Medical Advisory Committee Consensus
Last updated: December 22, 2024
Overview
These guidelines are a consensus document from the 2023-2024 and the 2024-2025 Maple’s Medical Advisory Committees (MAC). As a reminder, the MAC is an independent group of physicians and NPs practicing on Maple.
This article is meant to provide some guidance on the approach to common chief complaints that present on Maple.
The MAC providers based these guidelines on their personal knowledge and professional judgement, and any new evidence in the field gathered through their continuing medical education practice. They will provide these guidelines independent from Maple.
Note: The purpose of these guidelines is to guide focused histories for some of the most common complaints on Maple. The guidelines are not meant to:
Prompt providers for topics/education points that are relevant in a consult.
Be a direct template to paste into a consult for a patient.
Be official Maple Policy, and as such, this messaging should not be communicated to patients.
As with all MAC guidelines, these guidelines are for medical education purposes only for providers on the Maple platform and is not meant to represent a standard of practice in the field of telemedicine or a direct reference for medical care.
In the past several years, the risks and benefits of virtual care compared to in-person care (and especially access to in-person care) have proven to be dynamic. Even now, these factors vary widely throughout the country. Understandably, what may be appropriate and acceptable to be treated via virtual care in one circumstance may be unacceptable in another case. It is always important to be aware of your college guidelines on virtual care that apply to any specific visit.
These guidelines are not intended to reflect not supersede any guidelines issued by medical regulatory bodies.
Providers should ultimately use their medical judgment in specific clinical cases. This document is confidential to Maple and their providers and is not to be shared, copied, nor reproduced without permission from Maple.
⚠️ All visits including for the frequent chief complaints in this document should include an introduction, limitations of telemedicine, clarifying what the patient is looking for in the visit, a review of PMHx/Meds (and supplements)/Allergies as well as proper return to clinic/in person care instructions.
Contraception
Have you ever had a history of heart disease, diabetes, stroke, breast/cervical cancer, or liver disease?
Do you experience new or worsening headaches? Have you been diagnosed with migraine headaches? [A migraine is usually a moderate or severe gradual onset headache felt as a throbbing pain on one side of the head]. If so, do you have an aura with your migraines? [An aura is where you have warning signs before your headache begins such as changes to your vision, such as black spots / wavy lines or numbness/pins and needles].
Have you ever had a blood clot (also known as DVT/PEs)? These are clots that cause swollen and painful arms, legs or chest pain. Have any of your immediate family?
Have any of your immediate family or second-degree relatives ever had breast cancer? [Note, may prompt discussion but this isn’t a contraindication].
Have you had any new abnormal uterine bleeding (ie unexpected bleeding between your periods or new bleeding after sex?). [If there are concerns for STI/need for sexual health screening, consider referring for in-person care].
Are you up-to-date with your cervical screening (pap smear test)?
Do you smoke? If so for how long have you been a smoker and how many cigarettes do you smoke in a day?
Have you had a recent Blood Pressure done - you can often have this done at a local pharmacy. [Consider in person follow-up it is >135/85. Refer to Hypertension Canada for specific target ranges].
What is your height and weight? [Note, obesity may increase VTE risk for certain types of BCP].
Education:
Risks: Please note potential adverse effects to hormonal contraception include headaches, stomach upset, breast tenderness, weight gain, as well as an increased risk of blood clots (including a slight increased risk of stroke). Please seek medical assessment in the event you are suspecting an adverse effect.
It’s also important to remember to continue to make appointments to get regular Pap tests every 3 years starting at age 25.
If not being followed routinely by in person care, consider doing your blood pressure at a local pharmacy occasionally to ensure it isn’t high. Consider in person follow-up if your readings are consistently >135/85.
Here is a great website that provides information about contraception: https://www.sexandu.ca/contraception/. And in particular what to do about missed pills: https://www.sexandu.ca/sos/.
Note: If the patient is interested in an IUD or implant, refer to in person care. Many providers finish the consult by given some instruction on how and when to start BCP if giving a new prescription.
Erectile Dysfunction (ED):
How long have you been experiencing these symptoms? How often do you experience these issues? Do these problems occur during every sexual encounter or only occasionally?
