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Topic Key Feature Skills Phase(s)
Abdominal Pain Given a patient with abdminal pain, paying particular attention to its location and chronicity: Clinical Reasoning Skills History
Abdominal Pain Given a patient with abdminal pain, paying particular attention to its location and chronicity: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Abdominal Pain Given a patient with abdminal pain, paying particular attention to its location and chronicity: Clinical Reasoning Skills, Selectivity Investigation
Abdominal Pain In a patient with diagnosed abdominal pain (e.g., gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (e.g., with. medication, lifestyle modifications). Clinical Reasoning Skills Treatment
Abdominal Pain In a woman with abdominal pain: Clinical Reasoning Skills Hypothesis generation, Investigation
Abdominal Pain In a woman with abdominal pain: Clinical Reasoning Skills Hypothesis generation
Abdominal Pain In a woman with abdominal pain: Clinical Reasoning Skills Physical, Diagnosis
Abdominal Pain In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. Clinical Reasoning Skills, Selectivity Physical, Diagnosis
Abdominal Pain In specific patient groups (e.g., children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Abdominal Pain 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
Abdominal Pain Given a patient with a life-threatening cause of acute abdominal pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Clinical Reasoning Skills Diagnosis
Abdominal Pain 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, Clinical Reasoning Skills Treatment
Abdominal Pain 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, Referral
Abdominal Pain In a patient with chronic or recurrent abdominal pain: Clinical Reasoning Skills Follow-up
Abdominal Pain In a patient with chronic or recurrent abdominal pain: Clinical Reasoning Skills, Communication Skills Treatment
Abdominal Pain In a patient with chronic or recurrent abdominal pain: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Abdominal Pain Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Advanced Cardiac Life Support Keep up to date with advanced cardiac life support (ACLS) recommendations (i.e., maintain your knowledge base). Professionalism Treatment
Advanced Cardiac Life Support Promptly defibrillate a patient with ventricular fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach). Clinical Reasoning Skills, Selectivity Treatment
Advanced Cardiac Life Support Diagnose serious arrhythmias (V tach, V fib, supraventricular tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols. Clinical Reasoning Skills Diagnosis, Treatment
Advanced Cardiac Life Support Suspect and promptly treat reversible causes of arrhythmias (e.g., hyperkalemia, digoxin toxicity, cocaine intoxication) before confirmation of the diagnosis. Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Advanced Cardiac Life Support Ensure adequate ventilation (i.e., with a bag valve mask), and secure the airway in a timely manner. Clinical Reasoning Skills, Selectivity Treatment
Advanced Cardiac Life Support In patients requiring resuscitation, assess their circumstances (e.g., asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.) Clinical Reasoning Skills Diagnosis, Treatment
Advanced Cardiac Life Support In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (e.g., resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically. Patient Centered Approach Treatment, Follow-up
Advanced Cardiac Life Support Attend to family members (e.g., with counselling, presence in the code room) during and after resuscitating a patient. Professionalism, Communication Skills Treatment
Advanced Cardiac Life Support In a pediatric resuscitation, use appropriate resources ( e.g., Braeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes. Clinical Reasoning Skills Treatment
Advanced Cardiac Life Support Note: Shock is not dealt with in this topic. Note
Allergy In all patients, always inquire about any allergy and clearly document it in the chart. Re-evaluate this periodically. Clinical Reasoning Skills History, Follow-up
Allergy Clarify the manifestations of a reaction in order to try to diagnose a true allergic reaction (e.g., do not misdiagnose viral rashes as antibiotic allergy, or medication intolerance as true allergy). Clinical Reasoning Skills History, Diagnosis
Allergy In a patient reporting allergy (e.g., to food, to medications, environmental), ensure that the patient has the appropriate medication to control symptoms (e.g., antihistamines, bronchodilators, steroids, an EpiPen). Clinical Reasoning Skills Treatment
Allergy Prescribe an EpiPen to every patient who has a history of, or is at risk for, anaphylaxis. Clinical Reasoning Skills Treatment
Allergy Educate appropriate patients with allergy (e.g., to food, 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. Clinical Reasoning Skills, Patient Centered Approach Treatment, Follow-up
Allergy Advise patients with any known drug allergy or previous major allergic reaction to get a MedicAlert bracelet. Clinical Reasoning Skills, Patient Centered Approach Treatment
Allergy In a patient presenting with an anaphylactic reaction: Selectivity, Clinical Reasoning Skills Diagnosis
Allergy In a patient presenting with an anaphylactic reaction: Selectivity, Clinical Reasoning Skills Treatment
Allergy In a patient presenting with an anaphylactic reaction: Clinical Reasoning Skills Treatment
Allergy In patients with anaphylaxis of unclear etiology refer to an allergist for clarification of the cause. Clinical Reasoning Skills Referral
Allergy In the particular case of a child with an anaphylactic reaction to food: Clinical Reasoning Skills Treatment
Allergy In the particular case of a child with an anaphylactic reaction to food: Clinical Reasoning Skills Treatment
Allergy In a patient with unexplained recurrent respiratory symptoms, include allergy (e.g., sick building syndrome, seasonal allergy) in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Anemia Assess the risk of decompensation of anemic patients (e.g., volume status, the presence of congestive heart failure [CHF], angina, or other disease states) to decide if prompt transfusion or volume replacement is necessary. Clinical Reasoning Skills, Selectivity Diagnosis, Treatment
Anemia In a patient with anemia, classify the anemia as microcytic, normocytic, or macrocytic by using the MCV (mean corpuscular value) or smear test result, to direct further assessment and treatment. Clinical Reasoning Skills Diagnosis, Investigation
Anemia In all patients with anemia, determine the iron status before initiating treatment. Clinical Reasoning Skills Investigation, Diagnosis
Anemia In a patient with iron deficiency, investigate further to find the cause. Clinical Reasoning Skills Investigation
Anemia Consider and look for anemia in appropriate patients (e.g., 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. Clinical Reasoning Skills, Selectivity Hypothesis generation, Investigation
Anemia In patients with macrocytic anemia: Clinical Reasoning Skills Hypothesis generation
Anemia In patients with macrocytic anemia: Clinical Reasoning Skills History, Physical
Anemia As part of well-baby care, consider anemia in high-risk 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). Clinical Reasoning Skills, Selectivity Hypothesis generation
Anemia When a patient is discovered to have a slightly low hemoglobin 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. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Anemia In anemic patients with menorrhagia, determine the need to look for other causes of the anemia. Clinical Reasoning Skills Hypothesis generation
Antibiotics In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context). Clinical Reasoning Skills, Selectivity Treatment
Antibiotics In patients with a clinical presentation suggestive of a viral infection, avoid prescribing antibiotics. Clinical Reasoning Skills Treatment
Antibiotics In a patient with a purported antibiotic allergy, rule out other causes (e.g., intolerance to side effects, non-allergic rash) before accepting the diagnosis. Clinical Reasoning Skills Hypothesis generation, History
Antibiotics Use a selective approach in ordering cultures before initiating 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 immunocompromised patients). Selectivity Investigation
Antibiotics In urgent situations (e.g., cases of meningitis, septic shock, febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis). Selectivity Treatment
Anxiety Do not attribute acute symptoms of panic (e.g., shortness of 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). Selectivity, Clinical Reasoning Skills Diagnosis, Hypothesis generation
Anxiety When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Anxiety When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Clinical Reasoning Skills Diagnosis, History
Anxiety When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Clinical Reasoning Skills History, Diagnosis
Anxiety In patients with known anxiety disorders, do not assume all new symptoms are attributable to the anxiety disorder. Clinical Reasoning Skills Diagnosis, Hypothesis generation
Anxiety Offer appropriate treatment for anxiety: - benzodiazepines (eg. deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics). - non-pharmacologic treatment. Clinical Reasoning Skills Treatment
Anxiety In a patient with symptoms of anxiety, take and interpret an appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder. Clinical Reasoning Skills Diagnosis, History
Asthma In patients of all ages with respiratory symptoms (acute, chronic, recurrent): Clinical Reasoning Skills Hypothesis generation, Diagnosis
Asthma In patients of all ages with respiratory symptoms (acute, chronic, recurrent): Clinical Reasoning Skills History, Physical
Asthma In a child with acute respiratory distress, distinguish asthma or bronchiolitis from croup and foreign body aspiration by taking an appropriate history and doing a physical examination. Clinical Reasoning Skills, Selectivity History, Physical
Asthma In a known asthmatic, presenting either because of an acute 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. Clinical Reasoning Skills Diagnosis
Asthma In a known asthmatic with an acute exacerbation: Clinical Reasoning Skills, Selectivity Treatment
Asthma In a known asthmatic with an acute exacerbation: Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Asthma In a known asthmatic with an acute exacerbation: Selectivity, Clinical Reasoning Skills Treatment
Asthma For the ongoing (chronic) treatment of an asthmatic, propose a stepwise management plan including: - self-monitoring. - self-adjustment of medication. - when to consult back. Clinical Reasoning Skills, Patient Centered Approach Treatment
Asthma For a known asthmatic patient, who has ongoing or recurrent symptoms: Clinical Reasoning Skills, Patient Centered Approach History, Diagnosis
Asthma For a known asthmatic patient, who has ongoing or recurrent symptoms: Clinical Reasoning Skills, Patient Centered Approach Treatment
Atrial Fibrillation In a patient who presents with new onset atrial fibrillation, look for an underlying cause (e.g., ischemic heart disease, acute myocardial infarction, congestive heart failure, cardiomyopathy, pulmonary embolus, hyperthyroidism, alcohol, etc.) Clinical Reasoning Skills Hypothesis generation
Atrial Fibrillation In a patient presenting with atrial fibrillation, Clinical Reasoning Skills, Selectivity Hypothesis generation
Atrial Fibrillation In a patient presenting with atrial fibrillation, Clinical Reasoning Skills, Selectivity Treatment
Atrial Fibrillation In an individual presenting with chronic or paroxysmal atrial fibrillation, Patient Centered Approach, Clinical Reasoning Skills Diagnosis, Treatment
Atrial Fibrillation In an individual presenting with chronic or paroxysmal atrial fibrillation, Clinical Reasoning Skills Hypothesis generation, Follow-up
Atrial Fibrillation In patients with atrial fibrillation, when the decision has been made to use anticoagulation, institute the appropriate therapy and patient education, with a comprehensive follow-up plan. Clinical Reasoning Skills Treatment, Follow-up
Atrial Fibrillation In a stable patient with atrial fibrillation, identify the need for rate control. Clinical Reasoning Skills Hypothesis generation, Treatment
Atrial Fibrillation In a stable patient with atrial fibrillation, arrange for rhythm correction when appropriate. Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Bad News When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality. Patient Centered Approach, Communication Skills Treatment
Bad News Give bad news: - in an empathic, compassionate manner - allowing enough time. - prividing translation, as necessary. Communication Skills Treatment
Bad News Obtain patient consent before involving the family. Patient Centered Approach, Professionalism Treatment
Bad News After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding. Patient Centered Approach, Communication Skills Follow-up
Behavioural Problems Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour: - Look for medical conditions (e.g., hearing impairment, depression, other psychiatric diagnoses, other medical problems). - Look for psychosocial factors (e.g., abuse, substance use, family chaos, peer issues, parental expectations). - Recognize when the cause is not attention deficit disorder (ADD) (e.g., learning disorders, autism spectrum disorder, conduct disorder). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Behavioural Problems When obtaining a history about behavioural problems in a child: - Ask the child about her or his perception of the situation. - Use multiple sources of information (e.g., school, daycare). Clinical Reasoning Skills History
Behavioural Problems When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (e.g., do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.). Clinical Reasoning Skills Treatment
Behavioural Problems In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis: - Specifically look for substance abuse, peer issues, and other stressors. - Look for medical problems (bipolar disorder, schizophrenia). Do not say the problem is "just adolescence". Clinical Reasoning Skills Hypothesis generation, Diagnosis
Behavioural Problems In elderly patients known to have dementia, do not attribute behavioural problems to dementia without assessing for other possible factors (e.g., medication side effects or interactions, treatable medical conditions such as sepsis or depression). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Breast Lump Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Clinical Reasoning Skills, Selectivity History, Diagnosis
Breast Lump Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Clinical Reasoning Skills, Patient Centered Approach Treatment
Breast Lump Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Clinical Reasoning Skills, Patient Centered Approach Treatment
Breast Lump Given a woman presenting with a breast lump (i.e., clinical features): Selectivity, Clinical Reasoning Skills Diagnosis, Treatment
Breast Lump Given a woman presenting with a breast lump (i.e., clinical features): Patient Centered Approach, Professionalism Treatment, Follow-up
Breast Lump Given a woman presenting with a breast lump (i.e., clinical features): Clinical Reasoning Skills Investigation, Treatment
Breast Lump In a woman who presents with a malignant breast lump and knows the diagnosis: Clinical Reasoning Skills Diagnosis, Treatment
Breast Lump In a woman who presents with a malignant breast lump and knows the diagnosis: Clinical Reasoning Skills, Selectivity Hypothesis generation, History
Breast Lump In a woman who presents with a malignant breast lump and knows the diagnosis: Patient Centered Approach, Clinical Reasoning Skills Follow-up, Treatment
Cancer In all patients, be opportunistic in giving cancer prevention advice (e.g., stop smoking, reduce unprotected sexual intercourse, prevent human papillomavirus infection), even when it is not the primary reason for the encounter. Patient Centered Approach, Communication Skills Treatment
Cancer In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (e.g., with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing). Clinical Reasoning Skills, Selectivity Diagnosis
Cancer In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.) Patient Centered Approach, Professionalism Follow-up, Treatment
Cancer In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (e.g., family issues, loss of job), and the patient’s ability to cope with these consequences. Patient Centered Approach, Communication Skills History
Cancer In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (e.g., diarrhea, feet paresthesias), as the patient may not volunteer this information. Clinical Reasoning Skills History, Follow-up
Cancer In patients with a distant history of cancer who present with new symptoms (e.g., shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Cancer In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.) Communication Skills, Professionalism Treatment, Follow-up
Cancer Note: For pain control, see the key features on chronic disease and palliative care. See also the key feature on depression. Note
Chest Pain Given a patient with undefined chest pain, take an adequate history to make a specific diagnosis (e.g., determine risk factors, whether the pain is pleuritic or sharp, pressure, etc.). Clinical Reasoning Skills History
