a priority topic and how it could appear on exams · •practice taking histories, physical exams,...

Orientation To Your Examinations

Plus

A Priority Topic and how it could appear on exams

PRIORITY TOPIC:

IMMUNIZATIONS

how this can appear on exams

PART ONE

Exams!

To practice medicine in Quebec, up to how many exams might you have to do?

a) Twob) Threec) Fourd) Five

#1 mistake residents

make on exams:

Not reading very carefully!

3 Licensing bodies:

• College of Family Physicians of Canada

• Medical Council of Canada

• College des médecins du Québec

Exams to get be able to practice in Quebec:

• Medical Council of Canada1. LMCC2

• College of Family Physicians of Canada1. Written SAMP

2. Oral SOO

• College des médecins du Québec1. ALDO

2. Examen de L’Office Québécois de la langue Française

Since most of you will forget everything we say…

Exam information and links are on the Family Medicine website

Why residents fail

1.

2.

They don’t know enough

They make avoidable mistakes

1. They don’t know enough

We are building a virtual study guide so

residents can spend:

more time studying,

less time searching for references

I asked what strategies the “Top

performers” used during their

residency

Started 6-12 months in advance

Used the College Priority Topics as their study guide

The most commonly cited resource was “American Family Physician” articles

LMCC2

REGISTER

TODAY !

The LMCC2 exam is about 1st principles

• Can you take a history• Can you do a relevant and organized physical

exam• Can you manage acute situations• Can you interpret lab or radiology tests properly• Is your communication with patients open,

empathic and clear• Can you approach ethical situations according to

Canadian medical principles• Can you interact with colleagues clearly and

professionally

• Deal with a medical error• Deal with unprofessional behaviour• Ethical dilemma• Deal with confidentiality• Patient autonomy – informed

consent…

You might need to know how to:

WHAT YOU NEED TO BRING:

Entrance card

LMCC2 2 days

SATURDAY SUNDAY

8 10-minute stations 4 6-minute couplet stations1 14-minute station

10 minute stations

• In some cases, the clinical encounter ends at nine minutes and is

followed by a one-minute oral examination.

• The physician examiner may ask one to three pre-specified

questions related to the patient problem.

6 min - Clinical encounter

• Obtain a focused relevant history or

• Conduct a focused physical examination

“Couplet” stations

6 min – Pt encounter probe

• Review and interpret patient-related materials before or after the patient encounter

• Interpret x-rays, computed tomography images, laboratory results, etc.

• Record physical exam findings after the clinical encounter

• Provide a differential diagnosis.

• Detail an initial investigation or management plan

“Couplet” stations

When you walk into the room:

Be observant

Go back to “Bates” Basics

Practice the elements of a proper History of Presenting Illness

Review a systematic approach to physical exams (and SAY IT OUT LOUD)

Listen to Mike Kirlew podcasts for acute management and lots of exam tips

http://mcc.ca/examinations/mccqe-part-ii/exam-preparation-resources/

Interactive orientation presentation:

http://mcc.ca/examinations/mccqe-part-ii/exam-preparation-resources/

Common error

Identify the 2 most important words in this instruction:

“List 3 factors that will determine this patient’s prognosis”

SAMP

Short Answer Management Problems

All day, 6-hour, computer-based written exam

Rules for the SAMPS

Your answers MUST be specific

NOT acceptable answers:

“Lipid profile”

“Complete blood count”

“Electrolyes”

Acceptable answers:

“LDL-cholesterol”

“Hemoglobin”

“Blood sodium”

Also NOT acceptable:

“Ultrasound”

“CT scan”

Acceptable :

“Abdominal Ultrasound”

“Brain CT scan”

READ SAMP QUESTIONS CAREFULLY

Versus

“Name 3 predisposing factors of this

diagnosis for this patient?”

“Name 3 predisposing factors for this

diagnosis”

Expect a lot of questions like:

What is the most important test to order first?

What is the most important diagnosis to consider first?

What is the most important intervention to do now?

Most residents are surprised by how few “guidelines” type of questions there are

The S

“Simulated Office Oral”

To test competency in the patient-centredmethod.

