Family Medicine Shelf Review Stefanie Kreamer, MD
Hepatitis Hep A: • vaccination indications: MSM, IVDUs, persons working with Hep A virus or infected primates, chronic liver disease, persons that receive clotting factor concentrates. (these days all kids are vaccinated) • Most commonly reported hepatitis virus; always acute; fecal-oral • Early fecal shedding and less infectious once jaundiced Hepatitis B: • likelihood of transmission ↑with the level of HBV DNA in the serum • treat infant of a Hep B+ mom with Hep B Ig within 12 hrs of birth + vaccination (prevents 90% of infection) • all mothers should be screened for hepatitis B surface antigen • If Hep status of mother is unknown give baby vaccine and test mom; if mom is +, give baby Ig within 7 days. • adult at risk for Hep B immunize for Hep B if not immunized – sexually active persons with > 1 partner in the last 6 mo, persons seeking evaluation/treatment for a STD, current/recent IVDU, MSM, health care and public safety workers exposed to blood or body fluids, ESRD, HIV, chronic liver disease. • immunizations for an adult: 1 injection at time 0, another 1 - 2 mo later, a 3rd injection 4 - 6 mo after the 2nd • IgM anti-HBc early infection. • HBeAg replication. • anti-HBs exposure with immunity, recovery phase, or vaccination. • HBsAg either chronic infection or early infection. Hep C: • screen for HCV infection in persons at high risk for infection AND one-time screening for HCV infection to adults born between 1945 and 1965
H. Influenzae • Vaccines against Hib are 95% - 100% effective in preventing invasive Hib disease. • vaccine doesn’t ↓rate of otitis media, as most cases are caused by non-typeable H influ. • Adverse reactions are rare; no serious reactions recorded; systemic reactions (fever, irritability) are infrequent • most common side effects: mild fever, local redness, swelling, or warmth • should not be administered before 6 wks, as immune tolerance to the antigen may be induced.
Varicella • immunization recommended for adults who have not had evidence of infection or immunization. • US-born before 1980 are considered immune, with the exception of health care workers and pregnant women. • 2 doses of vaccine are required, 4 - 8 wks apart, regardless of age; should not be given before 12 mo • testing is not necessary in those with uncertain immunity; vaccine is well-tolerated in those already immune • Non-immune pregnant women or immunocompromized should not receive the vaccine until after delivery • household contacts of immunocompetent pregnant women do not need to delay vaccination. • Rarely (1%), people receiving the vaccine may develop infection; the case is mild, and is not contagious.
Tdap: • tetanus-diphtheria 5-component acellular pertussis (Tdap) is recommended for adults 19 - 64 to replace the next booster dose of tetanus • Tdap should be given to pts 65 yrs and older • should be administered regardless of the interval since the most recent Td-containing vaccine. • Td booster every 10 yrs • Tetnus: – Clean, minor wound + vaccination within 10 yrs do nothing – Potentially contaminated wound + >5 yrs since vaccination give booster – High risk wound + unimunized give tetanus Ig + vaccination
MMR • People born before 1957 do not need to be vaccinated with MMR and are considered immune • Contraindicated in neomycin allergy • Live attenuated vaccine • Not for pregnant or immunocompromized patients • Wait 3 mo if blood or Ig products given
Rubella • mild self-limited illness, but during pregnancy can result in fetal death or congenital defects • If a woman is rubella non-immune, vaccination should not occur if pregnant or planning pregnancy in next 4 wks • vaccine is contraindicated in pregnancy; inadvertent vaccination is not an indication for therapeutic abortion. • If the patient is currently pregnant and nonimmune, she should be vaccinated early in the postpartum period
Meningitis • Meningitis vaccination is indicated for those with functional asplenia or travelers to endemic areas. • 2 doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16. • College students and military recruits are at risk
Pneumococcus • PPSV23: adult vaccination indications: chronic diseases, functional asplenia, residents of long-term care facilities. • pneumococcal polysaccharide vaccination if >65 yrs or <65 with chronic medical conditions – 2nd 5 yr revaccination in pts w/CKD, liver disease, immunodeficiency, asplenia
• PCV13: for infants and toddlers at 2, 4, 6, and 12 to 15 months
Influenza • Vaccination is 30% - 90% effective in preventing influenza or complications from influenza. • vaccination is recommended annually for kids 6 mo and older • minimum age for vaccination with the trivalent inactivated influenza vaccine (TIV) is 6 months • minimum age for the live, attenuated influenza vaccine (LAIV) is 2 yrs – Do not give to immune-compromized or those around them
• administer 2 doses (separated by 4 wks) to children 6 mo - 8 yrs who are receiving the seasonal vaccine for the first time, or who were vaccinated for the 1st time during the previous influenza season, but only received 1 dose • Intranasal influenza should only be used in healthy adults < 50 and kids > 2 yrs; not for pregnant or immunocompromised adults • Inactivated is for everyone > 6 mo except those with egg allergies
HPV • Recommended (not required) for all women and men 9-26 yrs • History of genital warts or abnormal Pap are not are not reasons to avoid vaccination. • People sexually active w/many partners should be immunized if they meet criteria • To be most effective, the vaccine should be given before a female becomes sexually active. • It can be administered when a patient has an abnormal Pap test or when a woman is breast-feeding. • It can also be given when a patient is immunocompromised because of a disease or medication. • It is not recommended for use during pregnancy.
Herpes Zoster • vaccination recommended for those 60 or older regardless of having had a prior episode of herpes zoster • vaccination is not approved for persons younger than 60
Lung Cancer • no screening improves mortality and no screening is recommended • Same true for many other cancers and illnesses- for the shelf exam, if you haven’t heard of the screening tool, it probably doesn’t exist or isn’t used
Colorectal Cancer • screen with FOBT, sigmoidoscopy, or colonoscopy in adults beginning at age 50 and continuing until age 75 • if family history, screen 10 yrs before cancer was found in the family member, or at 50, whichever is sooner • Recommend against screening > 85 yrs
Breast Cancer • • • • • • • •
Mammographic screening has been shown to ↓mortality from breast cancer. Screening before age 50 should be individualized, and take into account risks & preferences Do not do a mammogram if <30 yrs (do ultrasound) Biopsy all palpable masses in women >40 Persistent mass or bloody fluid after FNA excisional biopsy women between the age of 50 - 74 should get screening mammograms every 2 years. significant # of additional imaging procedures & biopsies were performed for women performing BSE recommend against the performance of BSE for women at average risk for breast cancer. High risk criteria: – 2 first-degree relatives with breast cancer, 1 of whom was diagnosed when < age of 50. – A combo of 3 or more 1st or 2nd relatives w/breast cancer regardless of age at diagnosis. – A combination of breast and ovarian cancer among first- and second degree relatives. – A first-degree relative with bilateral breast cancer. – A combo of 2 or more 1st or 2nd relatives w/ovarian cancer, regardless of age at diagnosis – A first- or second-degree relative with both breast and ovarian cancer at any age. – A male relative with breast cancer. – Ashkenazi Jewish women should be offered testing if any 1st relative (or 2 2nd degree on the same side) are diagnosed with breast or ovarian cancer.
Prostate Cancer • There is evidence supporting DRE & PSA testing as a screen, but concerns exist regarding false + tests and any actual reduction in mortality that is gained from doing the tests. • AAFP feels evidence is insufficient to recommend for or against routine screening in men younger than 75 • USPSTF: recommends against routine PSA screening • In patients who are interested in screening, physicians should discuss potential benefits and harms
Cervical Cancer • Screen women age 21-65 via Pap smear cytology every 3 yrs OR every 5 yrs via cytology +HPV testing starting at 30 • Recommend against screening in women under 21 • AAFP says screening was low in previously screened women after the age of 65 and USPSTF recommends against it • ACS recommends discontinuing screening at 70, but also notes that a woman who has had 3 or more normal, technically satisfactory Pap tests, and no abnormal Pap tests in the last 10 yrs can safely stop • No screening in women who have had a hysterectomy with cervix removal if no history of high grade lesion
AAA • one-time screening for AAA by ultrasonography in men aged 65 to 75 who have ever smoked. • no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. • recommends against routine screening for AAA in women
GC/Chlamydia • screen for chlamydial infection in all sexually active women ages 24 and younger and in older women who are at increased risk. • The USPSTF recommends against routinely providing screening for chlamydial infection in women ages 25 and older, whether or not they are pregnant, if they are not at increased risk. • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection in men.