Do you have trouble getting an erection, maintaining an erection, or both? How about premature ejaculation? Do you have any pain or discomfort during sex?
Do you wake up in the morning with an erection sometimes? Can you have erections during masturbation?
Are you able to have an erection that allows for penetration?
How is your libido?
Have you started any new medications (such as antidepressants)?
Have you tried any treatments for ED in the past? If so, what were they and were they effective?
ED is quite common among men of all ages. The most common cause is anxiety and/or depression. Has there been any recent stressors? How has your mental health and mood been lately?
Have you ever had an in-person provider assess you for this issue? Have you had regular physical exams or routine bloodwork that would check for diabetes, cholesterol levels, etc?
Have you had any surgeries, particularly in the pelvic area?
Do you know your blood pressure? What is your average reading?
Do you use any nitrate containing supplements (such as nitro spray)?
Do you use any recreational drugs? If so, which ones? (note: poppers contain chemical substances similar to nitro, and are a contradiction to ED medication)
Do you have any leg pain when exercising or climbing stairs?
Do you get any painful erections? If so, is there any curve of the penis (Peyronie’s disease?)
Do you have any chest pain or difficulty breathing during exercise? Sometimes ED can be a sign of coronary artery disease. On Up to Date, there is a flow diagram for “evaluation for safety of sexual activity” in patients with stable CVD – consider screening especially if new start >40yrs.
Education:
ED is a multifactorial issue that is best addressed with a combination of lifestyle changes (diet and exercise), general health optimization and medications. Therefore, it is advisable that you have a full physical exam and possibly bloodwork regularly with an in person provider to determine if there are any new underlying causes like diabetes, vasoconstriction/cardiac concerns, thyroid issues, stress or low testosterone levels.
Example of patient education for Viagra:
Viagra is taken as needed 30-60min prior to intercourse (but can help up to 4h). It dilates blood vessels and helps with the generation and maintenance of an erection. Given the limitations of telemedicine and the potential for resale of these medications, my practice is to give a prescription for 8 tabs (with two renewals, which should last you about 3 months. Of course, you are welcome to reconsult here when you run out. The max dose is 100mg daily.
ED medication does not cause physical dependence; however, it does not treat the underlying cause of ED. All medications have the possibility of side effects for a minority of patients. Potential side effects include headaches, dizziness, and facial flushing and runny nose, hearing/visual loss changes. We start at a lower dose to try and avoid these.
If you develop an erection that lasts longer than 3 hours after using the medication, please go to the ER. Don't use any recreational drugs with this medication (including but not limited to stimulants and cocaine). Never take Nitro products including Nitro spray, Nitro patch, etc., with these medications - these medications are commonly used to treat heart conditions. The combination of this medication with Nitro products can lead to fainting, chest pain, arrhythmia, or even death.
Sinusitis
This chief complaint often comes with strong expectations for an antibiotic prescription. Therefore, consider starting this consultation clearly setting expectations, letting patient know that they may or may not require antibiotics depending on the assessment, and they are agreeing to this if they would like to proceed with the consult. Ensure to review previous visits, since recurrent bacteria sinusitis requiring regular antibiotics is likely not appropriate to be assessed on Maple.
What are your symptoms and when did they begin?
Do you have congestion/stuff nose? Do you have nasal discharge and if so what colour? Do you have pain to the upper teeth? Is your sense of smell reduced or gone?
Do you have facial pressure or pain? Is it worse if you tap your forehead or cheek area?
Do you have a fever (temp of > 38 degrees Celsius)?
Do you have any history of sinus infections? Have you recently been on antibiotics for any reason including bacterial sinusitis?
Have you tried to self treat/ medicate with anything, and if so what have you tried?
Conservative measures if suspecting viral:
Over the counter (OTC) Nasal saline rinses at least 3 times a day.
OTC decongestants, whether nasal sprays like Otrivin (xylometazoline) or oral medications like pseudoephedrine, should be used with caution. Using them for more than three consecutive days can lead to a rebound effect, where congestion actually worsens once the medication is stopped.
Acteminophen 500-1000 mg and/or ibuprofen 400-600 mg every 6-8 hours can be taken for pain. The two can be taken together or by alternating them.
