the lower limbs ✓ Decreased fetal activity ✓ Symptoms of preterm labor (e.g., low backache; menstrual-like cramps; contractions) ▪ Patient concerns ▪ Focused symptoms review ▪ Depression and intimate-partner violence screens each trimester ▪ Vitals: blood pressure, weight ▪ Exam: fundal height, fetal heart tones, estimated fetal weight, and presentation ▪ Investigations ▪ Risk assessment ▪ Patient education  FAM 551 86 Important screening tests Fetal anatomy ultrasound can be offered at 16 to 20 weeks EGA to evaluate for structural anomalies Group B Streptococcus (GBS) Screening at 35–37 weeks Screening for diabetes during pregnancy All pregnant females should be screened for Gestational diabetes at 24-28 weeks in low-risk women and at 1st antenatal visit in high-risk women. The two steps approach: 1st step: (Glucose challenge test (GCT), also called a "one-hour GTT"). ▪ A non-fasting 50-gram oral glucose load is given ▪ Plasma glucose is measured one hour later in venous plasma. ▪ If < 145: normal reading ▪ If ≥145 mg/dL proceed to next step. 2nd step: (confirmation): The 100-gram three-hour oral GTT ▪ Daily diet of 150-gram glucose for 3 days before the test. ▪ Overnight fasting for 8 – 10 hrs. ▪ A fasting blood sample is taken then a 100-gram oral glucose load is given ▪ Blood samples are collected at 1,2,3, hours later, checked for blood glucose ▪ DM Is diagnosed when two glucose values are elevated Fasting < 105 One hour < 185 Two hours < 165 Three hours < 145 The one step approach: 75-gram two-hour oral GTT ▪ Is diagnostic of DM when one glucose value is elevated Fasting 95-125 One hour < 180 Two hours < 155  FAM 551 87 Management of common problems during pregnancy Nausea and vomiting: ▪ Reassure women that mild to moderate nausea and vomiting are common in pregnancy and are likely to resolve before 16 to 20 weeks. ▪ Lifestyle modifications: small frequent protein meals, and avoidance of fried and heavily seasoned food. ▪ Nonpharmacological interventions: ginger (250 mg oral capsules taken four times daily). ▪ Pharmacological interventions: antiemetics. ▪ Pyridoxine (vitamin B6) is considered first-line treatment: 12.5 to 25 mg TID ▪ Antiemetics and antihistamines are common prescription oral medications. ▪ For pregnant women with moderate-to-severe nausea and vomiting: consider intravenous fluids, ideally on an outpatient basis. ▪ If vomiting is severe and not responding to primary care or outpatient management: Consider referral for secondary care. Heartburn gastroesophageal reflux disease (GERD) ▪ Nonpharmacologic interventions include eating small, frequent meals; avoiding fried, greasy, and spicy foods; and eating slowly and chewing food well. Like nonpregnant patients with these symptoms, it is helpful to avoid lying down immediately after eating, to take walks after meals, and to drink fluids between meals. ▪ Pharmacologic agents used to treat heartburn include: - Antacids: Antacids containing sodium bicarbonate or magnesium trisilicate should be avoided. - H2-antagonists as ranitidine, are the most well studied; they have generally shown significant symptom improvement with minimal side effects. Because of a lack of evidence regarding safety in the first trimester, histamine antagonists are not recommended during the first trimester. - Proton pump inhibitors as omeprazole have been most widely studied in pregnancy. Symptomatic vaginal discharge ▪ Advise pregnant women who have vaginal discharge that this is common during pregnancy, but if it is accompanied by symptoms such as itching, soreness, an unpleasant smell or pain on passing urine, there may be an infection that needs to be investigated and treated. ▪ Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause. ▪ Optimal treatment for symptomatic vulvovaginal candidiasis consists of a topical imidazole (clomitrazole or miconazole) for 7 days ▪ Treatment of symptomatic bacterial vaginosis may be achieved with a topical or oral agent. Back pain and pelvic pain ▪ Are common in pregnancy and occur in more than two-thirds of pregnancies, and often interfere with daily activities and sleep. ▪ Usual recommendations include stretching and strengthening exercise, oral or topical analgesics, massage, heat therapy, or ice therapy.  