Chest Pain Given a clinical scenario suggestive of life-threatening conditions (e.g., pulmonary embolism, tamponade, dissection, pneumothorax), begin timely treatment (before the diagnosis is confirmed, while doing an appropriate work-up). Selectivity Diagnosis, Treatment
Chest Pain In a patient with unexplained chest pain, rule out ischemic heart disease. Clinical Reasoning Skills, Selectivity Hypothesis generation, Investigation
Chest Pain Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease: Clinical Reasoning Skills Diagnosis
Chest Pain Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease: Clinical Reasoning Skills Investigation
Chest Pain Given a suspected diagnosis of pulmonary embolism: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Chest Pain Given a suspected diagnosis of pulmonary embolism: Selectivity Treatment
Chest Pain Note: See also the key features on ischemic heart disease. Note
Chronic Disease In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose: - acute complications of the chornic disease (e.g., diabetic ketoacidosis). - acute exacerbations of the disease (e.g., asthma exacerbation, acute arthritis). - a new, unrelated condition. Clinical Reasoning Skills Diagnosis
Chronic Disease Regularly reassess adherence (compliance) to the treatment plan (including medications). Clinical Reasoning Skills History, Follow-up
Chronic Disease In patients with chronic disease: Clinical Reasoning Skills History
Chronic Disease In patients with chronic disease: Clinical Reasoning Skills Treatment, Hypothesis generation
Chronic Disease In patients with chronic disease, actively inquire about: - the psychological impact of diagnosis and treatment. - functional impairment. - underlying depression or risk of suicide. - underlying substance abuse. Patient Centered Approach, Clinical Reasoning Skills History
Chronic Disease Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan. Patient Centered Approach History
Chronic Obstructive Pulmonary Disease In all patients presenting with symptoms of prolonged or recurrent cough, dyspnea, or decreased exercise tolerance, especially those who also have a significant smoking history, suspect the diagnosis of chronic obstructive pulmonary disease (COPD). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Chronic Obstructive Pulmonary Disease When the diagnosis of COPD is suspected, seek confirmation with pulmonary function studies (e.g., FEV1). Clinical Reasoning Skills Investigation
Chronic Obstructive Pulmonary Disease In patients with COPD, use pulmonary function tests periodically to document disease progression. Clinical Reasoning Skills Investigation, Follow-up
Chronic Obstructive Pulmonary Disease Encourage smoking cessation in all patients diagnosed with COPD.* Clinical Reasoning Skills, Patient Centered Approach Treatment
Chronic Obstructive Pulmonary Disease Offer appropriate vaccinations to patients diagnosed with COPD (e.g., influenza/pneumococcal vaccination). Clinical Reasoning Skills Treatment
Chronic Obstructive Pulmonary Disease In an apparently stable patient with COPD, offer appropriate inhaled medication for treatment (e.g., anticholinergics/bronchodilators if condition is reversible, steroid trial). Clinical Reasoning Skills Treatment
Chronic Obstructive Pulmonary Disease Refer appropriate patients with COPD to other health professionals (e.g., a respiratory technician or pulmonary rehabilitation personnel) to enhance quality of life. Clinical Reasoning Skills Referral
Chronic Obstructive Pulmonary Disease When treating patients with acute exacerbations of COPD, rule out co-morbidities (e.g., myocardial infarction, congestive heart failure, systemic infections, anemia). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Chronic Obstructive Pulmonary Disease In patients with end-stage COPD, especially those who are currently stable, discuss, document, and periodically re-evaluate wishes about aggressive treatment interventions. Patient Centered Approach, Clinical Reasoning Skills Treatment, Follow-up
Chronic Obstructive Pulmonary Disease Note: See the key features on Smoking Cessation. Note
Contraception With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise. Patient Centered Approach, Communication Skills Treatment
Contraception In patients using specific contraceptives, advise of specific factors that may reduce efficacy (e.g., delayed initiation of method, illness, medications, specific lubricants). Clinical Reasoning Skills, Patient Centered Approach Treatment
Contraception In aiding decision-making to ensure adequate contraception: Clinical Reasoning Skills History
Contraception In aiding decision-making to ensure adequate contraception: Clinical Reasoning Skills, Patient Centered Approach History
Contraception In aiding decision-making to ensure adequate contraception: Patient Centered Approach, Communication Skills History
Contraception In aiding decision-making to ensure adequate contraception: Clinical Reasoning Skills Treatment
Contraception In patients using hormonal contraceptives, manage side effects appropriately (i.e., recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo–Provera]). Clinical Reasoning Skills Treatment
Contraception In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post-coital contraception. Clinical Reasoning Skills Treatment
Contraception In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in post-coital contraception (emergency contraceptive pill, intrauterine device). Clinical Reasoning Skills Treatment
Cough In patients presenting with an acute cough: Clinical Reasoning Skills, Selectivity Hypothesis generation
Cough In patients presenting with an acute cough: Clinical Reasoning Skills Diagnosis
Cough In patients presenting with an acute cough: Clinical Reasoning Skills Treatment
Cough In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (e.g., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis). Clinical Reasoning Skills Hypothesis generation
Cough In patients with a persistent (e.g., for weeks) cough: Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Cough In patients with a persistent (e.g., for weeks) cough: Clinical Reasoning Skills Investigation
Cough Do not ascribe a persistent cough to an adverse drug effect (e.g., from an angiotensin-converting enzyme inhibitor) without first considering other causes. Clinical Reasoning Skills Diagnosis
Cough In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.) Clinical Reasoning Skills Hypothesis generation, Diagnosis
Counselling In patients with mental health concerns, explore the role of counselling in treating their problems. (Intervention is not just about medication use.) Clinical Reasoning Skills, Patient Centered Approach Treatment
Counselling When making the decision about whether to offer or refer a patient for counselling: Clinical Reasoning Skills Treatment
Counselling When making the decision about whether to offer or refer a patient for counselling: Patient Centered Approach Treatment
Counselling When making the decision about whether to offer or refer a patient for counselling: Professionalism Treatment
Counselling When making the decision about whether to offer or refer a patient for counselling: Professionalism Treatment
Counselling When counselling a patient, allow adequate time. Professionalism Treatment
Counselling When counselling a patient, recognize when you are approaching or exceeding boundaries (e.g., transference, counter-transference) or limits (the problem is more complex than you originally thought), as this should prompt you to re-evaluate your role. Professionalism, Clinical Reasoning Skills Treatment
Crisis Take the necessary time to assist patients in crisis, as they often present unexpectedly. Patient Centered Approach, Professionalism Treatment
Crisis Identify your patient’s personal resources for support (e.g., family, friends) as part of your management of patients facing crisis. Patient Centered Approach, Clinical Reasoning Skills History, Treatment
Crisis Offer appropriate community resources (e.g., counselor) as part of your ongoing management of patients with a crisis. Patient Centered Approach, Professionalism Treatment
Crisis Assess suicidality in patients facing crisis. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Crisis Use psychoactive medication rationally to assist patients in crisis. Clinical Reasoning Skills Treatment
Crisis Inquire about unhealthy coping methods (e.g., drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis. Clinical Reasoning Skills Hypothesis generation, History
Crisis Ask your patient if there are others needing help as a consequence of the crisis. Patient Centered Approach Hypothesis generation, History
Crisis Negotiate a follow-up plan with patients facing crisis. Clinical Reasoning Skills, Communication Skills Treatment, Follow-up
Crisis Be careful not to cross boundaries when treating patients in crisis (e.g., lending money, appointments outside regular hours). Professionalism Treatment
Crisis Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises. Professionalism Treatment
Crisis When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia), Clinical Reasoning Skills Treatment
Crisis When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia), Professionalism Treatment
Crisis When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia), Professionalism Treatment
Croup In patients with croup, Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Croup In patients with croup, Clinical Reasoning Skills, Selectivity Treatment
Croup Before attributing stridor to croup, consider other possible causes (e.g., anaphylaxis, foreign body (airway or esophagus), retropharyngeal abcess, epiglottitis). Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Croup In any patient presenting with respiratory symptoms, look specifically for the signs and symptoms that differentiate upper from lower respiratory disease (e.g., stridor vs. wheeze vs. whoop). Clinical Reasoning Skills History, Physical
Croup In a child presenting with a clear history and physical examination compatible with mild to moderate croup, make the clinical diagnosis without further testing (e.g., do not routinely X-ray). Clinical Reasoning Skills, Selectivity Diagnosis, Investigation
Croup In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup). Clinical Reasoning Skills Treatment
Croup In a patient presenting with croup, address parental concerns (e.g., not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms. Clinical Reasoning Skills, Communication Skills Treatment, Follow-up
Deep Venous Thrombosis In patients complaining of leg pain and/or swelling, evaluate the likelihood of deep venous thrombosis (DVT) as investigation and treatment should differ according to the risk. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Deep Venous Thrombosis In patients with high probability for thrombotic disease (e.g., extensive leg clot, suspected pulmonary embolism) start anticoagulant therapy if tests will be delayed. Clinical Reasoning Skills, Selectivity Treatment
Deep Venous Thrombosis Identify patients likely to benefit from DVT prophylaxis. Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Deep Venous Thrombosis Utilize investigations for DVT allowing for their limitations (e.g., Ultrasound and D-dimer). Clinical Reasoning Skills, Selectivity Investigation, Diagnosis
Deep Venous Thrombosis In patients with established DVT use oral anticoagulation appropriately, (e.g., start promptly, watch for drug interactions, monitor lab values and adjust dose when appropriate, stop warfarin when appropriate,provide patient teaching). Clinical Reasoning Skills Treatment, Follow-up
Deep Venous Thrombosis Consider the possibility of an underlying coagulopathy in patients with DVT, especially when unexpected. Clinical Reasoning Skills Hypothesis generation
Deep Venous Thrombosis Use compression stockings in appropriate patients, to prevent and treat post-phlebitic syndrome. Clinical Reasoning Skills Treatment
Dehydration When assessing the acutely ill patient, look for signs and symptoms of dehydration. (e.g., look for dehydration in the patient with a debilitating pneumonia). Clinical Reasoning Skills Hypothesis generation
Dehydration In the dehydrated patient, assess the degree of dehydration using reliable indicators (e.g., vital signs) as some patients' hydration status may be more difficult to assess (e.g., elderly, very young, pregnant). Clinical Reasoning Skills Physical, Investigation
Dehydration In a dehydrated patient, Clinical Reasoning Skills Treatment, Diagnosis
Dehydration In a dehydrated patient, Clinical Reasoning Skills Treatment
Dehydration When treating severe dehydration, use objective measures (e.g., lab values) to direct ongoing management. Clinical Reasoning Skills Investigation, Treatment
Dehydration In a dehydrated patient, Clinical Reasoning Skills Hypothesis generation
Dehydration In a dehydrated patient, Clinical Reasoning Skills Treatment
Dehydration Treat the dehydrated pregnant patient aggressively, as there are additional risks of dehydration in pregnancy. Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Dementia In patients with early, non-specific signs of cognitive impairment: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dementia In patients with early, non-specific signs of cognitive impairment: Clinical Reasoning Skills Diagnosis
Dementia In patients with obvious cognitive impairment, select proper laboratory investigations and neuroimaging techniques to complement the history and physical findings and to distinguish between dementia, delirium, and depression. Clinical Reasoning Skills Investigation
Dementia In patients with dementia, distinguish Alzheimer’s disease from other dementias, as treatment and prognosis differ. Clinical Reasoning Skills Diagnosis
Dementia In patients with dementia who exhibit worsening function, look for other diagnoses (i.e., don’t assume the dementia is worsening). These diagnoses may include depression or infection. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dementia Disclose the diagnosis of dementia compassionately, and respect the patient’s right to autonomy, confidentiality, and safety. Patient Centered Approach, Communication Skills Diagnosis, Treatment
Dementia In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.) Clinical Reasoning Skills Diagnosis
Dementia In following patients diagnosed with dementia: Clinical Reasoning Skills Follow-up, Physical
Dementia In following patients diagnosed with dementia: Clinical Reasoning Skills, Patient Centered Approach Treatment
Dementia Assess the needs of and supports for caregivers of patients with dementia. Patient Centered Approach History
Dementia Report to the appropriate authorities patients with dementia who you suspect should not be driving. Professionalism, Clinical Reasoning Skills Treatment
Dementia In patients with dementia, look for possible genetic factors to provide preventive opportunities to other family members, and to aid in appropriate decision-making (e.g., family planning). Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, History
Dementia Note: Specific cognition-enhancing pharmacotherapy (initiation/discontinuation) may be assessed later, as controversy on indications diminishes. Note
Depression In a patient with a diagnosis of depression: Clinical Reasoning Skills, Selectivity History
Depression In a patient with a diagnosis of depression: Clinical Reasoning Skills, Selectivity Treatment
Depression Screen for depression and diagnose it in high-risk groups (e.g., certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Depression In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient. Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, Treatment
Depression After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (e.g., anxiety, bipolar disorder, personality disorder). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Depression In a patient diagnosed with depression, treat appropriately: - drugs, psychotherapy. - monitor response to therapy. - active modification (e.g., augmentation, dose changes, drug changes). - referral as necessary. Clinical Reasoning Skills Treatment, Follow-up
Depression In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Depression In patients presenting with depression, inquire about abuse: - sexual, physical, and emotional abuse (past and current, witnessed or inflicted). - substance abuse. Clinical Reasoning Skills, Patient Centered Approach History, Hypothesis generation
Depression In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction. Clinical Reasoning Skills, Selectivity Diagnosis
Depression Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (e.g., bipolar disorder, schizoaffective disorder, organic disease). Clinical Reasoning Skills Diagnosis
Depression In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Diabetes Given a symptomatic or asymptomatic patient at high risk for diabetes (e.g., patients with gestational diabetes, obese, certain ethnic groups, and those with a strong family history), screen at appropriate intervals with the right tests to confirm the diagnosis. Clinical Reasoning Skills, Selectivity Investigation, Hypothesis generation
Diabetes Given a patient diagnosed with diabetes, either new-onset or established, treat and modify treatment according to disease status (e.g., use oral hypoglycemic agents, insulin, diet, and/or lifestyle changes). Clinical Reasoning Skills Treatment, Follow-up