Depression • Screen for depression if accurate diagnosis/treatment/follow up is available
Pre-op Evaluation •
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Potential surgical complications: – infectious (wound infections, pneumonia, urinary tract infections, bacterial endocarditis, and sepsis) – cardiac (MI, cardiac arrest, pulmonary edema, and complications of CHF)Most likely to be lethal – pulmonary (pneumonia, atelectasis, bronchitis, respiratory failure)baseline CXR not indicated for surgery pts – thrombosis (peripheral venous thromboembolism, arterial thrombosis) – adverse reactions to anesthesia – gastrointestinal (ulcer disease, ileus, hyperemesis) – psychologic (delirium, exacerbation of existing psychiatric disease). Low-risk procedures: risk of cardiac death less than 1% – breast surgery, cataract surgery, superficial dermatologic surgery, and endoscopy. – generally do not require additional cardiac preoperative testing. Moderate-risk procedures: risk of cardiac death between 1% and 5% – carotid endarterectomies, head and neck, intrathoracic and intraperitoneal, orthopedic, and prostate surgeries. High-risk procedures: risk of cardiac death greater than 5%. – high anticipated blood loss and include aortic or peripheral vascular surgery. Guidelines for preoperative cardiac evaluation: – If a patient has no known heart disease, the evaluator should look at clinical predictors for heart disease. – Major clinical predictors require coronary artery evaluation prior to surgery, and include unstable coronary syndromes, decompensated CHF, significant arrhythmias, or severe valvular disease. – Intermediate clinical predictors: mild angina, a prior MI, compensated CHF, DM, and renal insufficiency. – require looking at the patients’ functional capacity to determine level of preoperative cardiac testing. – In a patient with poor functional capacity, noninvasive testing is recommended. – Recent coronary revascularization is a risk for poor perioperative outcomes. – People with clinically important CAD should defer noncardiac procedures until 6 mo after revascularization – If surgery is necessary within 6 mo of revascularization, pre-op evaluation of coronary arteries is necessary Discontinue NSAIDs/Aspirin 1 wk prior to surgery; stop smoking 8 weeks pre-op
Don’t memorize this
Post-Op Fever • • • • • •
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Five Ws: Water (UTI), Wind (pneumonia), Wound (SSI), Walk (DVT), Wonder drugs (drug fever) Drug Fever: resolution occurs with discontinuation of suspected drug; B-lactams, sulfa, heparin, and amphotericin B Malignant hyperthermia: fever > 104, tachycardia, metabolic acidosis, Ca accumulation in skeletal muscle leading to rigidity; after exposure to halothane or succinylcholine; give antipyretics, oxygen, cooling blankets, and Dantrolene IV UTI risks: BPH, spinal anesthesia, urethral catheter UTI bugs: E. Coli, Proteus, Klebsiella, Staph Epi, pseudomonas, Candida Infection is most likely if 3 or more of the following are true: – Pre-op trauma ASA score >2 Onset on the second post-op day – WBC >10,000 BUN >15 Systemic manifestation such as chills and rigors Fever in first 24 hrs: preexisting infection, bacteremia, intraperitoneal leak, soft tissue infection, TSS, surgical trauma, meds, blood products, malignant hyperthermia – Soft tissue wound infection often due to beta hemolytic strep or clostridium 1 day – 1 week fever: UTI, pneumonia, SSI, catheter-related infection, preexisting infection, MI, EtOH withdrawal, gout, pancreatitis, PE, DVT – Atelectasis causes 90% of pulmonary complications of surgery – Suspect aspiration pneumonia in the elderly 1-4 weeks: SSI, thrombophlebitis, p. colitis, catheter-related, device-related, abscess, meds, DT, PE >1 month: blood transfusion, organ transplant-related, infective endocarditis, SSI, device-related, vascular graft, postpericardiotomy syndrome Cardiothoracic surgery pleural effusion Abdominal surgery ab abscess and pancreatitis OBGYN surgery endometritis, pelvic abscess, pelvic thrombophlebitis Orthopedic surgery surgical site infection Neurosurgery meningitis, DVT
Travel Medicine • Traveler’s diarrhea is most common illness – 30% - 70% of travelers.
• Next most common: URI, viral syndromes, skin conditions, parasitic infections, malaria, hepatitis, and other more rare infections. • CDC does not recommend antibiotic chemoprophylaxis for diarrhea • Heart disease is the most common cause of death while traveling. – 2nd most common (~ 25%) is accidents.
• Yellow fever is the only legally required immunization (only for some countries). • A single inactivated polio vaccine (IPV) booster is recommended for adult travelers who have had primary polio immunization, but who will be traveling to an area where polio is endemic. • Cholera and typhus are not required immunizations for travelers. • Hep A is the most common vaccine-preventable illness acquired by travelers, but vaccination is not required.
Equations: KNOW THEM •
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Sensitivity: probability that a symptom is present given that the person has the disease. The probability that the test is positive, given that the person is sick. – A/A+C Specificity: probability that the symptom is not present given that a person does not have a disease. The probability that the test is not positive, given that the person is not sick. – D/B+D Positive predictive value: probability that a + test correctly identifies an individual who actually has the disease. – A/A+B Negative predictive value: probability that a - test correctly identifies an individual who does not have the disease. – D/C+D
Disease
No Disease
Positive Test
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Negative Test
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Read p. 296-302 in Step Up to Step 2 or the Biostat/Ethics chapter in whatever book you have
Alternative Medicine (+ random facts) • • • • • •
Gingko biloba - dementia Garlic - prevention of heart disease St. John’s wort - depression Saw palmetto - BPH Bee pollen - ↑energy, studies do not clearly indicate benefit. EtOH guidelines: – nonpregnant women: no > 7/week, and no > 3/one occasion. – Men: no > 14/week and no > 4/one occasion. – patients > 65, no >1 drink/day.
• Atropine can decrease secretions and help the “death rattle.” • Ketorolac may help pain, lorazepam may help restlessness, haloperidol and thorazine may help agitation and hallucinations, both of which are also symptoms of impending death.