The goal of the SOO:

5 Stations - 15 minutes each

Patient Centred exploration of the patient’s problem

F

I

F

E

Fears

Ideas

Function (problem’s impact on their function)

Expectations

You are about to meet MrsDoe, 28 years old

Anatomy of a SOO

Evaluate PROBLEM 1+ “FIFE”

Evaluate PROBLEM 2+ “FIFE”

ManagePROBLEM 1

Manage PROBLEM 2

Explore pt’ssocial

context- Friends- Family- Finances- Life-stages

Provide a stunning context

integration statement

CONTEXT INTEGRATION STATEMENT

•“I can see why this is a problem for you at

this time …”

We will review the particularities of the SOO next month

The S

Summary of what you must do:

• REGISTER for the exams

• READ the essential information provided by the Colleges!

• Study by imagining what types of questions they might ask

• Practice taking histories, physical exams, and acute management out loud

• Download Dr Mike Kirlew’s podcasts

Priority Topic:

ImmunizationsHow this topic might appear on exams

Immunizations

Exam tips

Exam tips

Exam tips

Residents would perform better on exams if they:

Remembered to include lifestyle interventions, non-

pharmacological, and immunizations on their answers

Immunization

Key Feature1 Do not delay immunizations unnecessarily (e.g., vaccinate a child even if he or she has a runny nose).

2 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.

3 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.

4 Clearly document immunizations given to your patients.

5 In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different.

6 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).

Don’t leave easy exam points on the floor!

Key feature 5. In patients presenting with a

suspected infectious disease, assess immunization

status, as the differential diagnosis and consequent

treatment in unvaccinated patients is different.

In LMCC2 oral stations, ask about immunization status

Asked about immunizations

EXAMINER CHECKLIST

✓

- Healthy diet

- Alcohol limitation

- Exercise

- Smoking cessation

- Multidisciplinary team

- Vaccinations

For pretty much every SAMP or SOO -include health promotion

recommendations

I am not going to talk about childhood vaccine schedules

For premature babies, do you give the vaccines according to their chronological age or corrected age?

A child comes to you for her 4-month vaccine 7 weeks after her 2-month vaccine Which should you do?

a) Tell the mom she will have to come back at 8 weeks for the 4-month vaccine

b) Tell the mom that she can have the 4-month vaccine today while she is here

While it may be ok to give a booster later than the schedule,

It is not ok to give a booster earlier than the schedule

WHO, CDC, PHAC allow only 4 days earlier than the schedule . Earlier than that

interferes too much with the booster’s effectiveness

What resource provides the most up do date Canadian vaccination information?

When not to vaccinate

(Don’t be scared of the sniffles)

Key feature 1 - “Do not delay

immunizations unnecessarily

With respect to vaccinations, there

are:

• Contraindications• Precautions

There is only 1 permanent contraindication that is

applicable to all vaccines

Thou shalt not

vaccinate if:

The patient has

had a severe

allergic reaction

after a prior dose

of vaccine or to a

vaccine constituent

(anaphylaxis)

Anaphylaxis is a IgE mediated systemic allergic reaction

Involves 2 or more organ systems, occuring minutes to hours post exposure:

• Skin - urticaria, angioedema, periorbital edema• Cardiovascular – hypotension, shock• Respiratory – tongue swelling, Wheeze, resp distress• Abdominal- cramps, diarrhea• Brain – loss of consciousness,

4 Vaccination “Precautions”

Antibody-containing Products

1.

2.

3.

4.

Moderate/ severe illness

Pregnancy

Immunosuppression

Moderate/ severe illness

According to the “PIQ”

• Fever• Extreme irritability or crying• Lethargy• Vomiting/ Diarrhea

Is this the disease getting worse, or is it

the vaccine

Recommendation is not to give live attenuated vaccines to pregnant women because there is a theoretical risk that the vaccine could produce a danger to the fetus.

Pregnancy

Name 5 (FIVE) live attenuated viral vaccines

1.2.3.4. 5.

MMR (Measles, Mumps, Rubella)VaricellaZosterRotavirusLive attenuated influenza (intranasal)

TWO live-attenuated bacterial vaccines

1.2.

Oral TyphoidBCG (tuberculosis)

Immunosuppression

• Congenital immunodeficiency• Cancer• HIV infection• Chemotherapy• Radiation therapy• Large doses of corticosteroids or

other immunosuppressant• Nephrotic syndrome

Wait before giving live-attenuated vaccines to people who have had antibody –containing products

Antibody-containing Products

Live attenuated vaccines need to replicate within the host

High antibody level impair the immune response to live

attenuated vaccines

Source of antibodies that can interfere with the immune response to live-attenuated vaccines:

1.Mother’s antibodies to her newborn2.Blood transfusions3.Immunoglobulin transfusion4.Another live-attenuated vaccine

You are best to administer a live-attenuated vaccine when the person’s antibody titre is low

How could this key

feature look on an exam?