Diabetes Given a patient with established diabetes, advise about signs and treatment of hypoglycemia/hyperglycemia during an acute illness or stress (i.e., gastroenteritis, physiologic stress, decreased intake. Clinical Reasoning Skills, Patient Centered Approach Treatment
Diabetes In a patient with poorly controlled diabetes, use effective educational techniques to advise about the importance of optimal glycemic control through compliance, lifestyle modification, and appropriate follow-up and treatment. Communication Skills, Patient Centered Approach Treatment
Diabetes In patients with established diabetes: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Diabetes In patients with established diabetes: Clinical Reasoning Skills Treatment, Follow-up
Diabetes In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia. Clinical Reasoning Skills, Selectivity Diagnosis, Treatment
Diabetes Given a patient with diabetic ketoacidosis, manage the problem appropriately and advise about preventing future episodes. Clinical Reasoning Skills, Selectivity Treatment, Follow-up
Diarrhea In all patients with diarrhea, Clinical Reasoning Skills Diagnosis
Diarrhea In all patients with diarrhea, Clinical Reasoning Skills Treatment
Diarrhea In patients with acute diarrhea, use history to establish the possible etiology (e.g., infectious contacts, travel, recent antibiotic or other medication use, common eating place for multiple ill patients). Clinical Reasoning Skills Hypothesis generation, History
Diarrhea In patients with acute diarrhea who have had recent hospitalization or recent antibiotic use, look for clostridium difficile. Clinical Reasoning Skills Hypothesis generation
Diarrhea In patients with acute diarrhea, counsel about the timing of return to work/school (re: the likelihood of infectivity). Clinical Reasoning Skills Treatment
Diarrhea Pursue investigation, in a timely manner, of elderly with unexplained diarrhea, as they are more likely to have pathology. Clinical Reasoning Skills, Selectivity Hypothesis generation, Investigation
Diarrhea In a young person with chronic or recurrent diarrhea, with no red flag symptoms or signs, use established clinical criteria to make a positive diagnosis of irritable bowel syndrome (do not overinvestigate). Clinical Reasoning Skills, Selectivity Diagnosis
Diarrhea In patients with chronic or recurrent diarrhea, look for both gastro-intestinal and non-gastro-intestinal symptoms and signs suggestive of specific diseases (e.g., inflammatory bowel disease, malabsorption syndromes, and compromised immune system). Clinical Reasoning Skills History, Physical
Difficult Patient When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients. Clinical Reasoning Skills Diagnosis
Difficult Patient When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status. Patient Centered Approach History, Diagnosis
Difficult Patient In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times. Patient Centered Approach, Professionalism Treatment, Follow-up
Difficult Patient With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (e.g., psychiatric patients, patients with chronic pain). Selectivity Hypothesis generation, Diagnosis
Difficult Patient When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation. Professionalism Treatment, Diagnosis
Difficult Patient When dealing with difficult patients, set clear boundaries. Professionalism Treatment
Difficult Patient Take steps to end the physician-patient relationship when it is in the patient’s best interests. Professionalism, Patient Centered Approach Treatment
Difficult Patient With a difficult patient, safely establish common ground to determine the patient’s needs (eg. threatening or demanding patients). Patient Centered Approach, Professionalism Treatment
Disability Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a disability for that specific patient. Patient Centered Approach, Clinical Reasoning Skills Diagnosis
Disability Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis. Clinical Reasoning Skills History, Hypothesis generation
Disability In patients with chronic physical problems (e.g., arthritis, multiple sclerosis) or mental problems (e.g., depression), assess for and diagnose disability when it is present. Clinical Reasoning Skills, Patient Centered Approach Diagnosis, Hypothesis generation
Disability In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family). Patient Centered Approach History
Disability For disabled patients, offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration. Patient Centered Approach, Professionalism Treatment
Disability In patients at risk for disability (e.g., those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (e.g., exercises, braces, counselling, work modification). Clinical Reasoning Skills, Patient Centered Approach Treatment
Disability Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan). Clinical Reasoning Skills, Patient Centered Approach Treatment
Dizziness In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (e.g., arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dizziness In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope. Clinical Reasoning Skills History
Dizziness In patients complaining of dizziness, measure postural vital signs. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Physical
Dizziness Examine patients with dizziness closely for neurologic signs. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Physical, Hypothesis generation
Dizziness In hypotensive dizzy patients, exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dizziness In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dizziness In a dizzy patient, review medications (including prescription and over-the-counter medications) for possible reversible causes of the dizziness. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Dizziness Investigate further those patients complaining of dizziness who have: - signs or symptoms of central vertigo. - a history of trauma. - signs, symptoms, or other reasons (e.g., anticoagulation) to suspect a possible serious underlying cause. Selectivity Investigation
Domestic Violence In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (e.g., periodic annual exam, visits for anxiety/depression, ER visits). Patient Centered Approach, Clinical Reasoning Skills History
Domestic Violence In a patient in a suspected or confirmed situation of domestic violence: Selectivity, Clinical Reasoning Skills History
Domestic Violence In a patient in a suspected or confirmed situation of domestic violence: Clinical Reasoning Skills, Patient Centered Approach Treatment
Domestic Violence In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members. Clinical Reasoning Skills, Patient Centered Approach Treatment
Domestic Violence In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (e.g., helplessness, guilt), and its impact on children. Patient Centered Approach, Communication Skills Treatment
Dyspepsia In a patient presenting with dyspepsia, include cardiovascular disease in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Dyspepsia Attempt to differentiate, by history and physical examination, between conditions presenting with dyspepsia (e.g., gastroesophageal reflux disease, gastritis, ulcer, cancer), as plans for investigation and management may be very different. Clinical Reasoning Skills History, Physical
Dyspepsia In a patient presenting with dyspepsia, ask about and examine the patient for worrisome signs/symptoms (e.g., gastrointestinal bleeding, weight loss, dysphagia). Clinical Reasoning Skills History, Physical
Dysuria In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection. Clinical Reasoning Skills, Selectivity Diagnosis
Dysuria When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result. Clinical Reasoning Skills, Selectivity Treatment
Dysuria Consider non-urinary tract infection related etiologies of dysuria (e.g., prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate. Clinical Reasoning Skills Hypothesis generation
Dysuria When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (e.g., pregnancy, children, diabetes, urolithiasis). Clinical Reasoning Skills, Selectivity Hypothesis generation
Dysuria In patients with recurrent dysuria, look for a specific underlying cause (e.g., post-coital urinary tract infection, atrophic vaginitis, retention). Clinical Reasoning Skills Hypothesis generation
Earache Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM). Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Diagnosis, Physical
Earache Include pain referred from other sources in the differential diagnosis of an earache (eg. Tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.). Clinical Reasoning Skills Hypothesis generation
Earache Consider serious causes in the differential diagnosis of an earache (eg. tumors, temporal arteritis, mastoiditis). Clinical Reasoning Skills Hypothesis generation
Earache In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (e.g., through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (e.g., reassessment in 48 hours). Selectivity, Communication Skills Treatment
Earache Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.) Selectivity, Professionalism Treatment
Earache In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics). Clinical Reasoning Skills Treatment
Earache In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).* Clinical Reasoning Skills Hypothesis generation
Earache Test children with recurrent ear infections for hearing loss. Clinical Reasoning Skills Investigation
Earache Note: See the key features on fever. Note
Eating Disorders Whenever teenagers present for care, include an assessment of their risk of eating disorders (e.g., altered body image, binging, and type of activities, as dancers, gymnasts, models, etc., are at higher risk). as this may be the only opportunity to do an assessment. Clinical Reasoning Skills History
Eating Disorders When diagnosing an eating disorder, take an appropriate history to differentiate anorexia nervosa from bulimia, as treatment and prognosis differ. Clinical Reasoning Skills History
Eating Disorders In a patient with an eating disorder, rule out co-existing psychiatric conditions (e.g., depression, personality disorder, obsessive-compulsive disorder, anxiety disorder). Clinical Reasoning Skills Hypothesis generation, History
Eating Disorders When managing a patient with an eating disorder, use a multidisciplinary approach (e.g., work with a psychiatrist, a psychologist, a dietitian). Clinical Reasoning Skills, Professionalism Treatment, Referral
Eating Disorders When assessing a patient presenting with a problem that has defied diagnosis (e.g., arrhythmias without cardiac disease, an electrolyte imbalance without drug use or renal impairment, amenorrhea without pregnancy), include “complication of an eating disorder” in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Eating Disorders In the follow-up care of a patient with a known eating disorder: Clinical Reasoning Skills History, Diagnosis
Eating Disorders In the follow-up care of a patient with a known eating disorder: Clinical Reasoning Skills Hypothesis generation
Elderly In the elderly patient taking multiple medications, avoid polypharmacy by: - monitoring side effects. - periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate). - monitoring for interactions. Clinical Reasoning Skills Treatment, Follow-up
Elderly In the elderly patient, actively inquire about non-prescription medication use (e.g., herbal medicines, cough drops, over-the-counter drugs, vitamins). Clinical Reasoning Skills History
Elderly In the elderly patient, screen for modifiable risk factors (e.g., visual disturbance, impaired hearing) to promote safety and prolong independence. Clinical Reasoning Skills History, Hypothesis generation
Elderly In the elderly patient, assess functional status to: - anticipate and discuss the eventual need for changes in the living environment. - ensure that social support is adequate. Clinical Reasoning Skills, Patient Centered Approach Treatment, History
Elderly In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (e.g., pneumonia, appendicitis, depression). Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Epistaxis Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Epistaxis While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family. Patient Centered Approach, Clinical Reasoning Skills Treatment, Diagnosis
Epistaxis In a patient with an active or recent nosebleed, obtain a focused history to identify possible etiologies (e.g., recent trauma, recent upper respiratory infection, medications). Clinical Reasoning Skills History, Hypothesis generation
Epistaxis In a patient with an active or recent nosebleed, Clinical Reasoning Skills Physical
Epistaxis In a patient with an active or recent nosebleed, Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Treatment
Epistaxis In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site. Clinical Reasoning Skills Hypothesis generation
Epistaxis In a patient with a nosebleed, obtain lab work only for specific indications (e.g., unstable patient, suspicion of a bleeding diathesis, use of anticoagulation) Clinical Reasoning Skills, Selectivity Investigation, Hypothesis generation
Epistaxis In a patient with a nosebleed, provide thorough aftercare instructions (e.g., how to stop a subsequent nose bleed, when to return, humidification, etc.) Clinical Reasoning Skills Treatment, Follow-up
Family Issues Routinely ask about family issues to understand their impact on the patient’s illness and the impact of the illness on the family. Patient Centered Approach History
Family Issues Ask about family issues - periodically, - at important life-cycle points (e.g., when children move out, after the birth of a baby). - when faced with problems not resolving in spite of appropriate therapeutic interventions (e.g. medication compliance, fibromyalgia, hypertension). Patient Centered Approach, Clinical Reasoning Skills Hypothesis generation, History
Fatigue In all patients complaining of fatigue, include depression in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Fatigue Ask about other constitutional symptoms as part of a systematic approach to rule out underlying medical causes in all patients complaining of fatigue. Clinical Reasoning Skills History
Fatigue Exclude adverse effects of medication as the cause in all patients complaining of fatigue. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Fatigue Avoid early, routine investigations in patients with fatigue unless specific indications for such investigations are present. Selectivity Investigation
Fatigue Given patients with fatigue in whom other underlying disorders have been ruled out, assist them to place, in a therapeutic sense, the role of their life circumstances in their fatigue. Patient Centered Approach, Communication Skills Treatment
Fatigue In patients whose fatigue has become chronic, manage supportively, while remaining vigilant for new diseases and illnesses. Patient Centered Approach, Clinical Reasoning Skills Hypothesis generation, Treatment
Fever In febrile infants 0-3 months old: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Fever In febrile infants 0-3 months old: Clinical Reasoning Skills Investigation
Fever In a febrile patient with a viral infection, do NOT prescribe antibiotics. Clinical Reasoning Skills Treatment
Fever In a febrile patient requiring antibiotic therapy, prescribe the appropriate antibiotic(s) according to likely causative organism(s) and local resistance patterns. Clinical Reasoning Skills Treatment
Fever Investigate patients with fever of unknown origin appropriately (e.g., with blood cultures, echocardiography, bone scans). Clinical Reasoning Skills Investigation
Fever In febrile patients, consider life-threatening infectious causes (e.g., endocarditis, meningitis). Selectivity Hypothesis generation, Diagnosis
Fever Aggressively and immediately treat patients who have fever resulting from serious causes before confirming the diagnosis, whether these are infectious (e.g., febrile neutropenia, septic shock, meningitis) or non-infectious (e.g., heat stroke, drug reaction, malignant neuroleptic syndrome). Selectivity Treatment
Fever In the febrile patient, consider causes of hyperthermia other than infection (e.g., heat stroke, drug reaction, malignant neuroleptic syndrome). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Fever In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology. Clinical Reasoning Skills Hypothesis generation
Fractures In a patient with multiple injuries, stabilize the patient (e.g., airway, breathing, and circulation, and life-threatening injuries) before dealing with any fractures. Clinical Reasoning Skills Treatment
Fractures When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury. Clinical Reasoning Skills Physical
Fractures In patients with suspected fractures that are prone to have normal X-ray findings (e.g., scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-rays are normal. Clinical Reasoning Skills, Selectivity Treatment
Fractures In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (e.g., no obvious fracture), investigate appropriately (e.g., with bone scans, computed tomography) before excluding a fracture. Clinical Reasoning Skills Investigation
Fractures Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner. Selectivity Treatment, Diagnosis
Fractures In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X-rays) and adequate (e.g., narcotic) analgesia. Clinical Reasoning Skills Treatment