Insect and Animal Bites • •
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Rocky Mountain spotted fever: red macules on peripheral extremities that become purpuric and confluent. – treat with chloramphenicol that continues 2 to 3 days after the pt is afebrile Lyme disease: slowly spreading annular lesion—erythema chronicum migrans – early disseminated: lymphadenopahty, musculoskeletal pain, arthritis, & pericarditis: treat with IV therapy for 2 to 3 wk – Early localized can be treated with oral antibiotics (amoxicillin or doxycycline) for 14 to 21 days. – Ceftriaxone or cefotaxime and chloramphenicol are options. Tularemia: pain and ulceration at the bite site; treated with streptomycin intramuscularly. Brown recluse spider: local pain and itching, then a hemorrhagic bulla with surrounding erythema and induration. Black widow: mild prick followed by pain at the bite site. Head lice: erythematous popular rash and nits on the hair follicles; itching begins ~ 2 to 3 weeks after infestation – Treat: premethrin 1% and lindane; If treatment fails second-line is 0.5% malathion lotion. Scabies: Sarcoptes scabiei burrow into intertriginous areas, wrists, or areas where clothing is tight next to the skin -treat: oral ivermectin Chigger bites: linear pattern over wrists, ankles, and legs. Tinea corporis: spread by close person-to-person contact (as in school wrestling). – lesion is well-demarcated and annular with central clearing, erythema, and scaling of the periphery. – scraping the lesion and visualizing hyphae with microscopic examination, confirms diagnosis Bedbugs: infest unclothed areas—the neck, hands, and face. Fleas: bite the lower extremities; occur in clusters
Insect and Animal Bites •
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Cat Bite: hospitalization unless very superficial and does not appear infected. – amoxicillin/clavulanic acid is treatment of choice if not hospitalized (5 days prevention, 10 days to treat) – Clindamycin + floroquinolone if allergic to penicillin. Bite wounds on the hands should never be closed primarily. – often produces infection with P multocida. Local reactions occur as a result of toxic properties of venom, were as severe reactions are caused by allergic reaction to venom allergens Stingers should be removed promptly- scrap or brush off; rapid removal is key Local reactions occur almost immediately and last for a few hours – Treat with ice, antihistamine; give tetanus prophylaxis if not vaccinated Large local reactions are IgE mediated and develop over 24-48 hrs – Treat with oral steroids and give tetanus prophylaxis Anaphylaxis: give SQ or IM injection of 0.3-0.5 mL of 1:1000 epinephrine quickly and repeat in 10-15 minutes if needed; observe in the hospital for 12-24 hrs Animal Bites: clean local wound with soap and water, irrigate with saline, debridement of devitalized tissue; tetanus vaccination – moderate-severe wounds from dog/cat/human seen early after injury and without active infection should receive 3-5 days antibiotic prophylaxis (augmentin) where as complicated cellulitis should receive antibiotics for 7-14 days – Cats and dogs carry: staph, strep, anaerobs, pasturella – Humans carry: staph, strep, heomophilus, eilenella, anaerobes
Common Chronic Conditions • KNOW THESE
Diabetes • • •
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screen all > 45 yrs every 3 yrs; start earlier in people with risk factors risks: family hx in a first-degree relative, HTN, obesity, high-risk ethnic groups, previous hx of impaired glucose tolerance, abnormal lipids (↑TG,↓HDL), hx of GDM or a birth of a child > 9 lb. Type I: destrucTon of insulin producing pancreaTc β cells; point mutaTon in HLA DQ with ↑DR 3, 4 – Islet cell antibodies are present for years prior to development of overt type I DM – Prone to metabolize fatsketonesDKA which is characterized by high serum acetone, hyperglycemia, and anion gap metabolic acidosis Type II: stronger familial predisposition; associated with obesity, metabolic syndrome, hyperinsulinemia, HTN, HLD, hyperglycemia, central obesity – Prone to hyperosmolar states because of high blood sugar – Nonketotic hyperosmolar syndromeblood sugar becomes elevated approaching 1000 Gestational DM: more insulin in 3rd trimester; increased insulin resistance caused by elevated chorionic somatomamotropin, progesterone, and estrogens – Prone to develop non-pregnancy related DM II – Risks: >25, native American, African American, Hispanic, south or east asian, pacific islander, BMI >25, hx of glucose intolerance, history of GDM and DM in a first degree family member – Screen all women at 24-28 weeks – Treat with careful diet, and insulin when necessary
Diabetes Diagnosis •
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Diabetic diagnostic criteria: – 2 Random glucose > 200 with classic symptoms (polydipsia, polyuria, polyphagia, frequent infections, weight loss) (easy but low specificity) – 2 Fasting glucose >125 – 2 hr plasma glucose >200 after 75 g glucose load (costly and time consuming) – HGA1c is now used as a diagnostic tool • 6.5 and above is considered diabetic • 5.7-6.4 is considered pre-diabetic – 1-hr GTT is used for pregnant women, with 3-hr GTT being used for those that are + – Urinalyses are highly specific, but have low sensitivity. – Fasting glucose is more accurate and is generally recommended. – C-peptide should be low in Type I DM – Other tests: fasting lipids, serum creatinine, UA, urine microalbumin:creatinine ratios, dilated eye exam, regular foot exams, EKG, TSH Treatment goals: HGA1c <6.5%, fasting blood sugar < 120, 2 hr post-prandial sugar <140; BP <130/80, LDL <70 (old recommendation said <100); pts should be immunized with pneumococcal vaccine and annual influenza
Diabetes Management • • • • • • •
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Lispro/Aspart: rapid acting15 min onset, 30-90 min peak, 3-5 hr duration Regular: short acting30-50 min onset, 60-120 min peak, 5-8 hr duration NPH: intermediate1-3 hr onset, 7-15 hr peak, 18-24 hr duration Glargine/Detemir: long acting1 hr onset, no peak, 24 hr duration 40% - 50% of daily insulin should be Lantus, remaining 50% - 60% is Lispro before each meal, based on a preprandial glucose Diet and exercise: key components of type II DM treatment; 10% weight loss is a goal for most Metformin: – ↓glucose output during liver gluconeogenesis; improves insulin sensitivity in liver & muscle; can lower HGA1c 1.5-2%; no potential for hypoglycemia, reduces insulin levels, potentially helps wt loss, reduces TGs and LDL; popular first line drug – side effects: renal insufficiency (contraindicated if Cr >1.5), hepatic insufficiency, or CHF; contraindicated in nursing mothers Sulfonylureas: insulin secreatagogues that sTmulate beta cells in the pancreas to secrete insulin; 2% ↓in HGA1c; tendency to gain weight & lose effectiveness over time; risk for hypoglycemia Thiazolidinediones: improve insulin sensitivity in muscle and adipose tissue; decrease hepatic gluconeogenesis and increased peripheral glucose utilization; decrease in TG and increase in HDL; metabolized by the liver; may have slight increase in LDL, weight gain, and slow onset of action; require 12 weeks to become fully effective – ↓insulin resistance and sensiTze peripheral Tssues to insulin; good choice for those with insulin insensiTvity. – can be used as monotherapy, with insulin or in combination with metformin. – can ↓ HbA 1C by 1 - 2 %; can ↓the insulin dosage by 30% - 50%. – Edema is a common side effect, occurring in about 3% to 4 %; Other side effects include anemia & weight gain. Meglitinides: – short acting secretagogues that increase insulin secretion; taken no more than 2 hr before meals because of rapid onset – useful if blood sugars vary at mealTme; risk of hypoglycemia; can ↓ Hb A 1C by 0.5% -2% and are most valuable if fasting sugar is adequate, but postprandial sugars are high – should not be used in pts with hepatic dysfunction but safe in renal failure
Diabetes Management & Complications Alpha glucosidase inhibitors – delay carb absorption by inhibiting alpha glucosidase in the small intestine which decreases postprandial hyperglycemia; side effects are GI related; contraindicated in ketoacidosis and hepaTc disorders; can ↓the Hb A 1C by 0.7% to 1%; avoid if creatinine > 2.0 mg/dL. • -GLP-1 – gut-derived incretin hormone that stimulates insulin & suppresses glucagon secretion, delays gastric emptying, and reduces appetite and food intake. • ACE inhibitors are first choice for BP controlindicated for DM pts with systolic BP > 100 mm Hg. – can be used irrespective of creatinine levels, though K should be monitored as creatinine rises. – Providers do not need to wait to see microalbuminuria prior to initiating therapy. • Statins are drug of choice in treating hyperlipidemia in diabetes. – ↓ risk of coronary events and are excellent in ↓LDL. – less effect on the triglyceride levels, but in many patients, the decrease is enough to get patients to goal. • Niacin will ↓triglycerides, ↑HDL, and ↓LDL, but may ↑insulin resistance • Fibric acid derivaTves ↓triglycerides and ↑HDL, but have minimal effects on LDL. • Bile acid resins sequester bile acids in the GI tract. They can ↑triglyceride levels and are generally not used in diabeTcs. • Glycemic control is dependent on the total caloric intake, not the type of calorie taken in. Renal complications: • first indicaTon of renal compromise is an ↑in GFR followed by microalbuminuria. • ACE inhibitors have been shown to ↓ESRD and death by 41% in DM. • Lifestyle changes: glucose control, weight loss, and decreased protein intake can help • Nephrology referral is indicated if creatinine is ↑, or macro/macroalbuminuria despite maximal therapy. Diabetic retinopathy: • leading cause of blindness in the United States. • risk ↑with length of Tme pt has had DM, and the condiTon worsens with ↑Hb A 1C levels. • mild background abnormalities ↑vascular permeability & hemorrhageProliferative changes •