Gabriel, is brought in by his mother for

the influenza immunization. Gabriel is

healthy except for a suspected egg

allergy. He once developed an itchy skin

rash on his cheeks after eating

scrambled eggs.

He has never had a flu shot before. His

mother asks if Gabriel can have the flu

shot.

What do you suggest?

SAMP case :

Unless Gabriel’s reaction to egg was

anaphylactic, there is no

contraindication to him being vaccinated

against the influenza vaccine.

Atopy to egg is not a contraindication to

vaccination

ANSWER:

Adverse events from

vaccines

Which of the following statements is/are true?

a) The adverse reactions from live-attenuated vaccines tend to be systemic and can be similar to a non-contagious attenuated form of the disease

b) The adverse reactions from inactivated vaccines tend to be local reactions

c) The adverse reactions of live-attenuated and inactivated vaccines are similar

Adverse reactions to vaccinations

Fundamentally different between live attenuated and inactivated

vaccines

Adverse reactions to live attenuated vaccines tend to be similar to mild

version of the disease

Onset tends to be similar to the latency period of the natural

infection

Local vaccine reactions

• Local reactions occur at the injection site and include pain, swelling, and redness.

• Are more common after inactivated vaccines

• Usually occur within a few hours of the injection

• Tetanus and diphtheria toxoids most commonly are associated with severe local reactions.

Severe local reactions are called "hypersensitivity reactions."

Vaccination site reaction: Cellulitis:

• Progresses over 1st few hours

• Resolves within 48 hours• Only slightly painful• Systemic symptoms, even

fever are rare

• Starts a bit later• Gets progressively

worse• A lot of pain• Often associated

fever

Systemic reactions

- Occur more commonly with live-attenuated vaccines

- Systemic reactions are similar to a mild form of the natural disease.

- They occur near the middle to end of the natural disease's usual incubation period, at 7 to 21 days after vaccination.

Because measles causes a rash and fever, the most common adverse reactions after MMR vaccination are a mild rash and fever within 7-21 days post vaccine

OTHER possible adverse reactions to MMR:

• Joint pains• Thrombocytopenia

(1/40,000)

What if I inject in the wrong place?

Manufacturers recommend site of injection to: optimize effectiveness

Minimize adverse reactions

Diagnosis?

• Firm • Only slightly tender nodule• Began 2 months post-

vaccination• Lasted months

Post-vaccination site sterile abscess

Post-vaccination site nodule

Some inactivated (killed) vaccines contain Aluminum salts that increase the immunogenicity of the vaccine (“adjuvant”)

If injected into subcutaneously, there is an increased risk of sterile abscess and nodules

There’s Aluminum in vaccines?!

Aluminum is sometimes added to enhance

the immune response to certain vaccines. (“Adjuvant”)

DID YOU KNOW?• Aluminum is present in air, food, and

water.

Aluminum “ingestion” During first 6 months of life from the following sources

• Vaccines 4 mg• Breast milk 7 mg• Baby formula 38 mg• Soy milk formula 117 mg

Formaldehyde is sometimes used

during manufacturing to kill or weaken the virus/bacterium

Most is removed during the manufacturing process.The remaining trace amount is safe

DID YOU KNOW?

• Formaldehyde is a byproduct of normal metabolism.

Thimerosol was used as a preservative in

some multi-vial vaccines

• People were concerned because it contained a form of mercury

• But not the form of mercury that accumulates in the body

• Thimerosol is not longer used in the pediatric series of vaccines

Vaccine hesitant

patients

Key Feature 2. 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.

Imagine this:

It is the SUNDAY of the LMCC-2 exam.

The day of 6-minute couplet stations….

How do you think this resident performed on this

station?

READ THE QUESTION CAREFULLY

Know what the licensing body means by their words

Common mistakes made on LMCC2

exam

The Medical Council of Canada means for you to ask the patient questions and respond to their answers

How do you think this resident performed on this

station?

Vaccine hesitancy Station - Evaluator’s marking guide

O Asked about child’s vaccination history

O Asked about past reactions to vaccines

O Asked types of information mother has obtained (internet,

television, friends/family)O Inquired about mother’s concern about the vaccines

O Elicited child’s past medical history

O Elicited history of medications

O Asked about allergies

Social history

O - Child in daycare or at home

O - Exposure to other children

O - Exposure to family members who might be sick

Applicant’s general approach

O Displayed non-judgmental approach

NEVER Bull s--- !