Consider nasal steroids (some areas have this available OTC). This can be taken for 2-4 weeks depending on your symptoms.
In rare cases you can develop a bacterial infection on top of the viral sinusitis👇
If suspecting bacterial sinusitis:
Based on your symptoms, it sounds like you have bacterial sinusitis. >90% of sinusitis cases are due to viruses but when they last more than 1-2 weeks, you often have a secondary bacterial infection. This usually presents with worsening symptoms even after 1-2 weeks, along with fever, severe sinus pain on one side with green nasal discharge. I’ll prescribe you an antibiotic to take to treat this. It’s important to remember that antibiotics come with risks of side effects including upset stomach, diarrhea, c. Difficile infection of the intestines and resistance to antibiotics in the future.
RTC instructions: Should your symptoms worsen, or should you develop fever despite the antibiotic, then I recommend you seek in person care. If you have a worsening headache, worsening fever, stiff neck, chest pain or difficulty breathing or any neurological symptoms like double vision, weakness on one side, or difficulty speaking, you should go the nearest emergency department.
Pharyngitis
Along with your sore throat, have you had cough? Fever (>38C)?
Tender and swollen lymph nodes below your jaw around your neck? Enlarged tonsils or white pus on them when you look in the mirror?
All MAC members require at least a good attempt at a photo or video to visualize the throat. “Would it then be possible to send me a photo of the back of your throat (from real close in) while you are saying ahhhh? Works best if the camera/phone is placed right in front of your teeth. The photo should show just the back of your throat (no teeth!). Some people need to use a spoon in order to depress the tongue and visualize the tonsils.” Consider sending printout of how to take photo from Maple:
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Apply CENTOR score - https://www.mdcalc.com/calc/104/centor-score-modified-mcisaac-strep-pharyngitis.
CENTOR score is 4+: There is a significant possibility your sore throat is due to a strep infection. It’s reasonable to go ahead with antibiotics without doing a strep test. Although It’s important to remember that antibiotics only decrease the duration of symptoms due to strep throat by about 24h and come with risks of side effects including upset stomach, diarrhea, c. Difficile infection of the intestines and resistance to antibiotics in the future. Antibiotics do decrease the risk of serious complications like a peritonsillar abscess or rheumatic fever. Would you be interested in taking antibiotics?
CENTOR score 2-3: ideally you should get a strep test done in person at a pharmacy (often available in Quebec, Alberta, Nova Scotia, BC and possibly other provinces) or elsewhere.
CENTOR score 0-1: it’s very unlikely to be strep and we don’t recommend doing a strep test. Your symptoms are likely from a viral infection, and will improve on their own in the next 3-7 days. You can take Tylenol 1000mg and Advil 600mg together 3x a day for pain control. Try OTC lozenges and drink plenty of fluids.
Note: MAC members recommend writing even OTC meds such as NSAID, Tylenol, Tantum as a “prescription” for clarity, and some consider dexamethasone x 1 dose for severe symptoms after weighing risks/benefits:
Dexamethasone can decrease pain and swelling. This can help for pharyngitis whether the cause is bacterial or viral. Side effects are rare but can include mood swings, insomnia, irritability, nausea, vomiting and upset stomach.
RTC guidelines:
If you develop fever, difficulty opening your mouth, start drooling because you are unable to swallow your saliva and/or have difficulty breathing then you should go to your local ER to be assessed for a possible peritonsillar abscess or other complications of a throat infection.
Urinary Tract Infection (UTI)
Have you had any burning when you pee?
Peeing more than usual?
Blood in the urine? If so for how many days?
Have you had a uti in the past? If so when? Are your symptoms today similar to those in the past?
Have you had any antibiotics in the past 3 months?
When did your symptoms start?
Do you use any forms of birth control? When was your last period?
Have you had any:
Fever or chills or feeling generally unwell?
Vomiting?
Belly or Back pain?
Unusual vaginal discharge?
Any new sexual partners and/or recent unprotected intercourse that would put you at risk for a sexually transmitted infection?