FAM 551 88 Postpartum care The focus of routine care consists of mother-baby bonding, establishing breast-feeding, and delivering education regarding routine newborn and self-care. A complete physical, including a pelvic exam, should be conducted at approximately 6 weeks postpartum. Physiological changes Uterine Changes. ▪ The uterus increases significantly in size and weight during pregnancy. ▪ Immediately after delivery it weighs approximately 1 kg, is the size of a uterus at 20 weeks’ gestation (fundus palpable at the umbilicus), and begins the process of involution, the return to its nonpregnant size. Vaginal bleeding ▪ Usually heaviest in the hours following delivery, then decreases significantly. ▪ Brown or blood-tinged lochia occurs for about the next week. ▪ This is followed by white or yellow lochia, which continues for approximately 4 to 6 more weeks. ▪ In women who are not breastfeeding, menstruation usually restarts by the third postpartum month. ▪ In women who are breastfeeding, ovulation and menstruation can be suppressed for much longer. ▪ Anovulation will persist for longer periods of time in women who exclusively breastfeed their babies. Breast Changes. ▪ Breast engorgement, signalling increased milk production, typically occurs 1 to 4 days after delivery and can cause breast pain, milk leakage, and fever. ▪ In breastfeeding women, this is best managed by increasing frequency of feedings. ▪ In women who are not breastfeeding, the use of ice packs, supportive bras, and nonsteroidal anti- inflammatory drugs (NSAIDs) can reduce discomfort. Skin and hair ▪ Striae fade from red to silver but are permanent ▪ Hair loss usually noted from 1-5 months after delivery (Telogen effluvium). It is usually self- limited with restoration of normal hair patterns by 6-15 months after delivery. Sexual Changes ▪ Most couples do not resume intercourse until about 2 months or longer after delivery. ▪ Thereafter, sexual interest and activity may be reduced for several months, and sexual problems occur often. ▪ Anticipated postpartum sexual changes should be explained to the couple and reassurance that problems often resolve.  FAM 551 89 Common postpartum complications: ▪ Postpartum hemorrhage ▪ Urinary tract infection ▪ Postpartum pyrexia ▪ Hypertension Postpartum counseling ▪ Ask about common discomforts (e.g., urinary retention, constipation, perineal care). ▪ Determine the frequency of breast-feeding and commonly encountered problems. ▪ Counsel patients about routine newborn care, including how to take the baby’s temperature, anticipate URIs, use car safety seats, and perform jaundice checks. ▪ Offer information about postpartum depression, family support, and emotional self-care. ▪ Counsel patients about birth control methods. A. Postpartum blues and depression Postpartum blues ▪ Transient depression encountered in 30% to 70% of women during the first week postpartum, usually on the second- or third day following delivery. ▪ This self-limited disorder usually resolves within 3 to 10 days. ▪ Symptoms include tearfulness, sadness, and emotional lability. ▪ The etiology is not entirely clear but may be multifactorial and include hormonal changes following delivery, nutritional deficiencies, stress, sleep deprivation, and adjustment to the new role as a mother. Postpartum Depression ▪ Postpartum depression occurs in 10% to 20% of women following pregnancy, miscarriages, or abortions. ▪ The onset is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as occurring within 4 weeks’ postpartum, but it may occur as late as 1 year postpartum. ▪ The symptoms of postpartum depression are the same as those of major depression. ▪ The severity can vary from mild to severe and suicidal. ▪ There is a high recurrence rate in subsequent pregnancies and an increased risk in women with a history of depression unrelated to pregnancy. Screening all mothers for depression 4–6wk and 3–4mo postnatal by asking: ▪ During the past month, have you often been bothered by feeling down, depressed, or hopeless? ▪ During the past month, have you often been bothered by having little interest or pleasure in doing things? Postpartum Psychosis ▪ Postpartum psychosis is a rare, but potentially devastating, complication following pregnancy. ▪ All women with postpartum psychosis should be referred to a psychiatrist.  FAM 551 90 B. Breastfeeding Breastfeeding is universally recognized as the normative and preferred method of infant feeding. Mothers and infants who do not breastfeed have greater short- and long- term health risks. Indicators of good attachment ▪ Mouth wide open ▪ Less areola visible underneath the chin than above the nipple ▪ Chin touching the breast, lower lip rolled down, and nose free ▪ No pain. Correct breastfeeding positioning ▪ Head and whole body are well supported ▪ Baby held close to mother ▪ His face and stomach face the mother ▪ Head and shoulder are in one straight line, neck is not twisted Indicators of effective suckling ▪ slow, deep firm sucks alternate with break of suckling ▪ No other sounds except swallowing sounds are heard. Results of poor attachment ▪ Painful nipples ▪ Damaged nipples ▪ Engorgement ▪ Baby unsatisfied and cries a lot ▪ Baby feeds frequently and for a long time ▪ Decreased milk production Common breastfeeding problems For many women, difficulties in breastfeeding result in early termination of breastfeeding before the recommended period of time. However, with accurate advice and treatment, most of these difficulties can be overcome, and breastfeeding can be successfully sustained for longer periods. I. Inadequate milk intake It is the most common reason for early termination of breastfeeding. Causes of inadequate milk intake can be divided into insufficient milk production and failure of the infant to extract milk.  