In oral exams (SOO and LMCC2), if you aren’t sure,

“Adverse events following immunization” (AEFI)

We must report to Public Health Agency of Canada any serious or unexpected adverse reaction that

have a temporal association with immunization that is not clearly attributable to another cause

Specific

immunizations

Immunizations:

• Tetanus, Diphtheria, Pertussis• Pneumococcus• Influenza• Meningococcus• Varicella and Zoster• Hepatitis B and A

Highlight populations

most at risk

Exam tips

Exam tips

Exam tips

TDaP

and all its abbreviations

2 4 6 12 18 4-6 y

Quebec schedule

Grade 4 Grade 9

DTaP

Diptheria

Tetanus

acellular Pertussis

What does the “a” stand for?

Types of vaccines

Live Attenuatedo Viralo Bacterial

Inactivatedo Whole-Cell Viruso Fractionalo Toxoido Subunito Polysaccharideo Conjugate

DTaP

Tdap

DT

Td

DTaP

Tdap

DTTd

The Capital refers to the relative amount of that antigen

DTaP

Tdap

DTTd

Which of these options is given 6 times to children <18

years?

DTaP

Tdap

DT

Td

Which of these is given to adults at least once?

Public Health Agency of Canada (PHAC) recommends Tdap to pregnant women >26 wks if

haven’t received the pertussis vaccine as an adult

DTaP

Tdap

DT

Td

Given to children who cannot receive pertussis

component

Given q 10 years to everyone

DTaP

Tdap

DT

Td

Given to children who cannot receive pertussis

component

Given q 10 years to everyone

Which of these is given to adults at least once?

Which of these options is given 6 times to children <18

years?

DTaP

Tdap

DT

Td

Pertussis (Whooping cough)

• Young infants are the most vulnerable

• The first set of most inactivated vaccines only “prime” their immune system (“the primary series)

Infants depend on the population being vaccinated against pertussis (Tdap)

A man presents to your walk-in clinic with 3 weeks of persistent cough

Annals of Family Medicine (2013):

Mean duration of a cough after a URTI is 18 days

Patients expected their cough to resolve is 5-7 days

20% of adults with a cough lasting >2 weeks have

pertussis

Pertussis vaccination is a lot about protecting:

PERTUSSIS

Pregnant women >26

weeks

Pneumococcal

immunization

2 4 6 12 18 4-6 y

Quebec schedule

Grade 4 Grade 9

As a resident while trying to vaccinate a 12-month old baby against pneumococcus, I gave Pneumovax-23 instead of Prevnar-13

Streptococcus pneumoniae

A capsulated bacteria

Can cause upper respiratory tract infections and acute otitis media

“Invasive

pneumococc

al disease”:

• Pneumonia• Meningitis• Sepsis

Streptococcus pneumoniae

Strep pneumo vaccines

Polysaccharide vaccine Pneumovax-23

Pneumo Conjugatedvaccine Prevnar-C-13

Weak antigen

Children (< 2 years) do not develop a strong immune response to polysaccharide

vaccines unless they are conjugated to a protein

I gave Pneumovax-23 instead of Prevnar-13 to a 12 month old baby

This baby did not receive complete vaccine coverage for invasive strep pneumo disease

Hang on,

things are

going to get

a little

complicated!

People > 2 years “at high risk” of invasive pneumococcal disease should receive conjugated AND Polysaccharide-23 vaccines

High risk for pneumococcal meningitis:

Full series of pneu-conjugated vaccine AND Polysaccharide-23

• Asplenia or sickle cell disease; • Chronic Hepatic; Cardiac; Pulmonary disease• Diabetes • Severe chronic renal failure or nephrotic syndrome; • Immunocompromised:

• HIV infection;• Congenital immunodeficiencies• Chemotherapy• Radiation therapy to large bones (pelvis)• Corticosteroids or other immunosuppressants

Others >2 years who should get Pneum-Conj AND polysacharide-23

All healthy Adults > 65 years

PHACPIQ

CDC

Pneu-conj+

Pneu-23 Pneu-23

Groups at the HIGHEST risk of invasive pneumococcal disease and should have:

• Pneu-conj AND

• Polysach-23 AND booster 5 years later

1. Asplenia2. Immunocompromised3. Chronic renal disease/ Nephrotic syndrome

Ideally, if you have to give both, which should you give first?

Pneu-conj or Pneu-23

8 weeks

Pneu-23 Pneu-conj1 year!