Fractures In patients presenting with a fracture, look for and diagnose high-risk complications (e.g., an open fracture, unstable cervical spine, compartment syndrome). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Fractures Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations. Clinical Reasoning Skills, Selectivity Investigation
Fractures Note: These key features do not include technical and or psychomotor skills such as casting, reduction of dislocations, etc. See Procedural Skills. Note
Gastro-intestinal Bleed In a patient with blood in the stools who is hemodynamically stable, use history to differentiate upper vs. lower gastro-intestinal (GI) bleed as the investigation differs. Clinical Reasoning Skills Diagnosis, History
Gastro-intestinal Bleed In a patient with suspected blood in the stool, explore other possible causes (e.g., beet ingestion, iron, Pepto-Bismol) before doing extensive investigation. Clinical Reasoning Skills Hypothesis generation, History
Gastro-intestinal Bleed Look for patients at higher risk for GI bleed (e.g., previous GI bleed, intensive care unit admission, nonsteroidal anti-inflammatory drugs, alcohol) so as to modify treatment to reduce risk of GI bleed (e.g cytoprotection). Clinical Reasoning Skills Hypothesis generation, History
Gastro-intestinal Bleed In a patient with obvious GI bleeding, identify patients who may require timely treatment even though they are not yet in shock. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Gastro-intestinal Bleed In a stable patient with lower GI bleeding, look for serious causes (e.g., malignancy, inflammatory bowel disease, ulcer, varices) even when there is an apparent obvious cause for the bleeding (e.g., do not attribute a rectal bleed to hemorrhoids or to oral anticoagulation). Clinical Reasoning Skills, Selectivity Hypothesis generation
Gastro-intestinal Bleed In a patient with an upper GI bleed, Clinical Reasoning Skills Hypothesis generation
Gastro-intestinal Bleed In a patient with an upper GI bleed, Clinical Reasoning Skills History, Physical
Gender Specific Issues In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (e.g., women with coronary artery disease, depression in males). Clinical Reasoning Skills Hypothesis generation
Gender Specific Issues As part of caring for women with health concerns, assess the possible contribution of domestic violence. Clinical Reasoning Skills Hypothesis generation, History
Gender Specific Issues When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (e.g., work-life balance or between partners). Patient Centered Approach, Clinical Reasoning Skills Hypothesis generation, History
Gender Specific Issues Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (e.g., positioning for Pap, chaperones for genital/rectal exams). Professionalism Physical
Gender Specific Issues Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (e.g., ASA use in women). Clinical Reasoning Skills, Professionalism Hypothesis generation
Grief In patients who have undergone a loss, prepare them for the types of reactions (e.g., emotional, physical) that they may experience. Patient Centered Approach, Communication Skills Treatment
Grief In all grieving patients, especially those with a prolonged or abnormal grief reaction, inquire about depression or suicidal ideation. Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, History
Grief Recognize atypical grief reactions in the very young or the elderly (e.g., behavioral changes). Clinical Reasoning Skills, Patient Centered Approach Diagnosis
Grief In patients with a presentation suggestive of a grief reaction without an obvious trigger, look for triggers that may be unique to the patient (e.g., death of a pet, loss of a job). Patient Centered Approach History
Headache Given a patient with a new-onset headache, differentiate benign from serious pathology through history and physical examination. Selectivity History, Physical
Headache Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed): Selectivity, Clinical Reasoning Skills Investigation
Headache Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed): Selectivity, Clinical Reasoning Skills Diagnosis
Headache Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed): Selectivity Treatment
Headache Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed): Clinical Reasoning Skills Diagnosis
Headache Given a patient with a history of chronic and/or relapsing headache (e.g., tension, migraine, cluster, narcotic-induced, medication-induced), treat appropriately, and avoid narcotic, barbiturate dependence. Clinical Reasoning Skills Treatment
Headache In a patient with a history of suspected subarachnoid bleed and a negative CT scan, do a lumbar puncture. Selectivity, Clinical Reasoning Skills Hypothesis generation, Investigation
Headache In a patient suffering from acute migraine headache: Clinical Reasoning Skills Treatment
Headache In a patient suffering from acute migraine headache: Clinical Reasoning Skills, Patient Centered Approach Treatment, Referral
Hepatitis In a patient presenting with hepatitis symptoms and/or abnormal liver function tests, take a focused history to assist in establishing the etiology (e.g., new drugs, alcohol, blood or body fluid exposure, viral hepatitis). Clinical Reasoning Skills History, Hypothesis generation
Hepatitis In a patient with abnormal liver enzyme tests interpret the results to distinguish between obstructive and hepatocellular causes for hepatitis as the subsequent investigation differs. Clinical Reasoning Skills Diagnosis
Hepatitis In a patient where an obstructive pattern has been identified, Clinical Reasoning Skills, Selectivity Investigation
Hepatitis In a patient where an obstructive pattern has been identified, Clinical Reasoning Skills, Selectivity Treatment, Referral
Hepatitis In patients positive for Hepatitis B and/or C, Clinical Reasoning Skills Hypothesis generation, Investigation
Hepatitis In patients positive for Hepatitis B and/or C, Clinical Reasoning Skills Hypothesis generation, Investigation
Hepatitis In patients who are Hepatitis C antibody positive determine those patients who are chronically infected with Hepatitis C, because they are at greater risk for cirrhosis and hepatocellular cancer. Clinical Reasoning Skills Hypothesis generation, Investigation
Hepatitis In patients who are chronically infected with Hepatitis C, refer for further assessment and possible treatment. Clinical Reasoning Skills Treatment, Referral
Hepatitis In patients who are at risk for Hepatitis B and/or Hepatitis C exposure, Patient Centered Approach, Communication Skills Treatment
Hepatitis In patients who are at risk for Hepatitis B and/or Hepatitis C exposure, Clinical Reasoning Skills Treatment
Hepatitis Offer post-exposure prophylaxis to patients who are exposed or possibly exposed to Hepatitis A or B. Clinical Reasoning Skills Treatment, Hypothesis generation
Hepatitis Periodically look for complications (e.g., cirrhosis, hepatocellular cancer) in patients with chronic viral hepatitis, especially hepatitis C infection. Clinical Reasoning Skills Hypothesis generation, Follow-up
Hyperlipidemia Screen appropriate patients for hyperlipidemia. Clinical Reasoning Skills Hypothesis generation, History
Hyperlipidemia In all patients whose cardiovascular risk is being evaluated, include the assessment of lipid status. Clinical Reasoning Skills Investigation
Hyperlipidemia When hyperlipidemia is present, take an appropriate history, and examine and test the patient for modifiable causes (e.g., alcohol abuse, thyroid disease). Clinical Reasoning Skills Hypothesis generation, History
Hyperlipidemia Ensure that patients diagnosed with hyperlipidemia receive appropriate lifestyle and dietary advice. Periodically reassess compliance with this advice (especially in patients at overall low or moderate CV risk). Clinical Reasoning Skills, Patient Centered Approach Treatment, Follow-up
Hyperlipidemia In treating hyperlipidemic patients, establish target lipid levels based on overall CV risk. Clinical Reasoning Skills Diagnosis
Hyperlipidemia In patients receiving medication for hyperlipidemia, periodically assess compliance with and side effects of treatment. Clinical Reasoning Skills, Patient Centered Approach Treatment, Follow-up
Hypertension Screen for hypertension. Clinical Reasoning Skills Hypothesis generation, Physical
Hypertension Use correct technique and equipment to measure blood pressure. Psychomotor Skills/Procedure Skills Physical
Hypertension Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits). Clinical Reasoning Skills Diagnosis
Hypertension In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: Clinical Reasoning Skills History
Hypertension In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: Clinical Reasoning Skills Physical
Hypertension In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: Clinical Reasoning Skills Investigation
Hypertension In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): Selectivity, Clinical Reasoning Skills Hypothesis generation
Hypertension In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): Clinical Reasoning Skills, Selectivity Investigation, Treatment
Hypertension Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). Clinical Reasoning Skills, Patient Centered Approach Treatment
Hypertension In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors). Clinical Reasoning Skills Treatment
Hypertension Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly. Selectivity Diagnosis, Treatment
Hypertension In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits. Clinical Reasoning Skills Follow-up
Immigrants As part of the periodic health assessment of newly arrived immigrants: Clinical Reasoning Skills History
Immigrants As part of the periodic health assessment of newly arrived immigrants: Clinical Reasoning Skills Treatment
Immigrants As part of the ongoing care of immigrants, modify your approach (when possible) as required by their cultural context (e.g., history given only by husband, may refuse examination by a male physician, language barriers). Patient Centered Approach, Communication Skills Treatment, History
Immigrants When dealing with a language barrier, make an effort to obtain the history with the help of a medical interpreter and recognize the limitations of all interpreters (e.g., different agendas, lack of medical knowledge, something to hide). Communication Skills History
Immigrants As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Clinical Reasoning Skills History
Immigrants As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Clinical Reasoning Skills History
Immigrants As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Clinical Reasoning Skills, Patient Centered Approach History
Immigrants In immigrants presenting with a new or ongoing medical condition, consider in the differential diagnosis infectious diseases acquired before immigration (e.g., malaria, parasitic disease, tuberculosis). Clinical Reasoning Skills, Selectivity Hypothesis generation
Immigrants As part of the ongoing care of all immigrants, inquire about the use of alternative healers, practices, and/or medications (e.g., ‘‘natural’’ or herbal medicines, spiritual healers, medications from different countries, moxibustion). Clinical Reasoning Skills History
Immunization Do not delay immunizations unnecessarily (e.g., vaccinate a child even if he or she has a runny nose). Clinical Reasoning Skills Treatment
Immunization With parents who are hesitant to vaccinate their children, explore the reasons, and counsel them about the risks of deciding against routine immunization of their children. Patient Centered Approach, Communication Skills Treatment, History
Immunization Identify patients who will specifically benefit from immunization (e.g., not just the elderly and children, but also the immunosuppressed, travellers, those with sickle cell anemia, and those at special risk for pneumonia and hepatitis A and B), and ensure it is offered. Clinical Reasoning Skills Treatment, Hypothesis generation
Immunization Clearly document immunizations given to your patients. Clinical Reasoning Skills, Professionalism Treatment
Immunization In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different. Clinical Reasoning Skills History, Hypothesis generation
Immunization In patients presenting with a suspected infectious disease, do not assume that a history of vaccination has provided protection against disease (e.g., pertussis, rubella, diseases acquired while travelling). Clinical Reasoning Skills, Selectivity Hypothesis generation
In Children When evaluating children, generate a differential diagnosis that accounts for common medical problems, which may present differently in children (e.g., urinary tract infections, pneumonia, appendicitis, depression). Clinical Reasoning Skills Hypothesis generation
In Children As children, especially adolescents, generally present infrequently for medical care, take advantage of visits to ask about: - unverbalized problems (e.g., school performance). - social well-being (e.g., relationships, home, friends). - modifiable risk factors (e.g., exercise, diet). - risk behaviours (e.g., use of bike helmets and seatbelts). Clinical Reasoning Skills, Patient Centered Approach History, Treatment
In Children At every opportunity, directly ask questions about risk behaviours (e.g., drug use, sex, smoking, driving) to promote harm reduction. Clinical Reasoning Skills, Communication Skills History, Treatment
In Children In adolescents, ensure the confidentiality of the visit, and, when appropriate, encourage open discussion with their caregivers about specific problems (e.g., pregnancy, depression and suicide, bullying, drug abuse). Communication Skills, Patient Centered Approach Treatment
In Children In assessing and treating children, use age-appropriate language. Communication Skills, Patient Centered Approach Treatment, History
In Children In assessing and treating children, obtain and share information with them directly (i.e., don’t just talk to the parents). Communication Skills, Patient Centered Approach History, Treatment
In Children When investigation is appropriate, do not limit it because it may be unpleasant for those involved (the child, parents, or health care providers). Clinical Reasoning Skills, Selectivity Treatment, Investigation
Infections In patients with a suspected infection, Clinical Reasoning Skills Investigation
Infections In patients with a suspected infection, Clinical Reasoning Skills, Selectivity Investigation, Investigation
Infections When considering treatment of an infection with an antibiotic, do so Clinical Reasoning Skills, Selectivity Treatment
Infections When considering treatment of an infection with an antibiotic, do so Clinical Reasoning Skills, Selectivity Treatment
Infections Treat infections empirically when appropriate (e.g., in life threatening sepsis without culture report or confirmed diagnosis, candida vaginitis post-antibiotic use). Clinical Reasoning Skills, Selectivity Treatment
Infections Look for infection as a possible cause in a patient with an ill-defined problem (e.g., confusion in the elderly, failure to thrive, unexplained pain [necrotizing fasciitis, abdominal pain in children with pneumonia]). Clinical Reasoning Skills Hypothesis generation
Infections When a patient returns after an original diagnosis of a simple infection and is deteriorating or not responding to treatment, think about and look for more complex infection. (i.e., When a patient returns complaining they are not getting better, don’t assume the infection is just slow to resolve). Clinical Reasoning Skills Hypothesis generation
Infections When treating infections with antibiotics use other therapies when appropriate (e.g., aggressive fluid resuscitation in septic shock, incision and drainage abscess, pain relief). Clinical Reasoning Skills Treatment
Infertility When a patient consults you with concerns about difficulties becoming pregnant: Clinical Reasoning Skills History
Infertility When a patient consults you with concerns about difficulties becoming pregnant: Clinical Reasoning Skills Treatment
Infertility In patients with fertility concerns, provide advice that accurately describes the likelihood of fertility. Clinical Reasoning Skills Treatment
Infertility With older couples who have fertility concerns, refer earlier for investigation and treatment, as their likelihood of infertility is higher. Clinical Reasoning Skills, Selectivity Hypothesis generation, Referral
Infertility When choosing to investigate primary or secondary infertility, ensure that both partners are assessed. Clinical Reasoning Skills Hypothesis generation
Infertility In couples who are likely infertile, discuss adoption when the time is right. (Remember that adoption often takes a long time.) Patient Centered Approach, Clinical Reasoning Skills Treatment
Infertility In evaluating female patients with fertility concerns and menstrual abnormalities, look for specific signs and symptoms of certain conditions (e.g., polycystic ovarian syndrome, hyperprolactinemia, thyroid disease) to direct further investigations (e.g., prolactin, thyroid-stimulating hormone, and luteal phase progesterone testing). Clinical Reasoning Skills Hypothesis generation, History
Insomnia In patients presenting with sleep complaints, take a careful history to: - distinguish insomnia from other sleep-related complaints that require more specific treatment (e.g., sleep apnea or other sleep disorders, including periodic limb movements, restless legs syndrome, sleepwalking, or sleep talking). - assess the contribution of drugs (prescription, over-the-counter, recreational), caffeine, and alcohol. - make a specific psychiatric diagnosis if one is present. Clinical Reasoning Skills, Selectivity History, Diagnosis