Lipid Screening • Men: – Screen if >35 if no risk factors – Screen beginning at 20 if CAD risk factors
• Women: – Screen if > 45 if no risk factor – Screen beginning at 20 if CAD risk factors
Dyslipidemia 5 factors that determine LDL goal: smoking, HTN, low HDL, age (>45 men, >55 women), family history of premature CHD (male <55, female <65); high HDL is considered a negative risk • For pts with known CAD or DM treatment goal for LDL cholesterol is <70 mg/dL. • For a pt has no known CAD, the 10-year risk for CAD should be estimated using a NCEP risk calculator • If the 10-year risk > 20% LDL treatment goal should be <100 mg/dL. • If the risk is between 10% - 20% LDL treatment goal should be < 130 mg/dL. • If the risk is < 10% treatment goal should be < 160 mg/dL. • losing weight, a person can expect to ↑HDL by 5 - 10 points. • Smoking cessation increases HDL by 5 to 10 mg/dL, but does not affect LDL, VLDL, or triglycerides • AdopTng an exercise program ↑HDL by up to 15 points. • EaTng oat bran and decreasing life stress can ↓LDL, but is not likely to ↑HDL. • TG level is lowest in the fasTng state and ↑by an ~ 50 mg/dL postprandially. • As TG level ↑, the total and LDL cholesterol each ↓; total & LDL cholesterol are ↑when fasTng. HDL varies little • low HDL is the best predictor of an adverse outcome; However, high HDL does not guarantee immunity from CAD LDL <100 = optimal 100-129 = near optimal 130-159 = borderline high 160-189 = high >190 = very high Total cholesterol: <200 = desirable 200-239= borderline high 240 or greater = high HDL: <40 = low 60 or greater = high •
Dyslipidemia Treatment • •
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Fish oil: – high in omega-3 Fas and has been shown to be beneficial in lowering cholesterol; decreasing secretion of triglycerides by the liver. Cholesterol absorption Blocker: Ezetemibe (Zetia): – ↓cholesterol by interfering with the absorpTon of cholesterol in the gut. – ↓LDL and TGs only modestly. When added to a low-dose statin, ↓LDL as much as the max statin dose – Side effects: abdominal pain, diarrhea – Contraindications: hepatic insufficiency/active liver disease Statins: – rosuvastatin is best at lowering LDL (25-50%); mild decrease in TGs – first line therapy to reduce LDL, coronary events, strokes, cardiac death, and mortality of all causes; must monitor liver enzymes – Decrease LDL; some increase in HDL and some decrease in TG – Side effects = myopathy, myalgia, increased liver enzymes – Contraindicated in liver disease or with other p450 inhibitors, cyclosporine, macrolids, antifungals Bile acid sequestrants: cholestyramine, colestipol, colesevelam – Decrease LDL, increase HDL, no change in TG – Side effects = GI distress, constipation, decreased absorption – Contraindicated in dysbetalipoproteinemia or if TG > 400 Nicotinic acids: niacin – Increase HDL, some decrease in LDL and TGs, decreased mortality – Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity; NSAIDs block flushing – Contraindications: liver disease, severe gout; caution with DM, PUD Fibric Acids: Gemfibrozil, fenofibrate, clofibrate – Increase HDL, decrease LDL, decrease TGs – Side effects: dyspepsia, gallstones, myopathy – Contraindications: severe renal disease, severe hepatic disease
HTN • •
CVD risk double with each increase in blood pressure of 20/10 above 115/75 Diagnose: average of 2 BPs at 2 or more office visits – – – –
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Normal: <120/<80 Pre-hypertension: 120-139/80-90 Stage I hypertension: 140-159/90-99 Stage II hypertension: >160/100
Initial testing: electrolytes, Ca, Hct, UA, EKG Treatment goal: <140/90, and <130/80 for those with DM or kidney disease Lifestyle Modifications: DASH diet (high K and high Ca), no more than 2 EtOH drinks per day, increased physical activity, weight reduction Medication: thiazide diuretic is first line therapy in most settings – – – – – –
DM: ACE, ARB, diuretic, CCB, BB High risk for CAD: ACE, BB, diuretic, CCB CHF: ACE, ARB, BB, diuretic, aldosterone antagonist Post-MI: ACE, BB, aldosterone antagonist CKD: ACE, ARB CVA prevention: ACE, diuretic
HTN • • • • • •
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Weight reduction is most beneficial – systolic BP can ↓from up to 20 mm Hg for each 10 lb of weight lost. A DASH diet can ↓BP between 8 - 14 mm Hg. Dietary Na reducTon, ↑exercise and moderaTon of EtOH can lower systolic BP < 10 mm Hg. low-dose diuretics are most effective first-line treatment for preventing CV morbidity & mortality. PROGRESS study found that ACEI and diuretic in combo are effective in preventing recurrent stroke. Stage 2 hypertension: – 2-drug therapy is indicatedmost common is thiazide diuretic + ACE inhibitor, ARB, β-blocker, or CCB. coarctation of aortaHTN in arms, but is low or normal in the legs; Femoral pulsations are weak or absent. Correction should be considered if the gradient is > 20 mm Hg, not based on level of BP. renal artery stenosisACE-inhibitor renal scan or renal MRA would evaluate this. British Hypertension Society developed recommendations: persons < 55 years who are not black start an ACE inhibitor as first-line therapy (A). β-Blockers (B) can be used in this group, but are no longer considered ideal first-line therapy. persons who are > 55 years or black, the first-line therapy is either a CCB (C) or a diuretic (D).
Obesity – Underweight <18.5 Normal 18.5-24.9 Overweight: 25-29.9 – Obesity I: 30-34.9 Obesity II: 35-39.9 Extreme Obesity: >40 • Increased body weight is a major risk factor for disease and premature death • Treatment: begin treatment if BMI > 25 or waist-hip ratio >.9 in men or >.85 in women • Dietary restriction, physical activity, behavior therapy only 20% of pts will lose 20 lb and maintain the weight loss for 2 years • <1% of obese pts have a secondary nonpsychiatric cause for their obesity. • Hypothyroidism and Cushing syndrome are important examples that can generally be detected by history and physical • Appetite suppressants can be amphetamines (carry a significant risk for abuse) or nonamphetamine. • Medications do not demonstrate maintenance of weight loss once the discontinued. • Orlistat is a GI lipase inhibitor & boasts a 9% average weight loss, but a significant regain after discontinued. • Phentermine: noradrenergic agonist that allows its users to lose 3 to 4 kg > placebo, but regain is also common. • Sibutramine: mixed noradrenergic/serotonergic agonist w/5- 8% wt loss, but significant regain of wt once off Roux-en-Y gastric bypass. • procedure can result in up to 50% loss of the initial weight in some studies. • Complications are common and occur with about 40% of the cases and nutritional deficiency is common • limited to those with a BMI >40 kg/m 2, or >35 kg/m 2 if there are obesity-related comorbidities present. Metabolic Syndrome: insulin resistance characterized by abdominal obesity, dyslipidemia, elevated BP, and impaired fasting glucose • Waist > 102 cm in men, >88 cm in women • Triglycerides >150 • HDL <40 in men and <50 in women • BP >130/85 • Fasting glucose >110
Osteoporsis • poor acquisition of bone mass or accelerated bone loss. • African Americans are less at risk than Caucasians or Asians. • Obesity is considered to be protecTve because of ↑estrogen producTon, as long as the person is not sedentary. • Hyperthyroidism is a common cause of accelerated bone loss. • Weight-bearing acTvity is known to ↓bone loss. Primary osteoporosis • deterioration of bone mass not associated w/other chronic illnesses or problems; imaging studies are diagnostic • Increased risk with age, tobacco, low body weight, Caucasian or Asian, family hx, low Ca, sedentary lifestyle • Dexa scan after age 65, or 60 if high risk • Plain radiographs are not sensiTve enough to diagnose osteoporosis unTl total density has ↓by 50%. • DEXA scanning is most precise and is the test of choice.: T-score <-2.5 = osteoporosis; -1 to -2.5 = osteopenia • A T-score > 2.5 standard deviaJons below the mean (a score of −2.5 or lower) indicates osteoporosis. • Calcitonin directly inhibits osteoclastic bone resorption and is considered a reasonable treatment alternative for pts in whom estrogen replacement therapy is not recommended; also produces an analgesic effect • Bisphosphonates work by binding to the bone surface and inhibiting osteoclastic activity. • Vitamin D increases absorption of calcium in the GI tract. • Estrogen and selective estrogen receptor modulators (raloxifene or Evista) block the activity of cytokines. • Fluoride stimulates osteoblasts, but does not result in the formation of normal bone. • Osteoporosis: supplement 1200 mg Ca and 400-800 IU vit D daily; weight bearing exercise • Treatments: bisphosphonates, alendronate, risedronate, ibandronate, calcitonin, estrogen, PTH, raloxifene
Anemia • • • •
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Most common is Fe deficiency (Fe is absorbed in duodenum) MCV > 80 macrocytic; MCV < 80 microcytic Hemolysis decreased haptoglobin, increased LDH, increased unconjugated bilirubin microcytic: Fe deficiency, anemia of chronic disease, thalassemia, sideroblastic anemias. – Iron deficiency: RDW would be ↑due to variaTon in cell size. – Sideroblastic anemia: MCV would be normal, high, or low, but the red cells are dimorphic. – thalassemia: RDW would be normal because the red cells are uniformly small. B12 def: anemia, pallor, wt loss, fatigue, glossitis, neuro symptoms; usually, treatment is parenteral vitamin B 12 replacement weekly for 1 month, often with concurrent administration of folic acid. – Increased methylmalonic acid and homocysteine Folate Def: increased homocysteine Sickle Cell: AR trait seen in African, Mediterranean, or Asian heritage. – found before age 6 in 90% of patients, with acute pain crises as most common presentation. – Prophylaxis for pain crises involves ensuring adequate oxygenation and hydration. – Immunize against streptococcal infection; daily prophylaxis with penicillin until age 5. – Chronic analgesics and scheduled transfusions have not been shown to reduce pain crises.