High risk people > 2 yrs should get both vaccines

Pneumococcus

Pneumococcus

Influenza vaccinations

I can’t stand it when Family Medicine

residents only know the provincial vaccine

schedule!

They should know the PHAC recommendations!

Tiny Tots Dr Burko’s pet peeve:

Influenza vaccine

“If you can sit, you should receive the flu vaccine”

PHAC Recommends for everyone ≥6 months old

There are 2 types of flu vaccines

1. Inactivated intramuscular vaccine2. Intranasal live attenuated vaccine

In young children, (<9yrs) you have to give a BOOSTER of influenza

2 shots, given four weeks apart

Flu vaccines

Meningococcal

immunization

2 4 6 12 18 4-6 y

Quebec schedule

Grade 4 Grade 9

Neisseria meningitis

Similarities with Strep pneumonia

1. Both encapsulated bacteria

2. People with asplenia are at highest risk

3. Vaccines work best if a protein is conjugated to the polysaccharide antigen

Neisseria meningitis

ABCW-135Y

In Canada, the majority of invasive meningococcusinfections is caused by which 2 strains?

Men-Conjugated-CC

B

A,C, Y,W-135

4CMen-B

MenC-A-C,Y,W-135

Available Meningococcal vaccines

“Quadravalent”, (menactra)

(Bexerso)

Minimum coverage for meningococcus

= Most provincial Programs

Men-Conjugated-C Men-Conjugated-C

Babies(12 mo)

Early adolescence

(Grade 9)+

Maximum coverage available for meningococcus

• Men-C-C,A,Y,W-135

• 4C Men-B (Bexero)Men-C-A,C,Y,W-135

Babies + Every 5 years:

Populations most at highest risk for invasive meningococcus disease (NAME 3)

1. Functional or anatomic asplenia2. HIV infections3. Complement or factor D deficiencies

SAMP

40-yr old patient has is telling you he is about to leave for Mecca. He asks you what vaccinations he needs for his trip.

Name 5 (FIVE)

I shouldn’t need to know this! I send all my patients to Travel

Clinics!!

http://www.phac-aspc.gc.ca/index-eng.php

Key feature 3. 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.

Mecca and Sub SaharanVery high endemic rate of meningococcus

Should receive “Quadravalent” meningococcusvaccine prior to their trip

Travel vaccines for everyone

1. 2. 3.

4.

5.

Td +/- aP, ensure has had polio vaccine

MMR

Hepatitis B

Hepatitis A

Vaccines if going to Mecca or Sub Saharan Africa

Meningitis –C,A,Y,W-135 (“Quadravalent”)

Consult the travel recommendations on the Pubic Health Agency of Canada website

SAMP

A 6-year old previously well, presents to the emergency room with headache, fever, and disorientation.

His vaccinations include:2 months – DTaP-HB-IPV-Hib

Pneu-C-13Rotavirus

4 months – DTaP-HB-IPV-HibPneu-C-13Rotavirus

6 months – DTaP-IPV-HibInfluenza x 2 (4 weeks apart)

12 months – Men-CMMRPneu-C-13

18 months – DTaP-HB-IPV-HiBMMR

5 years – Tdap-IPV

On physical examination you note a macular rash on his face that does not blanch

QUESTION. Name the most likely bacterial pathogens that you would suspect in this patient? (NAME 3)

1.2.3.

N. meningococcus

Strep. pneumococcus

H. Influenza type b

Key feature 6. In patients presenting with a

suspected infectious disease, do not assume that a

history of vaccination has provided protection

against that disease







it is offered.

Influenza yearly (intrasmuscular)

4 principles of vaccinating immunocomprised

Chronic renal disease, **Nephrotic syndrome

1.

2.

3.

Try to give the live vaccines before becoming immunosuppressed….

Full protection against Strep pneumoniao Pneu-C13, then Pneu-23, 8 wks latero Booster Pneu-23 5-years later

4. Immune response to all vaccines is less effective, might want to test titres







it is offered.

Influenza yearly

Full protection against Strep pneumoniao Pneu-C13, then Pneu-23, 8 wks latero Booster Pneu-23 5 years later

1.

2.







it is offered.

SAMP

38 year old female with Sickle cell disease presents to your Emergency room with acute onset of hip pain.

QUESTION 1.

What is the most important intervention to do first? (NAME ONE)

Early and aggressive pain management

QUESTION 2.

Your patient’s daughter is 2-years old. Hemoglobin electrophoresis is HbS/HbC. What treatments are important in the management of her daughter? (NAME SIX)

1. 2. 3. 4.