Insomnia When assessing patients with sleep complaints, obtain a collateral history from the bed partner, if possible. Clinical Reasoning Skills History
Insomnia In all patients with insomnia, provide advice about sleep hygiene (e.g., limiting caffeine, limiting naps, restricting bedroom activities to sleep and sex, using an alarm clock to get up at the same time each day). Clinical Reasoning Skills, Patient Centered Approach Treatment
Insomnia In appropriate patients with insomnia, use hypnotic medication judiciously (e.g., prescribe it when there is a severe impact on function, but do not prescribe it without a clear indication). Clinical Reasoning Skills Treatment
Ischemic Heart Disease Given a specific clinical scenario in the office or emergency setting, diagnose presentations of ischemic heart disease (IHD) that are: - classic - atypical (e.g., in women, those with diabetes, the young, those at no risk). Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Ischemic Heart Disease In a patient with modifiable risk factors for ischemic heart disease (e.g., smoking, diabetes control, obesity), develop a plan in collaboration with the patient to reduce her or his risk of developing the disease. Clinical Reasoning Skills Treatment
Ischemic Heart Disease In a patient presenting with symptoms suggestive of ischemic heart disease but in whom the diagnosis may not be obvious, do not eliminate the diagnosis solely because of tests with limited specificity and sensitivity (e.g., electrocardiography, exercise stress testing, normal enzyme results). Selectivity, Clinical Reasoning Skills Diagnosis, Investigation
Ischemic Heart Disease In a patient with stable ischemic heart disease manage changes in symptoms with self-initiated adjustment of medication (e.g., nitroglycerin) and appropriate physician contact (e.g., office visits, phone calls, emergency department visits), depending on the nature and severity of symptoms. Clinical Reasoning Skills Treatment
Ischemic Heart Disease In the regular follow-up care of patients with established ischemic heart disease, specifically verify the following to detect complications and suboptimal control: - symptom control. - medication adherence. - impact on daily activities. - lifestyle modificatin. - clinical screening i.e., symptoms and signs of complications). Clinical Reasoning Skills, Patient Centered Approach History, Diagnosis
Ischemic Heart Disease In a person with diagnosed acute coronary syndrome (e.g., cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial infarction, unstable angina), manage the condition in an appropriate and timely manner. Selectivity Treatment
Joint Disorder In a patient presenting with joint pain, distinguish benign from serious pathology (e.g., sarcoma, septic joint): Selectivity, Clinical Reasoning Skills Hypothesis generation, History
Joint Disorder In a patient presenting with joint pain, distinguish benign from serious pathology (e.g., sarcoma, septic joint): Clinical Reasoning Skills, Selectivity Investigation, Diagnosis
Joint Disorder In a patient presenting with non-specific musculoskeletal pain, make a specific rheumatologic diagnosis when one is evident through history, physical examination, and investigations. (e.g., gout, fibromyalgia, monoarthropathy vs. polyarthropathy). Clinical Reasoning Skills Diagnosis
Joint Disorder In a patient presenting with a monoarthropathy, rule out infectious causes. (e.g., sexually transmitted diseases). Selectivity, Clinical Reasoning Skills Diagnosis, Hypothesis generation
Joint Disorder In patients presenting with musculoskeletal pain, include referred and visceral sources of pain in the differential diagnosis. (e.g., angina, slipped capital epiphysis presenting as knee pain, neuropathic pain). Clinical Reasoning Skills Hypothesis generation
Joint Disorder Clinically diagnose ligamentous injuries. Do NOT do an X-ray examination. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Physical, Diagnosis
Joint Disorder In a patient presenting with joint pain, include systemic conditions in the differential diagnosis (e.g., Wegener’s granulomatosis, lupus, ulcerative colitis). Clinical Reasoning Skills Hypothesis generation
Joint Disorder In patients with a diagnosed rheumatologic condition: Clinical Reasoning Skills History
Joint Disorder In patients with a diagnosed rheumatologic condition: Clinical Reasoning Skills Treatment
Joint Disorder In assessing patients with a diagnosed rheumatologic condition, search for disease-related complications (e.g., iritis). Clinical Reasoning Skills Hypothesis generation
Joint Disorder In patients experiencing musculoskeletal pain: Patient Centered Approach History
Joint Disorder In patients experiencing musculoskeletal pain: Clinical Reasoning Skills Treatment
Joint Disorder In patients experiencing musculoskeletal pain: Clinical Reasoning Skills Treatment, Referral
Joint Disorder In patients with rheumatoid arthritis, start treatment with disease-modifying agents within an appropriate time interval. Clinical Reasoning Skills Treatment
Lacerations When managing a laceration, identify those that are more complicated and may require special skills for repair (e.g., a second- versus third-degree perineal tear, lip or eyelid lacerations involving margins, arterial lacerations). Clinical Reasoning Skills, Selectivity Diagnosis, Physical
Lacerations When managing a laceration, look for complications (e.g., flexor tendon lacerations, open fractures, bites to hands or face, neurovascular injury, foreign bodies) requiring more than simple suturing. Clinical Reasoning Skills Diagnosis, Physical
Lacerations Given a deep or contaminated laceration, thoroughly clean with copious irrigation and debride when appropriate, before closing. Clinical Reasoning Skills Treatment
Lacerations Identify wounds at high risk of infection (e.g., puncture wounds, some bites, some contaminated wounds), and do not close them. Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Lacerations When repairing lacerations in children, ensure appropriate analgesia (e.g., topical anesthesia) and/or sedation (e.g., procedural sedation) to avoid physical restraints. Clinical Reasoning Skills Treatment
Lacerations When repairing a laceration, allow for and take adequate time to use techniques that will achieve good cosmetic results (e.g., layer closure, revision if necessary, use of regional rather than local anesthesia). Clinical Reasoning Skills Treatment
Lacerations In treating a patient with a laceration: Clinical Reasoning Skills History
Lacerations In treating a patient with a laceration: Clinical Reasoning Skills Treatment
Learning (Patients/Self-learning) As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties. Clinical Reasoning Skills History
Learning (Patients/Self-learning) In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (e.g., mental health problem, learning disability, hearing). Clinical Reasoning Skills History, Hypothesis generation
Learning (Patients/Self-learning) When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family. Patient Centered Approach, Communication Skills Hypothesis generation, Follow-up
Learning (Patients/Self-learning) When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them. Patient Centered Approach, Clinical Reasoning Skills Treatment, Referral
Learning (Patients/Self-learning) To maximize the patient’s understanding and management of their condition, Patient Centered Approach, Communication Skills Diagnosis, History
Learning (Patients/Self-learning) To maximize the patient’s understanding and management of their condition, Communication Skills, Patient Centered Approach Treatment
Learning (Patients/Self-learning) Continuously assess your learning needs. Professionalism NA
Learning (Patients/Self-learning) Effectively address your learning needs. Professionalism, Selectivity NA
Learning (Patients/Self-learning) Incorporate your new knowledge into your practice. Professionalism NA
Lifestyle In the ongoing care of patients, ask about behaviours that, if changed, can improve health (e.g., diet, exercise, alcohol use, substance use, safer sex, injury prevention (e.g., seatbelts and helmets). Patient Centered Approach, Communication Skills History
Lifestyle Before making recommendations about lifestyle modification, explore a patient’s readiness to change, as it may alter advice. Patient Centered Approach Treatment, History
Lifestyle Explore a person’s context (e.g., poverty) before making recommendations about lifestyle modification (e.g., healthy eating choices, exercise suggestions) so as to avoid making recommendations incompatible with the patient’s context. Patient Centered Approach Treatment, History
Lifestyle In the ongoing care of patients, periodically review their behaviours, recognizing that these may change. Clinical Reasoning Skills Hypothesis generation, Follow-up
Lifestyle In the ongoing care of a patient, regularly reinforce advice about lifestyle modification, whether or not the patient has instituted a change in behaviour. Clinical Reasoning Skills Treatment, Follow-up
Loss of Consciousness In an unconscious patient, assess ABC’s and resuscitate as needed. Clinical Reasoning Skills, Selectivity Diagnosis, Treatment
Loss of Consciousness As part of the assessment of a patient who has lost consciousness, obtain focused history from the patient or witnesses that would include duration, trauma, preexisting conditions, drugs, toxins, medications and seizure activity. Clinical Reasoning Skills Hypothesis generation, History
Loss of Consciousness Examine unconscious patients for localizing and diagnostic signs (e.g., ketone smell, liver flap, focal neurologic signs). Clinical Reasoning Skills Hypothesis generation, Physical
Loss of Consciousness In patients with a loss of consciousness and a history of head trauma, rule out intracranial bleeding. Clinical Reasoning Skills Hypothesis generation, Investigation
Loss of Consciousness In patients with a loss of consciousness who are anticoagulated, rule out intracranial bleeding. Clinical Reasoning Skills Hypothesis generation, Investigation
Loss of Consciousness Assess and treat unconscious patients urgently for reversible conditions (e.g., shock, hypoxia, hypoglycemia, hyperglycemia, and narcotic overdose). Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Loss of Consciousness When following up patients who have lost consciousness, assess and advise regarding return to work, sporting, driving and recreational activities to minimize the possibility of injury to self or others in the event of a recurrence. Clinical Reasoning Skills, Communication Skills Hypothesis generation, Treatment
Loss of Consciousness In patients who have had a loss of consciousness without a clear diagnosis, pursue investigations (e.g., rule out transient arythmia, seizure). Clinical Reasoning Skills Hypothesis generation, Investigation
Loss of Consciousness When following up patients who have lost consciousness and where there is potential for recurrent episodes, discuss specific preventive and protective measures (e.g., position changes with orthostatic pressure changes). Clinical Reasoning Skills Treatment, Hypothesis generation
Loss of Consciousness In patients with loss of consciousness following head trauma, treat and follow up according to current concussion guidelines. Clinical Reasoning Skills, Professionalism Treatment, Follow-up
Loss of Consciousness Advise authorities about appropriate patients with loss of consciousness (e.g., regarding driving status). Clinical Reasoning Skills, Professionalism Treatment
Loss of Weight Pursue an underlying cause in a patient with unexplained weight loss through history, physical examination (including weight) and appropriate investigations. Clinical Reasoning Skills Hypothesis generation
Loss of Weight Maintain an ongoing record of patients’ weights so as to accurately determine when true weight loss has occurred. Professionalism Physical
Loss of Weight In patients with persistent weight loss of undiagnosed cause, follow-up and reevaluate in a timely manner in order to decide whether anything needs to be done. Clinical Reasoning Skills Follow-up
Low-back Pain In a patient with undefined acute low-back pain (LBP): Selectivity Hypothesis generation, Diagnosis
Low-back Pain In a patient with undefined acute low-back pain (LBP): Clinical Reasoning Skills Diagnosis
Low-back Pain In a patient with confirmed mechanical low back pain: Clinical Reasoning Skills, Selectivity Investigation, Treatment
Low-back Pain In a patient with confirmed mechanical low back pain: Clinical Reasoning Skills Treatment
Low-back Pain In a patient with mechanical low back pain, whether it is acute or chronic, give appropriate analgesia and titrate it to the patient’s pain. Clinical Reasoning Skills Treatment
Low-back Pain Advise the patient with mechanical low back pain to return if new or progressive neurologic symptoms develop. Clinical Reasoning Skills Follow-up, Treatment
Low-back Pain In all patients with mechanical low back pain, discuss exercises and posture strategies to prevent recurrences. Clinical Reasoning Skills, Patient Centered Approach Treatment
Meningitis In the patient with a non-specific febrile illness, look for meningitis, especially in patients at higher risk (e.g., immuno-compromised individuals, alcoholism, recent neurosurgery, head injury, recent abdominal surgery, neonates, aboriginal groups, students living in residence). Clinical Reasoning Skills, Selectivity Hypothesis generation
Meningitis When meningitis is suspected ensure a timely lumbar puncture. Selectivity Investigation
Meningitis In the differentiation between viral and bacterial meningitis, adjust the interpretation of the data in light of recent antibiotic use. Clinical Reasoning Skills Diagnosis
Meningitis For suspected bacterial meningitis, initiate urgent empiric IV antibiotic therapy (i.e., even before investigations are complete). Selectivity, Clinical Reasoning Skills Treatment
Meningitis Contact public health to ensure appropriate prophylaxis for family, friends and other contacts of each person with meningitis. Clinical Reasoning Skills, Professionalism Treatment
Menopause In any woman of menopausal age, screen for symptoms of menopause and (e.g., hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes). Clinical Reasoning Skills, Patient Centered Approach History, Hypothesis generation
Menopause In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.) Clinical Reasoning Skills Diagnosis
Menopause In a patient with atypical symptoms of menopause (e.g., weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause. Selectivity Hypothesis generation, History
Menopause In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results. Clinical Reasoning Skills Diagnosis
Menopause When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices Clinical Reasoning Skills, Patient Centered Approach Treatment
Menopause In menopausal or perimenopausal women: Clinical Reasoning Skills, Selectivity History
Menopause In menopausal or perimenopausal women: Clinical Reasoning Skills Treatment
Menopause In a menopausal or perimenopausal women, provide counselling about preventive health measures (e.g., osteoporosis testing, mammography). Clinical Reasoning Skills Treatment
Menopause Establish by history a patient’s hormone-replacement therapy risk/benefit status. Clinical Reasoning Skills, Selectivity History
Mental Competency In a patient with subtle symptoms or signs of cognitive decline (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene), Clinical Reasoning Skills, Communication Skills History, Physical
Mental Competency In a patient with subtle symptoms or signs of cognitive decline (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene), Clinical Reasoning Skills Referral
Mental Competency In a patient with a diagnosis that may predict cognitive impairment, (e.g., dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Mental Competency When a patient is making decisions (e.g., surgery/no surgery, resuscitation status) think about the need to assess their mental competency. Clinical Reasoning Skills, Professionalism Hypothesis generation
Mental Competency In a patient with cognitive impairment, identify intact decision-making abilities, as many may be retained. Clinical Reasoning Skills, Selectivity Hypothesis generation, Treatment
Multiple Medical Problems In all patients presenting with multiple medical concerns (e.g., complaints, problems, diagnoses), take an appropriate history to determine the primary reason for the consultation. Selectivity, Clinical Reasoning Skills History
Multiple Medical Problems In all patients presenting with multiple medical concerns, prioritize problems appropriately to develop an agenda that both you and the patient can agree upon (i.e., determine common ground). Patient Centered Approach Treatment
Multiple Medical Problems In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (e.g., physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology. Clinical Reasoning Skills Hypothesis generation
Multiple Medical Problems Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it. Clinical Reasoning Skills Hypothesis generation, History
Multiple Medical Problems Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to: - simplify their management (pharmacologic and other). - limit polypharmacy. - minimize possible drug interactions. - update therapeutic choices (e.g., because of changing guidelines or the patient's situation). Clinical Reasoning Skills Treatment, Follow-up
