Last Minute study points

Read the SAMP instructions & do the practice exam (get to know the interface)

• http://www.cfpc.ca/uploadedFiles/Education/Certification_in_Family_Medicine_Examination/SAMPS%20instructions%20-%20Eng.pdf

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Four Principles of Family Medicine

1. The family physician is a skilled clinician.
2. Family medicine is a community-based discipline.
3. The family physician is a resource to a defined practice population.
4. The patient-physician relationship is central to the role of the family physician.

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Canadian CT head Rule – Minor Head injury pt

• Not for <16yo, GCS <13, non-trauma, coumadin / bleeding disorder, or obvious open skull #
• High risk – neurological intervention
  • GCS <15 2hours after injury
  • Suspected open or depressed skull #
  • Sign of basal skull fracture
    • Hemotympanum, racoon eyes, Battle’s sign
    • CSF otorrhea/rhinorrhea
  • Vomiting >=2
  • Age >=65
• Medium risk – CT
  • Retrograde Amnesia >=30min
  • Dangerous Mechanism
    • Pedestrian struck by vehicle
    • Occupant ejected from vehicle
    • Fall >=3 ft or 5 stairs

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The Ottawa SAH (Subarachnoid hemorrhage) Rule

• For alert patients older than 15 y with new severe nontraumatic headache reaching maximum intensity within 1 h
• Not for patients with new neurologic deficits, previous aneurysms, SAH, brain tumors, or history of recurrent headaches (≥3 episodes over the course of ≥6 mo)
• Investigate if ≥1 high-risk variables present:
  1. Age ≥40 y
  2. Neck pain or stiffness
  3. Witnessed loss of consciousness
  4. Onset during exertion
  5. Thunderclap headache (instantly peaking pain)
  6. Limited neck flexion on examination

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Canadian C-Spine rules (see neck pain post)

• Stable, Age >16, non-pregnant, GCS15, non-penetrating injury <48hr, no vertebral dz
• X-ray if
  • Age >65
  • Dangerous mechanism: Fall >3ft / 5 stairs, axial load, MCV >100km/h, motorized recreation vehicle / bicycle struck
  • Paresthesia in extremities
• Low risk factors for assessment of ROM
  • sitting position in ER
  • ambulatory at any time
  • Simple rearend MVA: except pushed into traffic, hit by bus, rollover, hit by high speed vehicle
  • Delayed onset of pain
  • No Midline C-spine tenderness
  • Rotate Neck 45 degree L and R 
    • X-ray if Can’t rotate neck 45 degree

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Ottawa Knee rules – X-ray if

• Age >55
• Isolated patellar tenderness
• Tenderness of head of fibula
• Inability to flex 90 degree
• Inability to wt bear (4 steps) immediately AND in ER

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Ottawa Ankle Rules – Not for pt <18yo

• Ankle X-ray if Pain in malleolar zone &
  • Bone tenderness on posterior 6cm of lateral or medial malleolus
  • Inability to wt bear (4 steps) both immediately and in ER
• Foot X-ray if Pain in midfoot zone &
  • Bone tenderness at base of 5th metatarsal
  • Bone tenderness at navicular bone
  • Inability to wt bear both immediately and in ER

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Statistics:

• Sensitivity = True positive / condition positive
• Specificity = True negative / condition negative
• Positive Predictive value = True positive / (true positive + False positive)
• Negative Predictive value = True Negative / (true negative + False negative)
• Positive likelihood ratio = sensitivity / (1-specificity)
• Negative likelihood ratio = (1-sensitivity) / specificity

	Events	Non-events
Experimental group (exposed)	A	B
Control Group (not exposed)	C	D

• Control event rate (CER) = C / (C+D)
• Experimental event rate (EER) = A / (A+B)
• Relative Risk = EER / CER
• Absolute risk Reduction (ARR) = CER – EER
• Relative Risk Reduction (RRR) = (CER – EER) / CER
• Number need to treat (NNT) 1 / ARR

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References:

• http://www.cfpc.ca/principles/
• http://www.emottawa.ca/assets/documents/research/cdr_cthead_poster.pdf
• http://jama.jamanetwork.com/article.aspx?articleid=1741823