Urinary Incontinence • Symptomatic bacteruria may cause incontinence in the elderly • CCBs urinary retention. • Diuretics ↑frequency and urgency, but usually not leakage. • β-Blockers inhibit bladder relaxation and therefore can cause both urinary leakage and urgency. • Hyperglycemia secondary incontinence because of polyuria • α-Blockers urethral sphincter relaxation and can cause urinary leakage • Stool impaction causative in up to 10% of pts with incontinence; disimpaction may restore continence. Urge Incontinence: • most common type of incontinence in the elderly. • detrusor hyperactivitystrong urge followed by an involuntary loss of urine. • anticholinergic medications are the drugs of choice -oxybutynin(Ditropan) and tolterodine (Detrol) Functional incontinence: • limitation that does not allow the pt to void in the bathroom (bed rest, paralysis, dementia); not a urinary tract problem Stress incontinence • loss of urine associated with ↑intra-abdominal pressure(sneezing, coughing, laughing, exercising), more common in women • caused by urethral hypermobility resulting in weakness of the pelvic floor musculature (Q tip test) • Kegel exercises are designed to strengthen the pelvic floor musculature. • Pseudoephedrine has been shown to help stress incontinence, Overflow incontinence: • overdistention of the bladder; loss of the ability to empty the bladder, usually due to neurogenic bladder (longstanding diabetes, alcoholism, disk disease) or because of outlet obstruction (prostatic enlargement). • frequent or constant leakage of small amount, but occasionally a large amount of urine is lost without warning. • postvoid residual < 50 mL = normal. A postvoid residual > 200 mL = inadequate bladder emptying
Sexual Dysfunction • • • • • • • • • • • • • • • • • •
In pts with ↓sex drive with no other complaints and no exam findings, assessment of hormone status is indicated. Testosterone levels should be checked in the morning, when they peak. Free testosterone is a more accurate measure of androgen status, as it measures bioavailable testosterone. -if low, workup should continue to get FSH, LH, PRL -if FSH and LH are low, but PRL normal, diagnosis is pituitary or hypothalamic failure -if FSH and LH are high, and PRL normal, diagnosis is testicular failure Prolactin (PRL) -if FSH and LH are low and PRL is high, 40% chance of pituitary adenomaget CT or MRI The TSH and prolactin levels may be indicated in the presence of other complaints or physical findings. TCA & SSRIs sexual dysfunction. Bupropion actually ↓the orgasm threshold and is least likely to cause sexual dysfunction. Premature ejaculation is the most common sexual dysfunction in men, affecting about 29% of the general population. Fluoxetine raises the threshold for orgasm, making it an effective treatment option. A penile brachial index can be performed to evaluate for significant vascular disease in patients with ED, nocturnal penile tumescence evaluation would be done to eliminate psychologic factors that inhibit arousal hypoactive sexual desire disorder Most commonly, this is a result of relationship problems, but growing evidence does suggest androgen deficiency may play a role in some women. Sexual aversion disorder is an extreme aversion to and avoidance of genital contact with a sexual partner. Sexual arousal disorder refers to the inability to maintain an adequate physiologic sexual excitement response. Dyspareunia refers to genital pain associated with intercourse.
Headache Red Flag signs: • onset aZer age 50, sudden onset, ↑in severity or frequency, signs of systemic disease, focal neuro symptoms (except those consistent with a visual aura), papilledema, or a headache after trauma. Cluster Headache: • Unilateral and orbital/temporal • Deep, excruciating pain for min-hours; peaks in 10-15 minutes and lasts 2 hrs w/o treatment • Associated with ipsilateral autonomic signs • More common in men • therapy is to provide relief from acute attacks, then to suppress headaches during the symptomatic period • Nifedipine has been shown to be effective, as has prednisone, indomethacin, and lithium. • The mainstay of abortive treatment is oxygen and triptans • Verapamil, lithium, divalproex, methysergide and prednisone may be used for prophylaxis • SQ or intranasal serotonin antagonists have been more efficacious. IV or IM ergotamine has been helpful Tension Headaches: • most common of all headaches encountered in clinical practice. • pericranial muscle tenderness with bilateral bandlike distribution of pain • episodes last from 30 min to several days, and headaches should occur < 15 times per month. • requires at least 2 of the following : Pressure/tightness, Bilateral, Mild to moderate, Not aggravated by activity, There is generally no nausea, Either photophobia or phonophobia may be present, but not both. • trial of NSAIDs may be appropriate, with follow-up if there is no improvement.
Migraine Headache • •
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moderate to severe headache with a pulsating quality Signs/Symptoms: unilateral location; nausea and/or vomiting; photophobia; phonophobia; worsening with activity; multiple attacks lasting for 4 hrs to 3 days; absence of history or physical exam findings that would cause headache Common migraine: headache without aura; most frequent Classic migraine: headache with aura Need neuroimaging ifrapidly increasing headache frequency, lack of coordination, focal neuro symptoms, awakened from sleep with headache Red Flag signs: sudden onset, increasing in severity and frequency, after age 50, risk factors for HIV or cancer, systemic illness signs, focal neuro signs, papilledema, post head trauma Prevention: amitriptyline, propranolol, timolol, divalproex sodium β-blockers are the most studied drug therapy, and are effective. Verapamil is the only CCB that studies show to have a prophylactic effect. Abortive/Acute therapy: if attacks are less than 2-4 times/monthErgotamines and triptans goal of prophylactic migraine therapy is to reduce the frequency of headache by 50% use TCAs
Wheezing • •
first episode of wheezing get a chest x-ray. Acute viral respiratory tract infections cause up to 50% of wheezing episodes in children < 2 years –
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Risk factors: fall or winter season, history of atopy, daycare, and passive smoke exposure.
Pneumonia causes 33% - 50% of wheezing children, and most are also caused by viruses as well. Bronchiolitis causes < 5% of episodes of wheezing, but is important, especially in preterm infants. Asthma is common in children, but is not diagnosed after one episode of wheezing. Wheezing is commonly heard in patients with CHF. –
Risk factors include HTN, glucose intolerance, and smoking.