Multiple Medical Problems In patients with multiple medical problems and recurrent visits for unchanging symptoms, set limits for consultations when appropriate (e.g., limit the duration and frequency of visits). Patient Centered Approach, Professionalism Treatment, Follow-up
Neck Pain In patients with non-traumatic neck pain, use a focused history, physical examination and appropriate investigations to distinguish serious, non-musculoskeletal causes (e.g., lymphoma, carotid dissection), including those referred to the neck (e.g., myocardial infarction, pseudotumour cerebri) from other non-serious causes. Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Neck Pain In patients with non-traumatic neck pain, distinguish by history and physical examination, those attributable to nerve or spinal cord compression from those due to other mechanical causes (e.g., muscular). Clinical Reasoning Skills History, Physical
Neck Pain Use a multi-modal (e.g., physiotherapy, chiropractic, acupuncture, massage) approach to treatment of patients with chronic neck pain (e.g., degenerative disc disease +/- soft neuro signs). Clinical Reasoning Skills Treatment
Neck Pain In patients with neck pain following injury, distinguish by history and physical examination, those requiring an X-ray to rule out a fracture from those who do not require an X-ray (e.g., current guideline/C-spine rules). Clinical Reasoning Skills, Selectivity Diagnosis, Investigation
Neck Pain When reviewing neck X-rays of patients with traumatic neck pain, be sure all vertebrae are visualized adequately. Clinical Reasoning Skills Diagnosis, Investigation
Newborn When examining a newborn, systematically look for subtle congenital anomalies (e.g., ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes. Clinical Reasoning Skills Hypothesis generation, Physical
Newborn In a newborn, where a concern has been raised by a caregiver (parent, nurse), Clinical Reasoning Skills Hypothesis generation
Newborn In a newborn, where a concern has been raised by a caregiver (parent, nurse), Clinical Reasoning Skills, Selectivity Physical, History
Newborn In a newborn, where a concern has been raised by a caregiver (parent, nurse), Clinical Reasoning Skills Diagnosis
Newborn Resuscitate newborns according to current guidelines. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Treatment
Newborn Maintain neonatal resuscitation skills if appropriate for your practice. Professionalism Treatment
Newborn When a parent elects to bottle feed, support their decision in a non-judgemental manner. Professionalism, Patient Centered Approach Treatment
Newborn In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (e.g., hips, heart, hearing). Clinical Reasoning Skills Follow-up, Physical
Newborn When discharging a newborn from hospital, Clinical Reasoning Skills, Communication Skills Treatment, Follow-up
Newborn When discharging a newborn from hospital, Clinical Reasoning Skills, Patient Centered Approach Follow-up
Obesity In patients who appear to be obese, make the diagnosis of obesity using a clear definition (i.e., currently body mass index) and inform them of the diagnosis. Clinical Reasoning Skills Diagnosis
Obesity In all obese patients, assess for treatable co-morbidities such as hypertension, diabetes, coronary artery disease, sleep apnea, and osteoarthritis, as these are more likely to be present. Clinical Reasoning Skills Hypothesis generation
Obesity In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated thyroid-stimulating hormone testing. Clinical Reasoning Skills, Selectivity Investigation, Treatment
Obesity In obese patients, inquire about the effect of obesity on the patient’s personal and social life to better understand its impact on the patient. Patient Centered Approach History
Obesity In a patient diagnosed with obesity, establish the patient’s readiness to make changes necessary to lose weight, as advice will differ, and reassess this readiness periodically. Patient Centered Approach History, Follow-up
Obesity Advise the obese patient seeking treatment that effective management will require appropriate diet, adequate exercise, and support (independent of any medical or surgical treatment), and facilitate the patient’s access to these as needed and as possible. Clinical Reasoning Skills Treatment
Obesity As part of preventing childhood obesity, advise parents of healthy activity levels for their children. Clinical Reasoning Skills Treatment
Obesity In managing childhood obesity, challenge parents to make appropriate family-wide changes in diet and exercise, and to avoid counterproductive interventions (e.g., berating or singling out the obese child). Clinical Reasoning Skills, Communication Skills Treatment
Osteoporosis Assess osteoporosis risk of all adult patients as part of their periodic health examination. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Osteoporosis Use bone mineral density testing judiciously (e.g., don’t test everybody, follow a guideline). Selectivity, Professionalism Investigation, Follow-up
Osteoporosis Counsel all patients about primary prevention of osteoporosis (i.e., dietary calcium, physical activity, smoking cessation), especially those at higher risk (e.g., young female athletes, patients with eating disorders). Clinical Reasoning Skills, Communication Skills Treatment
Osteoporosis In menopausal or peri-menopausal women, provide advice about fracture prevention that includes improving their physical fitness, reducing alcohol, smoking cessation, risks of physical abuse, and environmental factors that may contribute to falls (e.g., don’t stop at suggesting calcium and vitamin D). Clinical Reasoning Skills, Communication Skills Treatment, Hypothesis generation
Osteoporosis In patients with osteoporosis, avoid prescribing medications that may increase the risk of falls. Clinical Reasoning Skills Hypothesis generation, Treatment
Osteoporosis Provide advice and counseling about fracture prevention to older men, as they too are at risk for osteoporosis. Clinical Reasoning Skills Hypothesis generation, Treatment
Osteoporosis Treat patients with established osteoporosis regardless of their gender (e.g., use bisphosphonates in men). Clinical Reasoning Skills Hypothesis generation, Treatment
Palliative Care In all patients with terminal illnesses (e.g., end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e.., do not limit the use of palliative care to cancer patients). Patient Centered Approach, Clinical Reasoning Skills Treatment
Palliative Care In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e.., use a team approach when necessary). Patient Centered Approach Treatment
Palliative Care In patients approaching the end of life: Patient Centered Approach, Clinical Reasoning Skills History
Palliative Care In patients approaching the end of life: Patient Centered Approach, Clinical Reasoning Skills Treatment
Palliative Care In patients with pain, manage it (e.g., adjust dosages, change analgesics) proactively through: - frequent reassessments. - monitoring of drug side effects (e.g., nausea, constipation, cognitive impairment). Clinical Reasoning Skills Treatment, Follow-up
Palliative Care In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (e.g., wishes for treatment of infections, intubation, dying at home) Patient Centered Approach, Clinical Reasoning Skills History, Hypothesis generation
Parkinsonism In patients with suspected Parkinson’s disease, accurately distinguish idiopathic Parkinson’s disease from atypical Parkinson’s disease (e.g., disease at a young age, drug-related disease), as treatment differs. Clinical Reasoning Skills Diagnosis
Parkinsonism In the care of all patients with Parkinson’s disease, involve other health care professionals to enhance the patient’s functional status. Clinical Reasoning Skills, Professionalism Treatment, Referral
Parkinsonism In an elderly patient with a deterioration in functional status, look for and recognize Parkinson’s disease when it is present, as it is a potentially reversible contribution to the deterioration. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Parkinsonism In a patient with a tremor, do an appropriate physical examination (e.g., observation, use of techniques to enhance the tremor) to distinguish the resting tremor of parkinsonism from other (e.g., essential) tremors. Clinical Reasoning Skills Physical
Parkinsonism As part of the management of patients with Parkinson’s disease, identify anticipated side effects of medications, especially those with which you are unfamiliar. Clinical Reasoning Skills, Professionalism Treatment
Parkinsonism As part of the ongoing follow-up care of patients with Parkinson’s disease: - Assess functional status. - Monitor them for medication side effects. - Look for other problems (e.g., depression, dementia, falls, constipation), as they are more common Clinical Reasoning Skills Hypothesis generation, Follow-up
Periodic Health Assessment/Screening Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns). Clinical Reasoning Skills Treatment
Periodic Health Assessment/Screening In any given patient, selectively adapt the periodic health examination to that patient’s specific circumstances (i.e., adhere to inclusion and exclusion criteria of each manoeuvre/intervention, such as the criteria for mammography and prostate-specific antigen [PSA] testing). Selectivity, Patient Centered Approach Investigation, Hypothesis generation
Periodic Health Assessment/Screening In a patient requesting a test (e.g., PSA testing, mammography) that may or may not be recommended: Clinical Reasoning Skills Treatment, Investigation
Periodic Health Assessment/Screening In a patient requesting a test (e.g., PSA testing, mammography) that may or may not be recommended: Clinical Reasoning Skills, Patient Centered Approach Treatment, Investigation
Periodic Health Assessment/Screening Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice. Professionalism Treatment, Diagnosis
Personality Disorder Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for: - appointment length. - drug prescribing. - accessibility. Professionalism, Communication Skills Treatment, Follow-up
Personality Disorder In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.) Clinical Reasoning Skills Hypothesis generation
Personality Disorder Look for and attempt to limit the impact of your personal feelings (e.g., anger, frustration) when dealing with patients with personality disorders (e.g.,stay focused, do not ignore the patient’s complaint). Professionalism, Communication Skills Treatment
Personality Disorder In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary. Clinical Reasoning Skills, Selectivity Treatment
Personality Disorder When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions. Clinical Reasoning Skills, Selectivity Diagnosis, History
Pneumonia In a patient who presents without the classic respiratory signs and symptoms (e.g., deterioration, delirium, abdominal pain), include pneumonia in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Pneumonia In a patient with signs and symptoms of pneumonia, do not rule out the diagnosis on the basis of a normal chest X-ray film (e.g., consider dehydration, neutropenia, human immunodeficiency virus [HIV] infection). Clinical Reasoning Skills, Selectivity Diagnosis, Hypothesis generation
Pneumonia In a patient with a diagnosis of pneumonia, assess the risks for unusual pathogens (e.g., a history of tuberculosis, exposure to birds, travel, HIV infection, aspiration). Clinical Reasoning Skills History, Hypothesis generation
Pneumonia In patients with pre-existing medical problems (e.g., asthma, diabetes, congestive heart failure) and a new diagnosis of pneumonia: Clinical Reasoning Skills, Selectivity Treatment
Pneumonia In patients with pre-existing medical problems (e.g., asthma, diabetes, congestive heart failure) and a new diagnosis of pneumonia: Clinical Reasoning Skills, Selectivity Treatment, Hypothesis generation
Pneumonia Identify patients, through history-taking, physical examination, and testing, who are at high risk for a complicated course of pneumonia and would benefit from hospitalization, even though clinically they may appear stable. Selectivity History, Diagnosis
Pneumonia In the patient with pneumonia and early signs of respiratory distress, assess, and reassess periodically, the need for respiratory support (bilevel positive airway pressure, continuous positive airway pressure, intubation) (i.e., look for the need before decompensation occurs). Clinical Reasoning Skills, Selectivity Treatment
Pneumonia For a patient with a confirmed diagnosis of pneumonia, make rational antibiotic choices (e.g., outpatient + healthy = first-line antibiotics; avoid the routine use of “big guns”). Clinical Reasoning Skills, Professionalism Treatment
Pneumonia In a patient who is receiving treatment for pneumonia and is not responding: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Pneumonia In a patient who is receiving treatment for pneumonia and is not responding: Clinical Reasoning Skills Treatment, Diagnosis
Pneumonia Identify patients (e.g., the elderly, nursing home residents, debilitated patients) who would benefit from immunization or other treatments (e.g., flu vaccine, Pneumovax, ribavarine) to reduce the incidence of pneumonia. Clinical Reasoning Skills, Selectivity Treatment
Pneumonia In patients with a diagnosis of pneumonia, ensure appropriate follow-up care (e.g., patient education, repeat chest X-ray examination, instructions to return if the condition worsens). Clinical Reasoning Skills Follow-up
Pneumonia In patients with a confirmed diagnosis of pneumonia, arrange contact tracing when appropriate (e.g., in those with TB, nursing home residents, those with legionnaires’ disease). Clinical Reasoning Skills Follow-up, Referral
Poisoning As part of well-child care, discuss preventing and treating poisoning with parents (e.g., “child-proofing”, poison control number). Communication Skills, Clinical Reasoning Skills Treatment
Poisoning In intentional poisonings (overdose) think about multi-toxin ingestion. Clinical Reasoning Skills Hypothesis generation
Poisoning When assessing a patient with a potentially toxic ingestion, take a careful history about the timing and nature of the ingestion. Clinical Reasoning Skills History
Poisoning When assessing a patient with a potential poisoning, do a focused physical examination to look for the signs of toxidromes. Clinical Reasoning Skills Physical
Poisoning When assessing a patient exposed (contact or ingestion) to a substance, clarify the consequences of the exposure (e.g., don’t assume it is non-toxic, call poison control) Clinical Reasoning Skills Hypothesis generation, Treatment
Poisoning When managing a toxic ingestion, utilize poison control protocols that are current. Clinical Reasoning Skills, Professionalism Treatment
Poisoning When managing a patient with a poisoning, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Poisoning When managing a patient with a poisoning, Clinical Reasoning Skills Treatment
Poisoning When managing a patient with a poisoning, Clinical Reasoning Skills Hypothesis generation, Treatment
Pregnancy In a patient who is considering pregnancy: Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, Diagnosis
Pregnancy In a patient who is considering pregnancy: Clinical Reasoning Skills, Patient Centered Approach Treatment
Pregnancy In a female or male patient who is sexually active, who is considering sexual activity, or who has the potential to conceive or engender a pregnancy, use available encounters to educate about fertility. Communication Skills, Patient Centered Approach Treatment
Pregnancy In a patient with suspected or confirmed pregnancy, establish the desirability of the pregnancy. Clinical Reasoning Skills, Patient Centered Approach History, Treatment
Pregnancy In a patient presenting with a confirmed pregnancy for the first encounter: Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, History
Pregnancy In a patient presenting with a confirmed pregnancy for the first encounter: Clinical Reasoning Skills Diagnosis
Pregnancy In a patient presenting with a confirmed pregnancy for the first encounter: Clinical Reasoning Skills Treatment
Pregnancy In pregnant patients: Clinical Reasoning Skills, Selectivity Hypothesis generation, History
Pregnancy In pregnant patients: Clinical Reasoning Skills Treatment, Referral
Pregnancy In at-risk pregnant patients (e.g., women with human immunodeficiency virus infection, intravenous drug users, and diabetic or epileptic women), modify antenatal care appropriately. Selectivity, Clinical Reasoning Skills Treatment
Pregnancy In a pregnant patient presenting with features of an antenatal complication (e.g., premature rupture of membranes, hypertension, bleeding): Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Pregnancy In a pregnant patient presenting with features of an antenatal complication (e.g., premature rupture of membranes, hypertension, bleeding): Clinical Reasoning Skills, Selectivity Treatment
Pregnancy In a patient presenting with dystocia (prolonged dilatation, failure of descent): Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Pregnancy In a patient presenting with dystocia (prolonged dilatation, failure of descent): Clinical Reasoning Skills, Selectivity Treatment
