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COPD # COPD # Subjective: Reason for today's visit (scheduled or urgent): Spirometry confirms COPD (q2-3 years or as symptoms change): COPD Action Plan in place: # of Exacerbations: Medication use since last visit: Visits to ED / Admissions / ICU Admissions for COPD: Current smoker? Quit Date? Cessation offered? Physical activity goals: Target BMI (19-25): Fluvax / Pneumovax: Current medications: - SABA (Ventolin, Brycanyl): - LABA (Oxeze, Serevent): - LAAC (Atrovent, Spiriva): - ICS/LABA (Advair, Symbicort): Inhaler technique: Resting Oxygen Sat: Last ABG: Oxygen therapy (Nocturnal/Continuous): Pulmonary rehab: End of life issues discussed:
Dizziness # Dizziness # Subjective: Describe the dizziness? When does the dizziness occur? Consistent with [vertigo] [disequilibrium] [presyncope] [lightheadedness] [No hearing loss] [No tinnitus] [Denies feeling of fullness] [No photophobia, phonophobia or aura] [No hx of migraines] [dizziness during migraines] [No falls] [no urinary incontinence] [No hx of DM] [No hx of Parkinson's] [No hx of depression/anxiety/panic attacks] [Caffeine /day] [no nicotine] [ETOH /wk] Meds: [BP Medications] [Benzos] [TCA] [No recent medication initiation/discontinuation/dose change] # Objective: Vitals: [BP lying / sitting / standing] [alert and oriented x 3] CVS: [S1 S2] [regular] [no murmurs] [no carotid bruit] CNS: Cranial Nerves: II, III: [PERRLA] [confrontational visual fields intact] III, IV, VI: [normal EOM] [no diplopia] [no nystagmus] [no ptosis] V: [sensation intact] [masseters strong symmetrically] VII: [face symmetric without weakness] VIII: [hearing grossly intact] IX, X: [voice normal] [palate elevates symmetrically] [gag intact] XI: [SCM/trapezii 5/5] XII: [tongue protrudes midline] [no atrophy or fasciculation] Motor: [normal gait] [antalgic gait] [tandem gait intact] [no tremor] [no rigidity] [no bradykinesia] [no pronator drift] [normal reflexes bilat] Sensation: [No numbness] [proprioception intact] [vibration sense intact] Coordination: [rapid alternating and point-to-point (FNF, HTS) movements intact] [Romberg negative] [Dix-Hallpike]
Low Back Pain # Low Back Pain / Pain Radiating Down Leg # Subjective: Where is the pain the worst? (Back or leg dominant) Is your pain constant or intermittent? "Is there ever a time when you are in your best position or at the best time of your day when your pain stops, and I know it comes right back but is there a moment or two when the pain is gone?" What movements or positions make it worse? What movements or positions make it better? Have you had this same pain before? Have you had treatment before (have you ever had back surgery)? What can't you do now that you could do before you got the pain? # Objective: Observation: - [no surgical scars evident] - [no deformities of the spine] Movement: - flexion [with/without] pain - extension [with/without] pain Nerve root irritation tests: ("tell when I lift your leg if this reproduces your typical LEG pain.") - Straight leg raise [positive/negative] [right/left] Never root conduction tests: - L5 - ankle dorsiflexion R: [-]/5 L: [-]/5 - great toe extension R: [-]/5 L: [-]/5 - S1 - great toe flexion R: [-]/5 L: [-]/5 - ankle reflex R: [absent/reduced/normal/hyperreflexic] L: [absent/reduced/normal/hyperreflexic] High-low tests: - Plantar reflex R: [absent/reduced/normal/hyperreflexic] L: [absent/reduced/normal/hyperreflexic] - Saddle sensation [intact/abnormal]
Nocturnal Enuresis # Nocturnal Enuresis ## Enuresis = discrete episodes of urinary incontinence during sleep in children > 5yo ## Monosymptomatic Enuresis = enuresis in children without any other lower urinary tract symptoms and without a history of bladder dysfunction ## Secondary Enuresis = noctural enuresis occuring in a child that was previously dry for 6 months. Think regression: infectious causes, bullying, parental separation, trauma, etc. ## Refractory Enuresis = Nonresponse to active intervention is defined by <50% improvement in symptoms: refer to Pediatric Urology, Developmental/Behavioural Peds. ## DDx: Diabetes, OSA, Bladder/Bowel Dysfunction, Constipation, Hyperthyroidism, Renal disease, Seizure,Sickle cell, Pinworms, Psychogenic Polydipsia # Subjective: Is the child dry during the day? Daytime soiling? Constipated (hard stools / difficulty stooling)? Pain when urinating? Urinary frequency? Caffeine intake? Fluid intake after supper? Was the child previously dry for at least 6 months? (secondary enuresis) Family history? # Objective: (routine, including genitalia, spine, oropharynx - STOP BANG signs of sleep apnea) # Plan: Urinanalysis (Renal U/S and cystourethrogram are reserved for children with both night and daytime incontinence.) Education of parents: not child's fault, avoid punishment, high rate of spontaneous remission, avoid caffeine and high sugar beverages after 6pm, avoid routine use of 'pull ups', urinate just before bedtime Discussed motivational therapy - charts, calendars Discussed enuresis alarms - successful, high relapse rate Discussed Desmopressin - successful, minimal side effect, to avoid excessive fluid intake >8oz 1 hour prior to medication Desmopressin 0.2mg PO QHS (1 hour before bedtime), may be increased to a maximum of 0.4mg PO QHS after 10-14 days. RTC to assess response to Desmopressin within 1-2 weeks.

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