Priority Topics and Key Features with Corresponding Skill Dimensions and Phases of the Encounter Excerpt from Defining competence for the purposes of certification by the College of Family Physicians of Canada: The evaluation objectives in family medicine Working Group on the Certification Process ©Copyright 2010 The College of Family Physicians of Canada (CFPC) Priority Topics and Key Features Abdominal Pain .............................................................................................................................................................. 4 Advanced Cardiac Life Support ...................................................................................................................................... 5 Allergy ............................................................................................................................................................................ 6 Anemia ........................................................................................................................................................................... 7 Antibiotics ...................................................................................................................................................................... 8 Anxiety ........................................................................................................................................................................... 9 Asthma ......................................................................................................................................................................... 10 Atrial Fibrillation .......................................................................................................................................................... 11 Bad News ..................................................................................................................................................................... 12 Behavioural Problems .................................................................................................................................................. 13 Breast Lump ................................................................................................................................................................. 14 Cancer .......................................................................................................................................................................... 15 Chest Pain .................................................................................................................................................................... 16 Chronic Disease ........................................................................................................................................................... 17 Chronic Obstructive Pulmonary Disease ..................................................................................................................... 18 Contraception .............................................................................................................................................................. 19 Cough ........................................................................................................................................................................... 20 Counselling .................................................................................................................................................................. 21 Crisis............................................................................................................................................................................. 22 Croup ........................................................................................................................................................................... 23 Deep Venous Thrombosis ............................................................................................................................................ 24 Dehydration ................................................................................................................................................................. 25 Dementia ..................................................................................................................................................................... 26 Depression ................................................................................................................................................................... 27 Diabetes ....................................................................................................................................................................... 28 Diarrhea ....................................................................................................................................................................... 29 Difficult Patient ............................................................................................................................................................ 30 Disability ...................................................................................................................................................................... 31 Dizziness ...................................................................................................................................................................... 32 Domestic Violence ....................................................................................................................................................... 33 Dyspepsia ..................................................................................................................................................................... 34 Dysuria ......................................................................................................................................................................... 35 Earache ........................................................................................................................................................................ 36 Eating Disorders ........................................................................................................................................................... 37 Elderly .......................................................................................................................................................................... 38 Epistaxis ....................................................................................................................................................................... 39 Family Issues ................................................................................................................................................................ 40 Fatigue ......................................................................................................................................................................... 41 Fever ............................................................................................................................................................................ 42 Fractures ...................................................................................................................................................................... 43 Gastro-intensinal Bleed ............................................................................................................................................... 44 Gender Specific Issues ................................................................................................................................................. 