• Treatment should begin with diuresis. GERD – –
common cause of wheezing in the pediatric population. gold standard test is a 24-hour pH probe.
Asthma: • In pts with known asthma a CXR is indicated if pt has fever, rhonchi, or sputum to r/o pneumonia. • Peak flows do not confirm diagnosis of asthma, but are useful to monitor the status of known lung disease. • PFTs may be needed, but are usually done in a pulmonary laboratory.
Asthma genetic component, but the strongest identified predisposing factor for its development is atopy. Obesity is increasingly being recognized as a risk factor. most important component in the diagnosis of asthma is history. Pts typically have recurrent episodes of wheezing, but not all asthma includes wheezing, and not all wheezing is asthma. Cough is the only symptom in cough-variant asthma. CXR is useful to rule-out other causes; PFT is confirmatory, not diagnostic; Provocative testing for the rare pt in whom the diagnosis is in question, but should be used cautiously, as life-threatening bronchospasm may occur. • infections predispose to acute asthma exacerbations; However, use of empiric antibiotics is not recommended. • Peak flow measurements parallel FEV 1 and are an easy and inexpensive way to monitor asthma control. • 80% - 100% of the pts personal best are in the “green zone,” and indicate that the patient is doing well. • 50% - 80% of personal best are “yellow zone,” and are a warning to consider a step-up in therapy (review of medication technique, adherence, and environmental control, or use additional medication). • < 50% of the personal best are an indicator that the patient needs immediate medical attention. Mild intermittent: symptoms < 2x a week, with brief exacerbations, and with night-time symptoms < 2x a month are classified as Mild persistent: symptoms > 2x a week but < 1x a day; sometimes affect usual activity. Night-time symptoms occur > 2x a month Moderate persistent: daily symptoms & use of short-acting inhaler, with exacerbations that affect activity and may last for days. Night-time symptoms occur at least weekly. Severe persistent: continual symptoms that limit physical activities, with frequent exacerbations and night-time symptoms. Treatment: • Inhaled corticosteroids are preferred first-line agents for all pts with persistent asthma. • Long-acting β-agonists do not impact airway inflammation and should not be used without a corticosteroid. • A leukotriene receptor antagonist is a “second best” choice; improves lung function and rescue inhaler use • Inhaled corticosteroids and leukotriene antagonists have replaced cromolyn in current asthma therapy.
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COPD • • • • • • • • • • • •
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sensitive measure to diagnose COPD is the FEV 1:FVC ratio. – normal if it is 70% or more of the predicted value based on the pts gender, age, and height. most important intervention in smokers with COPD is to encourage smoking cessation. only drug therapy shown to improve COPD progression is supplemental O2 in those patients that are hypoxemic. Benefits of O2: longer survival, ↓hospitalizaTons, and be\er quality of life. Bronchodilators do not alter the course of decline in function, and COPD is not a steroid responsive disease. bonchodilators offer improvement in symptoms, exercise tolerance, and overall health status most commonly prescribed bronchodilators are anticholinergic ipratripium bromide and beta agonists Ipratropium is preferred as first-line because of longer duration and absence of sympathomimetic effects. Inhaled corticosteroids alone should not be first-line because pts receive more benefit from bronchodilators. Theophylline is a fourth-line therapy for pts who do not achieve adequate symptom control oxygen is not indicated until there is significant evidence of hypoxemia. Antibiotics can be useful to treat infection & exacerbation, but no evidence exists to support their use chronically. – improve outcomes when treating acute exacerbations – azithromycin, ciprofloxacin, and amoxicillin-clavulanate were found to be most effective spirometry is necessary to make the diagnosis, assess the disease severity, and monitor response to treatment.
COPD • •
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Asthma: presents earlier; may or may not be associated with smoking; episodic exacerbations with return to normal function COPD: presents midlife or later, long smoking history, slowly progressive; PFTs never return to normal. – Smoking associated with 90% of COPD cases – Non smoking causes = passive smoking, occupational exposures, alpha-1 antitrypsin deficiency – Baseline cough with white mucus, worsening dyspnea – Barrel chest, distant heart sounds, lung hyperinflation, flattened diaphragms on xray – CXR is normal until the disease is advanced – Primary diagnosis made by spirometry: FEV1/FVC < 0.7 fixed obstruction – FEV decreases by at least 50% by the time symptoms are present Chronic Bronchitis: cough & sputum production on most days for at least 3 mo during at least 2 consecutive yrs Emphysema: SOB caused by enlargement of respiratory bronchioles and alveoli caused by destruction of lung tissue Management of Stable COPD: quit smoking, pneumococcal and influenza vaccination – Stage I: mild FEV1 >80%; give short acting bronchodilator (albuterol and ipratropium) – Stage II: moderate; FEV 1 30-50%; give long acting bronchodilator (salmeterol and tiotropium) – Stage III: severe: FEV1 30-50%; inhaled steroids reduce the frequency of exacerbations – Stage IV: very severe: FEV1<30% or <50% with hypoxemia (SaO2 <88%; PaO2 <55); steroids + O2 Management of Acute COPD: most commonly caused by viral/bacterial infections – Keep O2 > 90% or 60 mmHg – Short acting bronchodilators (beta agonist + anticholinergic) – Systemic steroids shorten the course of exacerbation and reduce risk of relapse – If increased sputum or purulent sputum, give antibiotics • Pneumococcus, H. influenze, M. caterrhalis, Klebsiella, Pseudomonas
Cough • • • • • •
>8 wks = chronic common causes of chronic cough: asthma, postnasal drainage, smoking, and GERD acute: asthma exacerbation, acute bronchitis, aspiration, irritants (smoke, pollutants), allergic rhinitis, uncomplicated pneumonia, sinusitis with postnasal drip, and viral URI. ACEI, amiodarone, nitrofurantoin cause cough Centrally acting cough suppresant codine, dextromethrophan Chronic Bronchitis: – productive cough for at least 3 mo of the year for at least 2 consecutive years – most common cause of chronic cough in smokers.
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Acute bronchitis: – antibiotics are not indicated for uncomplicated acute bronchitis, regardless of duration of the cough. Antibiotics should be reserved for pts with significant COPD and CHF, those who are very ill-appearing, or the elderly.
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Pertussis: – Antibiotics do not alter the course unless initiated early in the illness; antibiotics do prevent transmission and ↓ need for respiratory isolaTon from 4 wks to 1 wk and are therefore recommended. – first-line is erythromycin x 14 days, or azithromycin x 5 days. Amoxicillin & amoxicillin/clavulanate not effective.
Pain • • • • • • • • •
Chronic pain recurrent or persistent pain lasting > 3 months; affects ~ 15% of the US population. Nociceptive pain stems from tissue damage (such as arthritis and/or tumor). Neuropathic pain is from sustained transmission of pain signals w/o ongoing tissue damage. It is described as numbness (hypoesthesia), ↑sensiTvity (hyperesthesia), pins & needles (paresthesia), or severe from innocuous stimuli (allodynia). NSAIDs are an excellent first-line medication for mild to moderate pain, especially w/ an inflammatory component Celecoxib (COX-2 inhibitor) may have better side effects, but is not first-line except in elderly or pts who failed NSAIDs. Tramadol: centrally acting synthetic opioid agonist that binds to μ-opioid receptors & inhibits serotonin & norepinepherine reuptake. It should not be a first-line option. TCAs like amitriptyline & anticonvulsants like gabapentin may work well in neuropathic pain, they are less well-studied in nociceptive pain and therefore are not good first-line agents. continued escalating opioid doses worsened analgesic response because NMDA receptors are upregulated and lead to tolerance, while pain receptors become increasingly more sensitive to stimuli. In situations of tolerance, switch from one opioid to another, starting at half the equivalent dose of the alternative med.