Pregnancy In a patient with clinical evidence of complications in labour (e.g., abruption, uterine rupture, shoulder dystocia, non-reassuring fetal monitoring): Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Pregnancy In a patient with clinical evidence of complications in labour (e.g., abruption, uterine rupture, shoulder dystocia, non-reassuring fetal monitoring): Clinical Reasoning Skills, Selectivity Treatment
Pregnancy In the patient presenting with clinical evidence of a postpartum complication (e.g., delayed or immediate bleeding, infection): Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Pregnancy In the patient presenting with clinical evidence of a postpartum complication (e.g., delayed or immediate bleeding, infection): Clinical Reasoning Skills, Selectivity Treatment
Pregnancy In pregnant or postpartum patients, identify postpartum depression by screening for risk factors, monitoring patients at risk, and distinguishing postpartum depression from the “blues.’’ Selectivity, Clinical Reasoning Skills Hypothesis generation, Diagnosis
Pregnancy In a breast-feeding woman, screen for and characterize dysfunctional breast-feeding (e.g., poor latch, poor production, poor letdown). Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, History
Prostate Appropriately identify patients requiring prostate cancer screening. Selectivity Diagnosis, History
Prostate In a patient suitable for prostate cancer screening, use and interpret tests (e.g., prostate-specific antigen testing, digital rectal examination [DRE], ultrasonography) in an individualized/sequential manner to identify potential cases. Selectivity, Patient Centered Approach Investigation, Diagnosis
Prostate In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality. Patient Centered Approach, Communication Skills History
Prostate In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment): Clinical Reasoning Skills, Patient Centered Approach Treatment
Prostate In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment): Clinical Reasoning Skills Hypothesis generation, Follow-up
Prostate In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread. Clinical Reasoning Skills History, Hypothesis generation
Prostate Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations. Clinical Reasoning Skills Diagnosis
Prostate In patients presenting with specific or non-specific urinary symptoms: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Prostate In patients presenting with specific or non-specific urinary symptoms: Clinical Reasoning Skills Diagnosis, Investigation
Rape/Sexual Assault Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not. Clinical Reasoning Skills, Professionalism Treatment
Rape/Sexual Assault Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counselling). Clinical Reasoning Skills Treatment
Rape/Sexual Assault Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information). Clinical Reasoning Skills, Professionalism History
Rape/Sexual Assault In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Rape/Sexual Assault Offer counselling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people. Clinical Reasoning Skills Treatment
Rape/Sexual Assault Revisit the need for counselling in patients affected by sexual assault. Clinical Reasoning Skills Treatment, Follow-up
Rape/Sexual Assault Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization. Clinical Reasoning Skills Hypothesis generation, History
Red Eye In addressing eye complaints, always assess visual acuity using history, physical examination, or the Snellen chart, as appropriate. Clinical Reasoning Skills History, Physical
Red Eye In a patient with a red eye, distinguish between serious causes (e.g., keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Clinical Reasoning Skills History
Red Eye In a patient with a red eye, distinguish between serious causes (e.g., keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Clinical Reasoning Skills Physical
Red Eye In a patient with a red eye, distinguish between serious causes (e.g., keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Clinical Reasoning Skills Investigation
Red Eye In a patient with a red eye, distinguish between serious causes (e.g., keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis): Clinical Reasoning Skills Referral
Red Eye In patients presenting with an ocular foreign body sensation, correctly diagnose an intraocular foreign body by clarifying the mechanism of injury (e.g., high speed, metal on metal, no glasses) and investigating (e.g., with computed tomography, X-ray examination) when necessary. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Red Eye In patients presenting with an ocular foreign body sensation, evert the eyelids to rule out the presence of a conjunctival foreign body. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Hypothesis generation, Physical
Red Eye In neonates with conjunctivitis (not just blocked lacrimal glands or ‘‘gunky’’ eyes), look for a systemic cause and treat it appropriately (i.e., with antibiotics). Clinical Reasoning Skills Hypothesis generation, Treatment
Red Eye In patients with conjunctivitis, distinguish by history and physical examination between allergic and infectious causes (viral or bacterial). Clinical Reasoning Skills Diagnosis, History
Red Eye In patients who have bacterial conjunctivitis and use contact lenses, provide treatment with antibiotics that cover for Pseudomonas. Clinical Reasoning Skills Treatment
Red Eye Use steroid treatment only when indicated (e.g., to treat iritis; avoid with keratitis and conjunctivitis). Clinical Reasoning Skills Treatment
Red Eye In patients with iritis, consider and look for underlying systemic causes (e.g., Crohn’s disease, lupus, ankylosing spondylitis). Clinical Reasoning Skills Hypothesis generation
Schizophrenia In adolescents presenting with problem behaviours, consider schizophrenia in the differential diagnosis. Clinical Reasoning Skills Hypothesis generation
Schizophrenia In “apparently” stable patients with schizophrenia (e.g., those who are not floridly psychotic), provide regular or periodic assessment in a structured fashion e.g., positive and negative symptoms, ther performance of activities of daily living, and the level of social functioning at each visit: - seeking collateral information from family members and other caregivers to develope a more complete assessment of symptoms and functional status; - competency to accept or refuse treatement, and document specifically; - suicidal and homicidal ideation, as well as the risk for violence; medication compliance and side effects. Clinical Reasoning Skills, Patient Centered Approach Follow-up, History
Schizophrenia In all patients presenting with psychotic symptoms, inquire about substance use and abuse. Clinical Reasoning Skills History
Schizophrenia Consider the possibility of substance abuse and look for it in patients with schizophrenia, as this is a population at risk. Clinical Reasoning Skills Hypothesis generation, History
Schizophrenia In patients with schizophrenia, assess and treat substance abuse appropriately. Clinical Reasoning Skills Treatment
Schizophrenia In decompensating patients with schizophrenia, determine: - if substance abuse is contributory. - the role of medication compliance and side-effect problems. - if psychosocial supports have changed. Clinical Reasoning Skills, Patient Centered Approach History, Hypothesis generation
Schizophrenia Diagnose and treat serious complications/side effects of antipsychotic medications (e.g., neuroleptic malignant syndrome, tardive dyskinesia). Clinical Reasoning Skills Treatment, Diagnosis
Schizophrenia Include psychosocial supports (e.g., housing, family support, disability issues, vocational rehabilitation) as part of the treatment plan for patients with schizophrenia. Patient Centered Approach, Clinical Reasoning Skills Treatment
Seizures In a patient having a seizure: Clinical Reasoning Skills Treatment
Seizures In a patient having a seizure: Clinical Reasoning Skills Treatment
Seizures In a patient having a seizure: Clinical Reasoning Skills, Selectivity Diagnosis, Hypothesis generation
Seizures In a patient presenting with an ill-defined episode (e.g., fits, spells, turns), take a history to distinguish a seizure from other events. Clinical Reasoning Skills History
Seizures In a patient presenting with a seizure, take an appropriate history to direct the investigation (e.g., do not overinvestigate; a stable known disorder may require only a drug-level measurement, while new or changing seizures may require an extensive work-up). Clinical Reasoning Skills History
Seizures In all patients presenting with a seizure, examine carefully for focal neurologic findings. Clinical Reasoning Skills Physical
Seizures In a patient with a previously known seizure disorder, who presents with a seizure or a change in the pattern of seizures: Clinical Reasoning Skills History
Seizures In a patient with a previously known seizure disorder, who presents with a seizure or a change in the pattern of seizures: Clinical Reasoning Skills Hypothesis generation
Seizures In the ongoing care of a patient with a stable seizure disorder: Clinical Reasoning Skills, Patient Centered Approach Treatment, History
Seizures In the ongoing care of a patient with a stable seizure disorder: Clinical Reasoning Skills Hypothesis generation
Seizures In the ongoing care of a patient with a stable seizure disorder: Clinical Reasoning Skills Treatment
Sex In patients, specifically pregnant women, adolescents, and perimenopausal women: Patient Centered Approach, Clinical Reasoning Skills History
Sex In patients, specifically pregnant women, adolescents, and perimenopausal women: Patient Centered Approach, Communication Skills Treatment
Sex Screen high-risk patients (e.g., post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (e.g., during the periodic health examination). Selectivity, Clinical Reasoning Skills Hypothesis generation, History
Sex In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes. Clinical Reasoning Skills Hypothesis generation, History
Sex In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately. Clinical Reasoning Skills Treatment
Sex In patients with identified sexual dysfunction, inquire about partner relationship issues. Patient Centered Approach History
Sexually Transmitted Infections In a patient who is sexually active or considering sexual activity, take advantage of opportunities to advise her or him about prevention, screening, and complications of sexually transmitted diseases (STDs). Patient Centered Approach, Clinical Reasoning Skills Treatment
Sexually Transmitted Infections In a patient with symptoms that are atypical or non-specific for STDs (e.g., dysuria, recurrent vaginal infections): Selectivity, Clinical Reasoning Skills Hypothesis generation
Sexually Transmitted Infections In a patient with symptoms that are atypical or non-specific for STDs (e.g., dysuria, recurrent vaginal infections): Clinical Reasoning Skills, Selectivity Investigation
Sexually Transmitted Infections In high-risk patients who are asymptomatic for STDs, screen and advise them about preventive measures. Clinical Reasoning Skills, Patient Centered Approach Treatment, Investigation
Sexually Transmitted Infections In high-risk patients who are symptomatic for STDs, provide treatment before confirmation by laboratory results. Clinical Reasoning Skills, Selectivity Treatment
Sexually Transmitted Infections In a patient requesting STD testing: Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, Treatment
Sexually Transmitted Infections In a patient requesting STD testing: Clinical Reasoning Skills, Patient Centered Approach History, Diagnosis
Sexually Transmitted Infections In a patient requesting STD testing: Clinical Reasoning Skills, Patient Centered Approach Diagnosis, Treatment
Sexually Transmitted Infections In a patient with a confirmed STD, initiate: - treatment of partner(s). - contact tracing through a public health or community agency. Clinical Reasoning Skills Treatment, Follow-up
Sexually Transmitted Infections Use appropriate techniques for collecting specimens. Psychomotor Skills/Procedure Skills, Clinical Reasoning Skills Investigation, Physical
Sexually Transmitted Infections Given a clinical scenario that is strongly suspicious for an STD and a negative test result, do not exclude the diagnosis of an STD (i.e., because of sensitivity and specificity problems or other test limitations). Selectivity, Clinical Reasoning Skills Diagnosis, Investigation
Skin Disorder In dealing with a persistent skin problem that is not responding to treatment as expected: Clinical Reasoning Skills Hypothesis generation, Diagnosis
Skin Disorder In dealing with a persistent skin problem that is not responding to treatment as expected: Clinical Reasoning Skills Treatment, Investigation
Skin Disorder In a patient presenting with a skin lesion, distinguish benign from serious pathology (e.g., melanoma, pemphigus, cutaneous T-cell lymphoma) by physical examination and appropriate investigations (e.g., biopsy or excision). Selectivity, Clinical Reasoning Skills Physical, Investigation
Skin Disorder In a patient presenting with a cutaneous manifestation of a systemic disease or condition (e.g., Wegener’s granulomatosis, lupus, a drug reaction), consider the diagnosis of systemic disease and confirm it through history, physical examination, and appropriate investigations. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Skin Disorder When prompted by a patient with a concern about a localized skin lesion or when screening for mucocutaneous lesions, inspect all areas of the skin (e.g., nails, scalp, oral cavity, perineum, soles of the feet, back of the neck). Clinical Reasoning Skills Physical
Skin Disorder Diagnose and promptly treat suspected life-threatening dermatologic emergencies (e.g., Stevens-Johnson syndrome, invasive cellulitis, chemical or non-chemical burns). Selectivity Diagnosis, Hypothesis generation
Skin Disorder In high-risk patients (diabetics, bed or chair bound, peripheral vascular disease): Clinical Reasoning Skills, Selectivity Physical
Skin Disorder In high-risk patients (diabetics, bed or chair bound, peripheral vascular disease): Clinical Reasoning Skills, Selectivity Treatment
Skin Disorder In a patient being treated for a new or persistent skin condition (e.g., acne, psoriasis), determine the impact on the patient’s personal and social life. Patient Centered Approach Treatment, History
Smoking Cessation In all patients, regularly evaluate and document smoking status, recognizing that people may stop or start at any time. Clinical Reasoning Skills Hypothesis generation, Follow-up
Smoking Cessation In smokers: Clinical Reasoning Skills, Patient Centered Approach Treatment
Smoking Cessation In smokers: Clinical Reasoning Skills History, Follow-up
Smoking Cessation In smokers motivated to quit, advise the use of a multi-strategy approach to smoking cessation. Clinical Reasoning Skills, Communication Skills Treatment, Follow-up
Somatization In patients with recurrent physical symptoms, diagnose somatization only after an adequate work-up to rule out any medical or psychiatric condition (e.g., depression). Clinical Reasoning Skills Diagnosis, Hypothesis generation
Somatization Do not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. Periodically reassess the need to extend/repeat the work-up in these patients. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Somatization Acknowledge the illness experience of patients who somatize, and strive to find common ground with them concerning their diagnosis and management, including investigations. This is usually a long-term project, and should be planned as such. Patient Centered Approach Treatment, Follow-up
Somatization In patients who somatize, inquire about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (e.g., with biofeedback, acupuncture, or naturopathy). Clinical Reasoning Skills Treatment, History
Stress In a patient presenting with a symptom that could be attributed to stress (e.g., headache, fatigue, pain) consider and ask about stress as a cause or contributing factor. Clinical Reasoning Skills, Communication Skills Hypothesis generation, History
Stress In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress). Patient Centered Approach History, Diagnosis
Stress In patients not coping with stress, look for and diagnose, if present, mental illness (e.g., depression, anxiety disorder). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Stress In patients not coping with the stress in their lives, Patient Centered Approach, Clinical Reasoning Skills History
Stress In patients not coping with the stress in their lives, Patient Centered Approach History, Treatment
Stress In patients experiencing stress, look for inappropriate coping mechanisms (e.g., drugs, alcohol, eating, violence). Clinical Reasoning Skills, Communication Skills Hypothesis generation, History
Stroke In patients presenting with symptoms and/or signs suggestive of stroke, include other diagnoses in the differential diagnosis (e.g., transient ischemic attack [TIA], brain tumour, hypoglycemia, subdural hematoma, subarachnoid bleed). Clinical Reasoning Skills Hypothesis generation
Stroke In a patient presenting with a stroke, differentiate, if possible, hemorrhagic from embolic/thrombotic stroke (e.g., through the history, physical examination, and ancillary testing, such as scanning and electrocardiography), as treatment differs. Clinical Reasoning Skills Diagnosis