FAM 551 91 A- Inadequate milk production which may be due to: ▪ Medications: such as selective serotonin reuptake inhibitors (SSRIs), decongestants (pseudoephedrine), and estrogen-containing oral contraceptives ▪ Diseases: Delay in the anticipated increase in milk production that normally occurs within the first five days of life. The most common reasons for such a delay include maternal prepregnancy obesity, pregnancy-induced hypertension, polycystic ovary syndrome, or preeclampsia. ▪ Surgeries: Previous breast surgery or irradiation. B- Poor milk extraction which may be due to: ▪ Poor feeding routines in the early postpartum period are the most common cause of insufficient milk intake, because frequent and complete breast emptying is necessary for adequate breast milk volume. They include infrequent feeding, inadequate latch-on, maternal-infant separation, and the use of supplemental formulas. ▪ Other causes: Sleepy and difficult to wake babies in the first several days, oral-motor or neurologic abnormalities Diagnosis of inadequate intake (The diagnosis of inadequate milk intake is made clinically by demonstrating insufficient feeding based on a nursing history, decreased infant urine and stool output, and excess weight loss of the infant.) ▪ Nursing history: During the first week of life, mothers with term infants generally nurse 8 to 12 times in 24 hours, and by 1 month after delivery, nursing usually decreases to seven to nine times per day. ▪ Infant urine and stool output: By the fifth day of life, infants with adequate intake urinate six to eight times daily and have three or more pale yellow and seedy stools daily. ▪ Infants’ weight: Term infants generally lose weight in the first three to five days of life with an average loss of 7% of their birth weight. They typically will regain their birth weight by one to two weeks of life. Once the mother's breasts feel full of milk by day three to five, the infant should not continue to lose weight. ▪ If an infant has lost 10% of its weight or fails to regain birthweight appropriately, inadequate intake should be considered, and direct observation of breastfeeding should be performed. Management ▪ Initial management is focused on determining and addressing the cause of inadequate milk supply or transfer by a thorough breastfeeding history and direct observation of breastfeeding may reveal either maternal or neonatal anatomical difficulties, or improper breastfeeding technique. ▪ The primary intervention depends upon the cause. ▪ Using breast pumps or manual hand expressions, especially after a feeding increases stimulation and emptying of the breast, thereby enhancing milk production. ▪ We do not recommend the routine use of galactagogues because there is limited evidence to support their efficacy, and because of potential safety concerns. These agents should never be used in place of an evaluation and correction of any modifiable factors. Even with herbal galactagogues, data is insufficient to determine their efficacy and safety.  FAM 551 92 II. Nipple and breast pain (After insufficient milk intake, nipple and breast pain are the most common causes of premature discontinuation of breastfeeding.) Causes of nipple and breast pain include: ▪ Nipple injury ▪ Engorgement ▪ Plugged ducts ▪ Nipple and breast infections ▪ Excessive milk supply Evaluation Evaluation of breast pain begins with a thorough history, examination of the infant and mother's breasts, and observation of feeding. A- History — about the onset and description of breast pain, feeding history that includes the frequency and duration of feedings, history of yeast infections, and maternal breast surgeries. B- Physical examination of the infant— Physical exam of the infant should focus on the head and neck: such as Oral candidiasis, Torticollis, Cleft lip and/or palate. C- Maternal breast exam — The mother's nipples should first be inspected for swelling, rash, and abrasions. A thorough breast exam should also be done to identify overfullness, masses, abscesses, tenderness, or areas of erythema indicating mastitis. D- Observed feeding — It is essential because most causes of breast pain in the lactating mother are due to incorrect breastfeeding technique. Assessment of the latch and feeding technique can be directly assessed. III. Sore or cracked nipples ▪ Sore nipples can be managed by ensuring proper latch-on, frequent position changes, alternating breasts during feedings, nipple shields, keeping the nipples clean and dry between feedings but don’t use soap, and applications of lanolin or the patient’s own breast milk. ▪ Vitamin E, herbal rubs, and other creams and topical agents should be avoided because of risk of absorption by the infant. IV. Engorgement ▪ Engorgement can be managed by: ▪ Allow the baby to finish 1st breast before switching to 2nd ▪ Apply cold compressor ▪ Breastfeed more frequent ▪ Improve baby position and attachment ▪ Breast massage ▪ Express milk ▪ Use systemic analgesics/anti-inflammatory drugs.  