Fatigue • Mononucleosis: often mistaken for streptococcal pharyngitis. – symptoms of sore throat, fatigue, fever, and adenopathy. – If given ampicillin (and other penicillin derivatives), up to 100% may develop rash
• Fatigue 3 months is more likely related to psychologic factors (depression, anxiety, stress, or adjustment reactions). • 3 general categories of fatigue: physiologic, physical, and psychologic. • Physiologic fatigue is because of overwork, lack of sleep, or a defined physical stressor like pregnancy. • Chronic fatigue syndrome & chronic idiopathic fatigue are distinct diagnoses that require > 6 months of symptoms. • Depression is 1 of the most common diagnoses in pts w/fatigue, especially when denying weakness/hypersomnolence
Sleep • Propranolol is known to cause nightmares • Hydrochlorothiazide can cause nocturia that inhibits sleep, • Alcohol causes excessive wakefulness, and allows people to fall asleep, but interferes with the ability to stay asleep. • drugs of choice for transient sleep onset problems are zolpidem (Ambien) or eszopiclone (Lunesta). • For sleep maintenance problems, zaleplon (Sonata) may be used. • Melatonin has been shown to help with adjustments to the sleep-wake cycle (ie, jet lag, shift work). • Benadryl can cause excessive somnolence, and may help with sleep onset, but not maintenance. • Good sleep hygiene: – wake up at a regular hour, exercise daily (not before bed), control sleep environment, light snack before bed, limit/eliminate EtOH, caffeine & nicotine, go to bed when sleepy, use bed for sleep & intimacy only, get out of bed if not asleep in 15-30 min
Acute Conditions • These questions will be similar to your internal medicine questions, but will focus more on risk factors/prevention/follow-up
Acute GI conditions Appendicitis: • Pain from an acute appendicitis usually starts in the periumbilical region before moving to the RLQ. • Only 22% of elderly patients with appendicitis present with classic symptoms, making the diagnosis more difficult. Pancreatitis: • generally settles in the mid-epigastric region with radiation to the back and is associated with nausea and vomiting. • Gallstones cause the majority of cases ; EtOH causes ~30% of the cases; 10 - 30% are idiopathic. • Less common causes: hyperCa, hyperlipidemia, trauma, medications, infections, and instrumentation (ERCP). • Ranson’s criteria assess the severity and prognosis of pancreatitis. On admission, 5 criteria are considered. – age > 55, WBC > 16,000/mm, glucose > 200 mg/dL, LDH > 350 IU/L, AST is > 250 U/L. • 6 other criteria reflect the development of complicaTons and include a ↓in Hct > 10, BUN ↑> 5 Ca < 8, PaO 2 < 60 mm Hg, base deficit > 4 mEq/L, and a fluid sequestration > 6 L. • These are assessed during the first 48 hours of admission. Gallstones: • Gallbladder pain is typically in the epigastric or right upper quadrant and radiates to the scapula. Cholecystitis: • Sudden cessation of inspiration during deep palpation of RUQ is Murphy signsuggests acute cholecystitis Choledocolithiasis: • ERCP is the gold standard for diagnosis and treatment of choledocholithiasis • usually performed in the setting of an acute cholecystitis with increased liver enzymes, amylase, or lipase.
Acute GI Conditions • Diverticulitis: – – – – –
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CT abdomen is test of choice f/u with colonoscopy 6-8 wk after symptoms clear Meperidine for pian relief Outpt abx: amox/Clav, TMP-SMX, Cipro Bleeding generally stops on its own
H. Pylori Gastritis: clarithro/amoxi/metronidazole + PPI Non H. Pylori Gastritis: H2 blocker/PPI Dysmotility: metoclopramide Non-ulcer dyspepsia: avoid food/meals that aggravate
Peptic Ulcer Disease • • • •
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risk factors: H.pylori, NSAIDs, smoking, personal or family history of PUD symptoms: epigastric pain improved with food; pain a few hours after eating; gradual onset; nocturnal symptoms Infection with H pylori is the leading cause of PUD, with use of NSAIDs the second most common H. Pylori: corkscrew shaped gram negative bacillus causing most non-NSAID related ulcers – Associated with gastric cancer – Test for H. Pylori by urea breath test or stool antigen testing – Serologic testing is very sensitive but cannot distinguish between active and treated infection – For those who test negative for H. Pylori, begin empiric therapy with PPI for 4-8 wks – Treatment: PPI + clarithromycin + amoxicillin Early endoscopy should be considered for pts with new-onset dyspepsia who are older than 55 yrs or who have symptoms that may be associated with upper GI malignancy – Alarm symptoms: weight loss, progressive dysphagia, recurrent vomiting, GI bleeding, family hx of cancer GERD is midepigastric and generally does not radiate. Reflux can be appropriately diagnosed by medical history and by evaluating the response to treatment. PUD management: CBC, liver enzymes, amylase, lipase, EKG, chest xray, ab U/S, pregnancy test Patients older than 50 with blood in the stool should undergo colonoscopy regardless of upper endoscopic findings
GI Conditions IBS: • constipation, diarrhea, alternating; lower ab pain, particularly in LLQ, intermittent cramping; may have mucus; may feel bloated • Rome Consensus Committee for IBS – symptoms for at least 12 wks (not necessarily consecutive) in the previous 12 months, and pain that is characterized by 2 of the following 3: (1) relieved by defecation, (2) onset is associated with a change in stool frequency, or (3) onset is associated with a change in the form or appearance of stool. • Alarm features: fever, anemia, weight loss, hematochezia, melena, bloody diarrhea, family history of colon cancer or IBD • Treat: antispasmodics (dicyclomine, homoscyamine), low dose TCAs, SSRI if depression or anxiety is present; increased fiver intake; loperamide to reduce frequency of stools; tegaserod for constipation; alosetron for diarrhea •
Esophagus: Esophageal spasm is often referred higher in the chest.
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Renal Calculi: Pain from renal calculi often radiates to the shoulder.
Nausea and Vomiting Metoclopramide improve gastric motility; can also cause diarrhea and extrapyramidal reactions phenothiazines (Compazine and Phenergan) cause drowsiness, dry mouth, and dizziness. Zofran is a serotonin receptor antagonist, and may cause dizziness and headache. ileusmild pain, followed by the acute onset of distension, nausea, vomiting, hyperactive bowel sounds nausea before eating in AM pregnancy, uremia, EtOH withdrawal, ↑ICP (meningiTs or space-occupying lesions) nausea after eating Gastroparesis and pancreatitis Cholelithiasisnausea, vomiting, and pain after eating fatty foods; RUQ ultrasound to identify stones in the gallbladder. Vestibular disorders nausea without any clear association with meals or time of day. Psychogenic vomiting: suspected in pts who are able to maintain adequate nutrition despite chronic symptoms; seen during social stress or in pts with a past history of a psychiatric disorder. Viral gastroenteritis: • Norwalk virus, reoviruses, and adenoviruses are common causes. • Symptoms begin acutely and are associated with typical viral syndrome symptoms. • self-limited, and will resolve within 5 days. • Oral rehydration is indicated as long as there are no signs of severe dehydration. Pancreatitis • likely due to gallstones or EtOH. • elevated serum amylase and lipase; CBC is likely normal • Elevated ALT is more suggestive of gallstone pancreatitis and is less likely when alcohol or hypertriglyceridemia • acute onset of significant nausea, vomiting, and epigastric pain. • symptoms occur after eating, and are improved when the patient does not eat. Pyloric stenosis • weight loss, dehydration, and occasionally a palpable olive mass in the epigastric area. • usually identified before 7 weeks of age.
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GI Bleeding • Upper endoscopy is the best diagnostic testing option in the setting of an acute upper GI bleed. Intussusception: • 2nd most common cause of lower GI bleeding in children • caused by the involution of one bowel segment into another bowel segment. Meckel diverticulum: • most common cause of significant GI bleeding in children. • 2% of the population; male-to-female = 2:1; 2 ft from ileocecal valve; 2 in long. 2% of cases have complications. • Most are asymptomatic, but a common presentation is painless large-volume intestinal hemorrhage. • noninvasive diagnostic modality is the technetium scan, often called the Meckel scan. Diverticulosis: • 5% - 15% with colonic diverticulosis develop severe diverticular bleeding. • It is unusual to find the source of bleeding during colonoscopy; tagged RBC scan should be the next step External Hemorrhoid: • arising distal to the dentate line. • When they thromboseacute pain and are hard and nodular on physical exam. • excision in the office w/local anesthesiaeliminates pain immediately and eliminates the risk of reoccurrence Anal Fissure: • split in the anoderm of the anal canal. It generally occurs after the passage of a hard bowel movement. • excruciating pain on defecation with blood found on the toilet paper. • After the BM, the patient may complain of an ache or spasm that resolves after a couple of hours.