Based on your answers, I agree with you that it sounds like you have a urinary tract infection (UTI) that is currently in the bladder, also called cystitis. We should treat you with antibiotics to prevent the infection from going up to a kidney (pyelonephritis). You should start to feel better within 24-48h. It is important to still finish the course of antibiotics. You can take OTC analgesia such as Tylenol and Advil with the antibiotics if needed. If symptoms aren’t improving, then you should consult again or seek in person care which point a urine culture should be done and a different antibiotic might be needed. Some things that may prevent future UTIs include staying hydrated, urinating after sexual activity, and practicing good hygiene with wiping front to back.
Should your symptoms worsen, or you develop a fever > 38C, one sided flank/back pain, worsening belly pain, new vaginal discharge, nausea and vomiting or unable to keep the antibiotics down, you should go to your local ER for in person medical attention.
Males: there are many causes of UTI type symptoms in a male, so I can’t assess you properly using virtual care. You need to see a doctor in person in a timely manner (ideally today or tomorrow) to be properly examined and to have a urinalysis to see if there are signs of an infection, or signs of a sexually transmitted infection vs. other causes of these symptoms. If it is a UTI, then you’d be started on antibiotics and the urine sample you would have given would be sent for a urine culture. You may require further testing (like a kidney ultrasound) so please do follow-up with an in-person practitioner ASAP. Consider writing the patient a letter to help with expediting next steps.
Recurrent UTI’s: Given that this is a recurrent infection, it is important you do a urinalysis and urine culture and possibly other testing as well to ensure it is indeed a UTI and not another medical issue. Therefore, it would be ideal for you to seek in person care as soon as possible. Note, in some jurisdictions, pharmacies can do this and prescribe antibiotics, or a patient can take their result back to Maple for further care.
Note: Current MAC members would still give an empiric Abx advising patient they’ll need to follow-up with the results of the urine when they are back and seek in-person medical attention if symptoms aren’t improving as expected in 24-48h.
Conjunctivitis
Important to emphasize limitations of virtual care: A comprehensive examination of the eye ideally requires an in person visit where we can check visual acuity, use a slit lamp to examine the different chambers of the eye, possibly apply a dye to look for scratches and check pressures in the eye. While most MAC members would still assess for simple conjunctivitis using Maple, all have a very low threshold to have the person seek in person care asap regardless of diagnosis for an eye exam, through an optometrist or medical practitioner.
HPI:
How long have you had eye redness? Is it only in one eye?
Have you had any cough/cold/sore throat/runny nose?
Do you have eye discharge and if so what colour?
Has your eye been crusted shut in the morning?
Is your vision only blurry when there’s discharge? Is your vision now back to normal after cleaning the eye? If your vision is not back to normal when wiping away any discharge, then you need to seek in person care asap for an exam.
Red flag screen:
Have you had any decrease in your vision? Eye pain? Headache? Eye pain when you look into a light (photophobia)? Vision changes or double vision or pain when moving your eyes in all directions? Any fever or chills? Do you wear contact lenses? Did you injure your eye or get something in in?
If any of these, or if any of these develop over the coming days, you need to see an in-person practitioner ASAP, even if that means going to the nearest emergency room.
Exam:
Current MAC members as well as MAC guidelines from previous years agree that any eye consults should either include a photo that is uploaded or be done as a video consultation. Many complaints of eye redness actually result in a diagnosis of cellulitis/shingles/blepharitis/etc.
Counselling for suspected conjunctivitis:
Your history is certainly is in keeping with conjunctivitis or ”pink eye”. From what you told me, I suspect this is bacterial conjunctivitis and would benefit from an antibiotic eye drop. Note, viral conjunctivitis requires only symptomatic management, allergic conjunctivitis requires systemic antihistamines, as topical antihistamines take weeks to take effect.
Clean the eye whenever there is any discharge. The discharge is infectious, so wash your hands and ensure towels/tissues used are thrown out or washed immediately so others aren’t infected.
You should see some improvement within 48h if not sooner. If not, you’ll have to seek in person care for a proper eye exam.
If suspecting a stye: This may take several weeks of warm compresses to go away. If it lasts more than 2 months then you’ll need to be referred to an ophthalmologist (eye surgeon) for further treatment.