FAM 551 93 V. Lactational Mastitis Diagnosis of mastitis is usually clinical with patients presenting with focal tenderness in one breast accompanied by fever and malaise Treatment includes: ▪ Changing breast feeding techniques. ▪ Frequent evacuation of the breast ▪ Pump frequently if unable to nurse. ▪ Apply moist compress or soak breast in warm water before feeding. ▪ Massage the affected area using a gentle but firm circular motion after warm soaks. ▪ Take antipyretic for fever or discomfort. ▪ Antibiotics VI. Plugged milk duct A plugged or blocked milk duct is a common issue during lactation, characterized by localized pain, swelling, and a palpable lump. If left untreated, it may lead to complications such as mastitis or breast abscess. Effective, evidence-based management is essential for resolving symptoms and maintaining breastfeeding success. Management ▪ Frequent breastfeeding or pumping, ideally every 2-3 hours ▪ Positioning the baby so their chin is aimed toward the blocked duct ▪ Gentle breast massage, especially toward the nipple and around the blocked duct. Massage can be done during breastfeeding or milk expression. ▪ Applying warm compresses before feeding or pumping ▪ Pain relievers, such as ibuprofen (safe for use in breastfeeding mothers). Maternal use of medications during breastfeeding The following general considerations help to guide decisions: ▪ Medications with the lowest risk to the infant should be selected, and dosing should be before the infant’s longest sleep interval. ▪ Use current, accurate resources. The LactMed database, produced by the National Library of Medicine is a free, authoritative reference for lactation compatibility for prescription and over- the-counter drugs. Available at https://www.ncbi.nlm.nih.gov/books/NBK501922/ ▪ Insulin, metformin, and second-generation sulfonylureas are generally preferred to treat diabetes mellitus during breastfeeding, but newer agents require caution because they have not been studied in lactation. ▪ Inhaled and nasal treatments for asthma and allergic rhinitis are unlikely to affect breastfed infants. ▪ Acetaminophen and ibuprofen are preferred analgesics during lactation. ▪ Herbal supplements are associated with risk of impurities and lack of study of effects on breastfed infants. ▪ Nonhormonal and progestin-only contraceptives are preferred over combination oral contraceptives. ▪ Contrast for computed tomography or magnetic resonance imaging is not concerning during lactation, but use of radiopharmaceuticals, such as iodine, can accumulate in the lactating breast and increase risk to the infant.  FAM 551 94 C. Family planning Numerous options are available to women for contraception and family planning. Discussion of these options ideally should occur in the prenatal period and again before discharge from the hospital. Hormonal Contraception ▪ OCPs are the most widely used reversible form of contraception. ▪ Available OCPs contain both estrogen and progestin or are progestin only. ▪ In breastfeeding women, the progestin-only pills are preferred because combination OCPs might reduce lactation. ▪ Progesterone-only pills, injectable long-acting depot medroxyprogesterone (Depo-Provera), progestin, eluting birth control implants, and any intrauterine device (IUD) may be used in the postpartum period by breastfeeding women. Intrauterine devices (IUDs) ▪ IUDs have a significant risk of expulsion if placed prior to 6 weeks’ postpartum. Barrier Contraception ▪ Barrier methods of contraception may also be used regardless of breastfeeding status. ▪ While not widely used, diaphragms and cervical caps must be refitted at the 6-week visit to ensure an appropriate fit since the cervix has changed in size and shape. Breastfeeding as Contraception ▪ Lactation-induced amenorrhea provides a high level of natural contraception in the first 6 months’ postpartum and with exclusively breastfeeding. ▪ However, this protection decreases if breastfeeding is reduced or if menses restart. ▪ As ovulation precedes the return of menses, this method should not be considered as reliable as other methods. ▪ After 6 months, if menses restart or if breastfeeding is reduced, alternate forms of contraception should be used.  FAM 551 95 Menopause Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, defined retrospectively after 12 consecutive months of amenorrhea without other cause. Average age of