Annual flu vaccination

Full pneumococcal vaccination

Full meningococcal vaccination

Penicillin prophylaxis bid until age 5

5.

Hydroxyurea

6.

Transcranial doppler ultrasounds age 2-16y







it is offered.

Varicella and Zoster

immunizations

In a LMCC2 physical exam stations

residents lose points if they don’t:

1.Have a very systematic approach

1.SAY what they are doing and DO what they are saying

Systematic Back exam

• Polite introduction

• Systematic approach:

– Inspection (outside the spine and then the spine itself)

– Schober

– ROM – flexion, extension, lateral flexion, rotation

– Peripheral nerve Strength, sensation, peripheral reflexes

– Straight leg test

– Gait

Examiner question:

“What do you think is the cause of this patient’s back pain?”

You answer:

“Based on the skin findings of a papular rash

distributed along the right thoracic dermatome,

the most likely diagnosis is a herpes zoster

reactivation (shingles)”

If this were a SOO

Have to explore the patient’s illness experience

Explore the impact of the illness on his life and functionExplore what he is most worried aboutExplore why he thinks this might have been triggeredExplore what he is hoping from you today

If this were a SAMP

James Black, 68 years old, presents to your family medicine clinic with a 3-day history of back pain.

He describes how the pain is making it difficult to take care of his wife who is recently disabled since suffering a stroke.

On physical examination you observe this:

Questions

What do you think is the cause of this patient’s problem (Name ONE).

1. Herpes zoster reactivation

What is the most important thing to address first? (Name ONE)

Manage his pain2.

SAMPS to ask questions like:

“What is the most important thing to do NOW”

“What is most important test to order”

1.

2.

3.

Start medication for neuropathic pain

Do a history and physical exam to determine if there is a predisposing cause of the zoster re-activation

Offer the herpes zoster vaccine at a later date to decrease the risk of recurrence

3. What interventions would be important to consider? (Name THREE)

The varicella vaccine can be used to prevent shingles

TRUE

FALSE

The varicella and the zoster vaccine are both live-attenuated vaccines

They are DIFFERENT

How effective is the Zoster vaccine to prevent shingles?

a) 25%b) 50%c) 75%

Lifetime risk of shingles for people >85-years is 50%

a) The Public Health Agency of Canada recommends the zoster vaccine to adults >60 years

a) The PHAC recommends the zoster vaccine to adults > 50 years

Prevents Shingles NNT 59Prevention of postheretic neuralgia NNT 364

Vaccinations for healthy adults >60 years recommended by the PHACNAME 3

1.Annual influenza vaccine2.Td every 10 years3.TdaP at least once as an adult4.Pneumo-23 vaccine5. Zoster vaccine

CHAPTER ..

Picking up exam points even when you “don’t know anything!”

EXAM

S In management questions for SAMP and SOO questions, do not forget to include

immunizations!

“Give 10 management interventions for long term management of COPD?”

Things residents forget on CCFP exams

- Healthy diet

- Alcohol limitation

- Exercise

- Smoking cessation

- Multidisciplinary team

- Pulmonary rehabilitation

- Influenza vaccine annually

- Pneumococcal vaccine

- If > 60, the zoster vaccine

SOO

James Leroy, 53 year old comes to your office because he has been having trouble breathing

Problem 1 – acute copd exacerbationProblem 2 – want to quit smoking

Management of Problem 1:

Must include:- Lifestyle

recommendations- vaccination

recommendations

SUMMARY FOR EXAMS STRATEGIES

①Read wording of questions very carefully

①Don’t talk too much. Listen to the patient

①Always add lifestyle modifications and advise to “management” sections of SAMPS and SOO

①Always ask yourself “is there a vaccine for this?”

②Study with questions like: “what is the most important thing to do NOW?” in mind

Key feature 4 - “Clearly

document immunizations given

to your patients.”

When I vaccinate patients in my clinic, adding to the immunization record in MYLE automatically updates that patient’s vaccine status in the Quebec vaccination registry

TRUEFALSE

Since 2014, there has been a mandatory registry of all immunizations given in Quebec

The Quebec Vaccination Registry

There is no direct connection between this registry and the immunization record in MYLE

The Vaccination Registry “does not remove health care institutions’ legal obligation to maintain client files up to date”.

Conclusion?

You have to ensure that your patients’ immunization status is documented in

both your local centre AND the Provincial registry

This is not the time to be avoidant!

Register

Read the College’s advice to applicants

a priority topic and how it could appear on exams · •practice taking histories, physical exams,...

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