45 Grief ............................................................................................................................................................................. 46 Headache ..................................................................................................................................................................... 47 Hepatitis ...................................................................................................................................................................... 48 Hyperlipidemia ............................................................................................................................................................ 49 Hypertension ............................................................................................................................................................... 50 Immigrants ................................................................................................................................................................... 51 Immunization ............................................................................................................................................................... 52 In Children ................................................................................................................................................................... 53 Page | 2 Infections ..................................................................................................................................................................... 54 Infertility ...................................................................................................................................................................... 55 Insomnia ...................................................................................................................................................................... 56 Ischemic Heart Disease ................................................................................................................................................ 57 Joint Disorder ............................................................................................................................................................... 58 Lacerations .................................................................................................................................................................. 59 Learning: ...................................................................................................................................................................... 60 Patients: ....................................................................................................................................................................... 60 Self Learning: ............................................................................................................................................................... 60 Lifestyle ........................................................................................................................................................................ 61 Loss of Consciousness .................................................................................................................................................. 62 Loss of Weight ............................................................................................................................................................. 63 Low-back Pain .............................................................................................................................................................. 64 Meningitis .................................................................................................................................................................... 65 Menopause .................................................................................................................................................................. 66 Mental Competency .................................................................................................................................................... 67 Multiple Medical Problems ......................................................................................................................................... 68 Neck Pain ..................................................................................................................................................................... 69 Newborn ...................................................................................................................................................................... 70 Obesity ......................................................................................................................................................................... 71 Osteoporosis ................................................................................................................................................................ 72 Palliative Care .............................................................................................................................................................. 73 Parkinsonism ............................................................................................................................................................... 74 Periodic Health Assessment/Screening ....................................................................................................................... 75 Personality Disorder .................................................................................................................................................... 76 Pneumonia ................................................................................................................................................................... 77 Poisoning ..................................................................................................................................................................... 79 Pregnancy .................................................................................................................................................................... 80 Prostate ....................................................................................................................................................................... 82 Rape/Sexual Assault .................................................................................................................................................... 83 Red Eye ........................................................................................................................................................................ 84 Schizophrenia .............................................................................................................................................................. 85 Seizures ........................................................................................................................................................................ 86 Sex ............................................................................................................................................................................... 87 Sexually Transmitted Infections .................................................................................................................................. 88 Skin Disorder ................................................................................................................................................................ 