Stroke Assess patients presenting with neurologic deficits in a timely fashion, to determine their eligibility for thrombolysis. Selectivity Treatment
Stroke In a patient diagnosed with stroke, involve other professionals as needed (e.g., a physical therapist, an occupational therapist, social service personnel, a physiatrist, a neurologist) to ensure the best outcome for the patient. Clinical Reasoning Skills, Patient Centered Approach Treatment, Referral
Stroke When caring for a stroke patient with severe/serious deficits, involve the patient and her or his family in decisions about intervention (e.g., resuscitation, use of a feeding tube, treatment of pneumonia). Patient Centered Approach, Communication Skills Treatment
Stroke In patients who have suffered stroke, diagnose “silent” cognitive deficits (not associated with sensory or motor symptoms or signs, such as inattention and impulsivity) when they are present. Clinical Reasoning Skills Diagnosis
Stroke Provide realistic prognostic advice about their disabilities to stroke patients and their families. Patient Centered Approach Treatment
Stroke In stroke patients with disabilities, evaluate the resources and supports needed to improve function (e.g., a cane, a walker, home care). Clinical Reasoning Skills, Patient Centered Approach Treatment
Stroke In the continuing care of stroke patients with deficits (e.g., dysphagia, being bedridden), include the prevention of certain complications (e.g., aspiration pneumonia, decubitus ulcer) in the treatment plan, as they are more common. Clinical Reasoning Skills Treatment, Hypothesis generation
Stroke In patients at risk of stroke, treat modifiable risk factors (e.g., atrial fibrillation, diabetes, hyperlipidemia, and hypertension). Clinical Reasoning Skills Treatment
Stroke In all patients with a history of TIA or completed stroke, and in asymptomatic patients at high risk for stroke, offer antithrombotic treatment (e.g., acetylsalicylic acid, clopidogrel) to appropriate patients to lower stroke risk. Clinical Reasoning Skills Treatment
Substance Abuse In all patients, and especially in high-risk groups (e.g., mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs). Clinical Reasoning Skills History
Substance Abuse In intravenous drug users: Clinical Reasoning Skills Hypothesis generation, Investigation
Substance Abuse In intravenous drug users: Clinical Reasoning Skills Treatment
Substance Abuse In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately. Clinical Reasoning Skills Diagnosis, Treatment
Substance Abuse Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (e.g., school failure, behaviour change). Clinical Reasoning Skills, Patient Centered Approach Treatment, Diagnosis
Substance Abuse Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (e.g., alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients). Selectivity, Patient Centered Approach Hypothesis generation, History
Substance Abuse Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.) Patient Centered Approach Treatment
Substance Abuse In patients abusing substances, determine whether or not they are willing to agree with the diagnosis. Patient Centered Approach History, Diagnosis
Substance Abuse In substance users or abusers, routinely determine willingness to stop or decrease use. Patient Centered Approach History, Treatment
Substance Abuse In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections, mental illness) and long-term complications (e.g., cirrhosis). Clinical Reasoning Skills, Patient Centered Approach History
Suicide In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (e.g., ideas, thoughts, a specific plan). Clinical Reasoning Skills History
Suicide Given a suicidal patient, assess the degree of risk (e.g., thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (e.g., immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling). Clinical Reasoning Skills, Selectivity Diagnosis, Treatment
Suicide Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (e.g., return to the emergency department [ED], call a crisis hotline, re-book an appointment). Clinical Reasoning Skills Treatment, Follow-up
Suicide In suicidal patients presenting at the emergency department with a suspected drug overdose, always screen for acetylsalicylic acid and acetaminophen overdoses, as these are common, dangerous, and frequently overlooked. Clinical Reasoning Skills Investigation
Suicide In trauma patients, consider attempted suicide as the precipitating cause. Clinical Reasoning Skills Hypothesis generation
Thyroid Limit testing for thyroid disease to appropriate patients, namely those with a significant pre-test probability of abnormal results, such as: - those with classic signs or symptoms of thyroid disease. - those whose symptoms or signs are not classic, but who are at a higher risk for disease (e.g., the elderly, postpartum women, those with a history of atrial fibrillation, those with other endocrine disorders). Clinical Reasoning Skills, Selectivity Investigation
Thyroid In patients with established thyroid disease, do not check thyroid-stimulating hormone levels too often, but rather test at the appropriate times, such as: - after changing medical doses. - when following patients with mild disease before initiating treatment. - periodically in stable patients receiving treatement. Clinical Reasoning Skills, Selectivity Investigation
Thyroid When examining the thyroid gland, use proper technique (i.e., from behind the patient, ask the patient to swallow), especially to find nodules (which may require further investigation). Psychomotor Skills/Procedure Skills Physical
Thyroid Note: The investigation of thyroid nodules is not covered here. Note
Trauma Assess and stabilize trauma patients with an organized approach, anticipating complications in a timely fashion, using the primary and secondary surveys. Clinical Reasoning Skills Treatment, Physical
Trauma Suspect, identify, and immediately begin treating life-threatening complications (e.g., tension pneumothorax, tamponade). Selectivity Treatment, Diagnosis
Trauma When faced with several trauma patients, triage according to resources and treatment priorities. Selectivity Treatment
Trauma In trauma patients, secure the airway appropriately (e.g., assume cervical spine injury, use conscious sedation, recognize a difficult airway, plan for back-up methods/cricothyrotomy). Clinical Reasoning Skills, Selectivity Treatment, Hypothesis generation
Trauma In a patient with signs and symptoms of shock: Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Trauma In a patient with signs and symptoms of shock: Clinical Reasoning Skills, Selectivity Physical, Diagnosis
Trauma In a patient with signs and symptoms of shock: Clinical Reasoning Skills, Selectivity Treatment
Trauma In trauma patients, rule out hypothermia on arrival and subsequently (as it may develop during treatment). Clinical Reasoning Skills Hypothesis generation, Physical
Trauma Suspect certain medical problems (e.g., seizure, drug intoxication, hypoglycemia, attempted suicide) as the precipitant of the trauma. Clinical Reasoning Skills Hypothesis generation
Trauma Do not move potentially unstable patients from treatment areas for investigations (e.g., computed tomography, X-ray examination). Clinical Reasoning Skills Treatment, Investigation
Trauma Determine when patient transfer is necessary (e.g., central nervous system bleeds, when no specialty support is available). Selectivity, Clinical Reasoning Skills Treatment, Referral
Trauma Transfer patients in an appropriate manner (i.e., stabilize them before transfer and choose the method, such as ambulance or flight). Clinical Reasoning Skills Treatment, Referral
Trauma Find opportunities to offer advice to prevent or minimize trauma (e.g., do not drive drunk, use seatbelts and helmets). Clinical Reasoning Skills Treatment
Trauma In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.) Clinical Reasoning Skills, Selectivity Diagnosis, Hypothesis generation
Travel Medicine Make sure travelers get up to date, timely, itinerary-specific advice from a reliable source (e.g., travel clinic, travel website). Clinical Reasoning Skills History, Hypothesis generation
Travel Medicine When seeing patients planning travel, discuss the common, non-infectious perils of travel (e.g., accidents, safer sex, alcohol, safe travel for women). Clinical Reasoning Skills History, Hypothesis generation
Travel Medicine In patients presenting with symptoms of infection without an obvious cause, especially those with a fever, enquire about recent travel history to identify potential sources (especially, but not exclusively, malaria). Patient Centered Approach, Communication Skills Hypothesis generation, Follow-up
Travel Medicine Provide prevention and treatment advice and prescribe medications for common conditions associated with travel (e.g., traveler’s diarrhea, altitude sickness). Patient Centered Approach, Clinical Reasoning Skills Treatment, Referral
Travel Medicine Ensure patients understand how to manage their chronic disease while traveling (e.g., diabetes, asthma, international normalized ratios [INRs]). Clinical Reasoning Skills Treatment
Travel Medicine Use patient visits for travel advice as an opportunity to update routine vaccinations. Clinical Reasoning Skills, Selectivity Treatment, Hypothesis generation
Travel Medicine Advise patients to check insurance coverage issues especially in regard to recent changes in chronic disease and any recent treatment changes. Professionalism Treatment, Hypothesis generation
Travel Medicine Advise patients traveling with medications to have an adequate supply, documentation of need for use, and to transport them securely (e.g., carry-on bag). Clinical Reasoning Skills Treatment, Hypothesis generation
Upper Respiratory Tract Infection Given an appropriate history and/or physical examination: Selectivity Diagnosis
Upper Respiratory Tract Infection Given an appropriate history and/or physical examination: Clinical Reasoning Skills Treatment
Upper Respiratory Tract Infection Make the diagnosis of bacterial sinusitis by taking an adequate history and performing an appropriate physical examination, and prescribe appropriate antibiotics for the appropriate duration of therapy. Clinical Reasoning Skills History, Treatment
Upper Respiratory Tract Infection In a patient presenting with upper respiratory symptoms: Clinical Reasoning Skills History, Diagnosis
Upper Respiratory Tract Infection In a patient presenting with upper respiratory symptoms: Clinical Reasoning Skills Diagnosis
Upper Respiratory Tract Infection In a patient presenting with upper respiratory symptoms: Clinical Reasoning Skills, Communication Skills Treatment
Upper Respiratory Tract Infection Given a history compatible with otitis media, differentiate it from otitis externa and mastoiditis, according to the characteristic physical findings. Clinical Reasoning Skills Diagnosis, Physical
Upper Respiratory Tract Infection In high-risk patients (e.g., those who have human immunodeficiency virus infection, chronic obstructive pulmonary disease, or cancer) with upper respiratory infections: Lood for complications more aggressively, and follow up more closely Clinical Reasoning Skills Hypothesis generation, Follow-up
Upper Respiratory Tract Infection In a presentation of pharyngitis, look for mononucleosis. Clinical Reasoning Skills Hypothesis generation, Physical
Upper Respiratory Tract Infection In high-risk groups: Selectivity, Patient Centered Approach Treatment
Upper Respiratory Tract Infection In high-risk groups: Clinical Reasoning Skills, Professionalism Treatment
Urinary Tract Infection Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (e.g., sepsis, pyelonephritis, impacted infected stones). Clinical Reasoning Skills Hypothesis generation, Investigation
Urinary Tract Infection Appropriately investigate all boys with urinary tract infections, and young girls with recurrences(e.g., ultrasound). Clinical Reasoning Skills Investigation
Urinary Tract Infection In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (e.g., pregnancy; immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy). Clinical Reasoning Skills Hypothesis generation, History
Urinary Tract Infection In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (e.g., pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (e.g.,pregnancy, sepsis, pyelonephritis). Selectivity Treatment
Urinary Tract Infection Given a non-specific history (e.g., abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up. Clinical Reasoning Skills Hypothesis generation, Investigation
Urinary Tract Infection In a patient with dysuria, exclude other causes (e.g., sexually transmitted diseases, vaginitis, stones, interstitial cystitis, prostatitis) through an appropriate history, physical examination, and investigation before diagnosing a urinary tract infection. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Vaginal Bleeding In any woman with vaginal bleeding, rule out pregnancy. Clinical Reasoning Skills Hypothesis generation, Diagnosis
Vaginal Bleeding In pregnant patients with vaginal bleeding Clinical Reasoning Skills Hypothesis generation, Diagnosis
Vaginal Bleeding In pregnant patients with vaginal bleeding Clinical Reasoning Skills Treatment, Hypothesis generation
Vaginal Bleeding In pregnant patients with vaginal bleeding Selectivity, Clinical Reasoning Skills Diagnosis, Treatment
Vaginal Bleeding In a non-pregnant patient with vaginal bleeding: Clinical Reasoning Skills Investigation, Diagnosis
Vaginal Bleeding In a non-pregnant patient with vaginal bleeding: Clinical Reasoning Skills, Selectivity Diagnosis, Treatment
Vaginal Bleeding In a non-pregnant patient with vaginal bleeding: Clinical Reasoning Skills Treatment
Vaginal Bleeding In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (e.g., with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination). Clinical Reasoning Skills Investigation
Vaginitis In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (e.g., lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.) Clinical Reasoning Skills Hypothesis generation, Physical
Vaginitis In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate treatment, and investigation in the future. Clinical Reasoning Skills Diagnosis
Vaginitis When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate. Clinical Reasoning Skills, Selectivity History, Treatment
Vaginitis In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.) Clinical Reasoning Skills, Selectivity Hypothesis generation, Diagnosis
Vaginitis In a child with a candidal infection, look for underlying illness (e.g., immunocompromise, diabetes). Clinical Reasoning Skills Hypothesis generation, Diagnosis
Violent/Aggressive Patient In certain patient populations (e.g., intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Clinical Reasoning Skills Hypothesis generation
Violent/Aggressive Patient In certain patient populations (e.g., intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Clinical Reasoning Skills Diagnosis
Violent/Aggressive Patient In certain patient populations (e.g., intoxicated patients, psychiatric patients, patients with a history of violent behaviour): Clinical Reasoning Skills Treatment
Violent/Aggressive Patient In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (e.g., hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don`t wait for them to sober up, and realize that their calming down with or without sedation does not necessarily mean they are better). Clinical Reasoning Skills, Selectivity Hypothesis generation
Violent/Aggressive Patient In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient. Clinical Reasoning Skills, Professionalism Treatment
Violent/Aggressive Patient In managing your practice environment (e.g., office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it. Professionalism Treatment
Well-baby Care Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record. Clinical Reasoning Skills, Psychomotor Skills/Procedure Skills Physical
Well-baby Care Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies). Clinical Reasoning Skills, Selectivity Treatment
Well-baby Care Anticipate and advise on breast-feeding issues (e.g., weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired. Clinical Reasoning Skills, Patient Centered Approach Hypothesis generation, Treatment
Well-baby Care At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues). Clinical Reasoning Skills Treatment
Well-baby Care Ask about family adjustment to the child (e.g., sibling interaction, changing roles of both parents, involvement of extended family). Patient Centered Approach History
Well-baby Care With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision: - their understanding of vaccinations. - the consequences of not vaccinating (e.g., congenital rubella, death). - the safety of unvaccinted children (e.g., no Third World travel). Patient Centered Approach, Clinical Reasoning Skills Treatment, History
Well-baby Care When recent innovations (e.g., new vaccines) and recommendations (e.g., infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision. Professionalism, Patient Centered Approach Treatment
Well-baby Care Even when children are growing and developing appropriately, evaluate their nutritional intake (e.g., type, quality, and quantity of foods) to prevent future problems (e.g., anemia, tooth decay), especially in at-risk populations (e.g., the socioeconomically disadvantaged, those with voluntarily restricted diets, those with cultural variations). Clinical Reasoning Skills History, Treatment

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