89 Smoking Cessation ....................................................................................................................................................... 90 Somatization ................................................................................................................................................................ 91 Stress ........................................................................................................................................................................... 92 Stroke........................................................................................................................................................................... 93 Substance Abuse .......................................................................................................................................................... 94 Suicide ......................................................................................................................................................................... 95 Thyroid ......................................................................................................................................................................... 96 Trauma ......................................................................................................................................................................... 97 Travel Medicine ........................................................................................................................................................... 98 Upper Respiratory Tract Infection ............................................................................................................................... 99 Urinary Tract Infection ............................................................................................................................................... 100 Vaginal Bleeding ........................................................................................................................................................ 101 Vaginitis ..................................................................................................................................................................... 102 Violent/Aggressive Patient ........................................................................................................................................ 103 Well-baby Care .......................................................................................................................................................... 104 3 | P a g e Abdominal Pain Key Feature Skill Phase 1 Given a patient with abdominal pain, paying particular attention to its location and chronicity: Clinical Reasoning History a) Distinguish between acute and chronic pain. b) Generate a complete differential diagnosis (ddx). Clinical Reasoning Hypothesis generation Diagnosis c) Investigate in an appropriate and timely fashion. Clinical Reasoning Investigation Selectivity 2 In a patient with diagnosed abdominal pain (e.g., Clinical Reasoning Treatment gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (e.g., with. medication, lifestyle modifications). 3 In a woman with abdominal pain: Hypothesis generation Clinical Reasoning Investigation a) Always rule out pregnancy if she is of reproductive age. b) Suspect gynecologic etiology for abdominal pain. Clinical Reasoning Hypothesis generation c) Do a pelvic examination, if appropriate. Clinical Reasoning Physical Diagnosis 4 In a patient with acute abdominal pain, differentiate between a Clinical Reasoning Physical Selectivity Diagnosis surgical and a non-surgical abdomen. 5 In specific patient groups (e.g., children, pregnant women, the Clinical Reasoning Hypothesis generation Selectivity Diagnosis elderly), include group-specific surgical causes of acute abdominal pain in the ddx. 6 Given a patient with a life-threatening cause of acute abdominal pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Selectivity Diagnosis a) Recognize the life-threatening situation. b) Make the diagnosis. Clinical Reasoning Diagnosis c) Stabilize the patient. Selectivity Treatment Clinical Reasoning d) Promptly refer the patient for definitive treatment. Selectivity Diagnosis Referral 7 In a patient with chronic or recurrent abdominal pain: a) Ensure adequate follow-up to monitor new or changing Clinical Reasoning Follow-up symptoms or signs. b) Manage symptomatically with medication and lifestyle Clinical Reasoning Treatment Communication modification (e.g., for irritable bowel syndrome). c) Always consider cancer in a patient at risk. Clinical Reasoning Hypothesis generation Diagnosis 8 Given a patient with a diagnosis of inflammatory bowel disease Clinical Reasoning Hypothesis generation Diagnosis (IBD) recognize an extra intestinal manifestation. Page | 4 Advanced Cardiac Life Support Key Feature Skill Phase 1 Keep up to date with advanced cardiac life support (ACLS) Professionalism Treatment recommendations (i.e., maintain your knowledge base). 2 Promptly defibrillate a patient with ventricular fibrillation (V Clinical Reasoning Treatment Selectivity fib), or pulseless or symptomatic ventricular tachycardia (V tach). 3 Diagnose serious arrhythmias (V tach, V fib, supraventricular Clinical Reasoning Diagnosis Treatment tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols. 4 Suspect and promptly treat reversible causes of arrhythmias Clinical Reasoning Hypothesis generation Selectivity Treatment (e.g., hyperkalemia, digoxin toxicity, cocaine intoxication) before confirmation of the diagnosis. 5 Ensure adequate ventilation (i.e., with a bag valve mask), and Clinical Reasoning Treatment Selectivity secure the airway in a timely manner. 6 In patients requiring resuscitation, assess their circumstances Clinical Reasoning Diagnosis Treatment (e.g., asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.) 7 In patients with serious medical problems or end-stage disease, Patient Centered Treatment Follow-up discuss code status and end-of-life decisions (e.g., resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically. 8 Attend to family members (e.g., with counselling, presence in Professionalism Treatment Communication the code room) during and after resuscitating a patient. 9 In a pediatric resuscitation, use appropriate resources ( e.g., Clinical Reasoning Treatment Braeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes. Note: Shock is not dealt with in this topic. 5 | P a g e Allergy Key Feature Skill Phase 1 In all patients, always inquire about any allergy and clearly Clinical Reasoning History Follow-up document it in the chart. Re-evaluate this periodically. 2 Clarify the manifestations of a reaction in order to try to Clinical Reasoning History Diagnosis diagnose a true allergic reaction (e.g., do not misdiagnose viral rashes as antibiotic allergy, or medication intolerance as true allergy). 3 In a patient reporting allergy (e.g., to food, to medications, Clinical Reasoning Treatment environmental), ensure that the patient has the appropriate medication to control symptoms (e.g., antihistamines, bronchodilators, steroids, an EpiPen). 4 Prescribe an EpiPen to every patient who has a history of, or is Clinical Reasoning Treatment at risk for, anaphylaxis. 5 Educate appropriate patients with allergy (e.g., to food, Clinical Reasoning Treatment Patient Centered Follow-up medications, insect stings) and their families about the symptoms of anaphylaxis and the self-administration of the EpiPen, and advise them to return for immediate reassessment and treatment if those symptoms develop or if the EpiPen has been used. 6 Advise patients with any known drug allergy or previous major Clinical Reasoning Treatment Patient Centered allergic reaction to get a MedicAlert bracelet. 7 In a patient presenting with an anaphylactic reaction: Selectivity Diagnosis a) Recognize the symptoms and signs. Clinical Reasoning b) Treat immediately and aggressively. Selectivity Treatment Clinical Reasoning c) Prevent a delayed hypersensitivity reaction through Clinical Reasoning Treatment observation and adequate treatment (e.g., with steroids). 8 In patients with anaphylaxis of unclear etiology refer to an Clinical Reasoning Referral allergist for clarification of the cause. 9 In the particular case of a child with an anaphylactic reaction to food: a) Prescribe an EpiPen for the house, car, school, and Clinical Reasoning Treatment daycare. b) Advise the family to educate the child, teachers, and Clinical Reasoning Treatment caretakers about signs and symptoms of anaphylaxis, and about when and how to use the EpiPen. 10 In a patient with unexplained recurrent respiratory symptoms, Clinical Reasoning Hypothesis generation include allergy (e.g., sick building syndrome, seasonal allergy) in the differential diagnosis. Page | 6 Anemia Key Feature Skill Phase 1 Assess the risk of decompensation of anemic patients (e.g., Clinical Reasoning Diagnosis Selectivity Treatment volume status, the presence of congestive heart failure [CHF], angina, or other disease states) to decide if prompt transfusion or volume replacement is necessary. 2 In a patient with anemia, classify the anemia as microcytic, Clinical Reasoning Diagnosis Investigation normocytic, or macrocytic by using the MCV (mean corpuscular value) or smear test result, to direct further assessment and treatment. 3 In all patients with anemia, determine the iron status before Clinical Reasoning Investigation Diagnosis initiating treatment. 4 In a patient with iron deficiency, investigate further to find the Clinical Reasoning Investigation cause. 5 Consider and look for anemia in appropriate patients (e.g., Clinical Reasoning Hypothesis generation Selectivity Investigation those at risk for blood loss [those receiving anticoagulation, elderly patients taking a nonsteroidal anti-inflammatory drug]) or in patients with hemolysis (mechanical valves), whether they are symptomatic or not, and in those with new or worsening symptoms of angina or CHF. 6 In patients with macrocytic anemia: Clinical Reasoning Hypothesis generation a) Consider the possibility of vitamin B12 deficiency. b) Look for other manifestations of the deficiency (e.g., Clinical Reasoning History Physical neurologic symptoms) in order to make the diagnosis of pernicious anemia when it is present. 7 As part of well-baby care, consider anemia in high-risk Clinical Reasoning Hypothesis generation Selectivity populations (e.g., those living in poverty) or in high-risk patients (e.g., those who are pale or have a low-iron diet or poor weight gain). 8 When a patient is discovered to have a slightly low hemoglobin Clinical Reasoning Hypothesis generation Selectivity Diagnosis level, look carefully for a cause (e.g., hemoglobinopathies, menorrhagia, occult bleeding, previously undiagnosed chronic disease), as one cannot assume that this is normal for them. 9 In anemic patients with menorrhagia, determine the need to Clinical Reasoning Hypothesis generation look for other causes of the anemia. 7 | P a g e Antibiotics Key Feature Skill Phase 1 In patients requiring antibiotic therapy, make rational choices Clinical Reasoning Treatment Selectivity (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context). 2 In patients with a clinical presentation suggestive of a viral Clinical Reasoning Treatment infection, avoid prescribing antibiotics. 3 In a patient with a purported antibiotic allergy, rule out other Clinical Reasoning Hypothesis generation History causes (e.g., intolerance to side effects, non-allergic rash) before accepting the diagnosis. 4 Use a selective approach in ordering cultures before initiating Selectivity Investigation antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunicompromised patients). 5 In urgent situations (e.g., cases of meningitis, septic shock, Selectivity Treatment febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis). Page | 8 Anxiety Key Feature Skill Phase 1 Do not attribute acute symptoms of panic (e.g., shortness of Selectivity Diagnosis Clinical Reasoning Hypothesis generation breath, palpitations, hyperventilation) to anxiety without first excluding serious medical pathology (e.g., pulmonary embolism, myocardial infarction ) from the differential diagnosis (especially in patients with established anxiety disorder). 2 When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Selectivity Hypothesis generation a) Exclude serious medical pathology. Clinical Reasoning Diagnosis b) Identify: Clinical Reasoning Diagnosis History - other co-morbid psychiatric conditions. - abuse. - substance abuse. c) Assess the risk of suicide. Clinical Reasoning History Diagnosis 3 In patients with known anxiety disorders, do not assume all Clinical Reasoning Diagnosis Hypothesis generation new symptoms are attributable to the anxiety disorder. 4 Offer appropriate treatment for anxiety: Clinical Reasoning Treatment - benzodiazepines (eg. deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics). - non-pharmacologic treatment. 5 In a patient with symptoms of anxiety, take and interpret an Clinical Reasoning Diagnosis History appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder. 9 | P a g e Asthma Key Feature Skill Phase 1 In patients of all ages with respiratory symptoms (acute, chronic, recurrent): Clinical Reasoning Hypothesis generation a) Include asthma in the differential diagnosis. Diagnosis b) Confirm the diagnosis of asthma by appropriate use of: Clinical Reasoning History Physical - history. - physical examination. - spirometry. 2 In a child with acute respiratory distress, distinguish asthma or Clinical Reasoning History Selectivity Physical bronchiolitis from croup and foreign body aspiration by taking an appropriate history and doing a physical examination. 3 In a known asthmatic, presenting either because of an acute Clinical Reasoning Diagnosis exacerbation or for ongoing care, objectively determine the severity of the condition (e.g., with history, including the pattern of medication use), physical examination, spirometry). Do not underestimate severity. 4 In a known asthmatic with an acute exacerbation: Clinical Reasoning Treatment a) Treat the acute episode (e.g., use beta-agonists Selectivity repeatedly and early steroids, and avoid under-treatment). b) Rule out co-morbid disease (e.g., complications, Selectivity Hypothesis generation Clinical Reasoning Diagnosis congestive heart failure, chronic obstructive pulmonary disease). c) Determine the need for hospitalization or discharge Selectivity Treatment Clinical Reasoning (basing the decision on the risk of recurrence or complications, and on the patient’s expectations and resources). 5 For the ongoing (chronic) treatment of an asthmatic, propose a Clinical Reasoning Treatment Patient Centered stepwise management plan including: - self-monitoring. - self-adjustment of medication. - when to consult back. 6 For a known asthmatic patient, who has ongoing or recurrent symptoms: Clinical Reasoning History a) Assess severity and compliance with medication Patient Centered Diagnosis regimens. b) Recommend lifestyle adjustments (e.g., avoiding Clinical Reasoning Treatment Patient Centered irritants, triggers) that may result in less recurrence and better control. 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