Lower GI Bleeding • • •
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Clinical: weakness, fatigability, pallor, chest pain, dizziness, tachycardia, hypotension, orthostasis Diagnostics: colonoscopy, angiography, technetium labeled or RBC scan, NG tube aspiration Hemorrhoids: most common cause of lower GI bleeding – Dilated veins in the hemorrhoidal plexus; internal above dentate line – Cause: constipation, straining, pregnancy, prolonged sitting (truck drivers) – Externalpainful, irritable, palpable lump – Internalbleeding and prolapsed – Treat: high fiber diet, stool softeners, surgery only when necessary Diverticular disease: – Usually asymptomatic, or may present with painless bleeding that stops spontaneously – If asymptomatic, treat with high fiber diet – DiverticulitisLLQ pain, fever, nausea, diarrhea, constipation; treat with bowel rest and Abx IBD: – UC causes continuous inflammation of the large bowel; higher risk for colon cancer – Crohn’s causes focal inflammation anywhere n the GI tract – Both may have numerous extraintestinal manifestation – Treat: antidiarrheal meds, anti-inflammatory meds, immunosuppressive meds, colectomy Colon Neoplasms: – Hyperplastic polyps are small, smooth growths of no prognostic significance – Adenomatous polyps are benign growths with malignant potential • Tubular, tubulovillous, villous – Larger polyps have higher risk of bleeding and becoming malignant – All patients >50 yrs with lower GI bleeding must be evaluated for colon cancer
Constipation • • • • • •
< 3 stools/week Causes: hypothyroid, HyperCa, HypoK, scleroderma, DM, MS, PD, amyloidosis, pregnancy, IBS, CCBs, carcotics, Anticholinergics, TCAs, diuretics, clonidine Lab testing only indicated if: alarm symptoms present, medical disorder is likely, or if no response to treatment. Alarm symptoms: hematochezia, family hx of colon cancer, family hx of IBD, positive FOBT, weight loss, or new onset of constipation in people > 50 years. Bulk-forming agents (psyllium) is well-tolerated for chronic constipation Osmotics like MgOH work well, but chronic use may cause hypermagnesemia. – Lactulose is another osmotic
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Stimulant laxatives like bisacodyl work well in acute settings, but research is not available to support their routine use Enemas are usually the treatment of choice for impaction, but not chronic constipation. Lubiprostone is beneficial in the treatment of adults with chronic constipation, but not as a first-line
Diarrhea • • • • • • • • • •
Acute diarrhea: an ↑number or ↓consistency of stool lasTng 14 days or less. Viral infections: 70% - 80% of acute infectious diarrhea; rotavirus is most frequent cause. Enteric adenoviruses are the second most common type. Rotavirus: in the winter months, and most cases occur between the 3 months and 2 years. Norwalk virus: Contaminated water, salads, or shellfish. Giardiasis: more prevalent in children in daycare centers. Salmonella: raw or undercooked meat (poultry, eggs) ; don’t usually treat Shigella: give flouroquinolones or Bactrim E. Coli O157:H7- bloody diarrhea, hemorrhagic, HUS, TTP ETEC: most common cause of traveler’s diarrhea1/3rd travelers to underdeveloped countries will get it – treat: fluoroquinolone (ciprofloxacin, ofloxacin, norfloxacin); trimethoprim/sulfamethoxazole or azithromycin are acceptable alternatives. – adults should eat potatoes, rice, wheat, noodles, crackers, bananas, yogurt, boiled vegetables, and soup. – Dairy products, alcohol, and caffeine should be avoided.
Acute Gastritis • • • • • • • • • • • • • • • • • •
Priority is to replace lost intravascular volume with IV NS Viral: low grade fever, headache, N/V, achy Bacterial: fever, headache, anorexia, fatigue Rotavirus is most common in kids Norwalk is most common in adults bloody invasive E. Coli, , Shigella, Yersinia, Entamoeba histolytica leukocytes salmonella, shigella, yersinia, EHEC and ETEC, C. Diff, campylobacter, E. Histolytica Acute diarrhealess than 2 weeks; Chronic diarrhea more than 4 weeks Traveler’s Diarrhea: enterotoxigenic E. coli Camper’s Diarrhea: Giardia Undercooked chicken salmonella or shigella Undercooked hamburger EHEC Mayonnaise/canned food S. aureus (6 hrs), clostridium (8-12 hrs), E. Coli (12-14 hrs), salmonella Raw seafoodvibrio, salmonella, or hep A Daycare shigella, giardia, rotavirus Symptoms: usually self limited; exceptions are profuse diarrhea, dehydration, >100.4, blood, severe ab pain, duration >48 hrs, children, elderly, immunocompromised Prevention: hand washing, keep children home from school, pasteurization, refrigeration, boiling water Treat: Cipro 500 mg BID for 1-2 days (except in kids or pregnant women); Azithromycin 1 1000mg dose; Rifaximin for noninvasive strains of E. Coli
Palpitations • •
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Important inquiries: caffeine, diet pills, stress, anemia, MV prolapsed, QT syndrome Rhythm disorders: sinus bradycardia, sinus tachycardia, WPW, sick sinus syndrome, premature atrial contractions, SVT, PVCs, AV block, ventricular tachycardias – Long QT syndrome: autosomal dominant; more common in females; increased risk for ventricular arrhythmia and sudden cardiac death; QT >500msec is dangerous – PVC occurring at rest and disappearing with exercise is usually benign – Primary supraventricular rhythm disturbances responds to BBs and CCBs; digoxin can be used – SVT can be treated with carotid sinus massage, valsalva, cold application to face, adenosine – Most pts with a.fib will need warfarin anticoagulation Psychiatric causes: panic disorder Structural : cardiomyopathy, ASD, VSD, congenital, MV prolapse, pericarditis, valvular disease, CHF, restrictive/hypertrophic/dilated cardiomyopathy – Dilated cardiomyopathy is the most common cause of sudden cardiac death Noncardiac causes: anemia, electrolyte disturbance, hyperthyroid, hypothyroid, hypoglycemia, hypovolemia, fever, pheochromocytoma, pulmonary disease, vasovagal syncope Medications/drugs: EtOH, caffeine, cocaine, tobacco, ephedra, diuretics, digoxin, beta agonists, theophylline, phenothiazine If >50 yrs, always consider coronary artery disease EKG is appropriate in all pts with palpitations, Holter monitor, Echo, stress test are also helpful Atrial fibrillation: rapid and irregular heart beat; fluttering PSVT: rapid and regular; will have normal history, physical, labs, and likely normal ECG; reassurance/observation Ventricular premature beats random, episodic, instantaneous beats, described as a “flip-flopping” sensation. Hypertrophic cardiomyopathycan be associated with atrial fibrillation or ventricular tachycardia; systolic ejection murmur (like aortic stenosis) worsening with Valsalva maneuver. Wolff-Parkinson- White syndrome (preexcitation syndrome) ECG demonstrates a short PR interval and δ-waves.
Chest Pain • • •
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Differential: MI, Angina, Percarditis, Aortic Dissection, PE, PNX, PNA, bronchitis, costochondritis, muscular strain, GERD, Esophageal spasm, cholelithiasis, anxiety, somatization, herpes zoster ER studies: CBC, electrolytes, BUN/Cr, PT, PTT, INR, glucose, EKG, CXR, cardiac enzymes, tropinin T and I Q 6-10 hrs for 3 cycles, O2 sat MONA- morphine, oxygen, nitroglycerin, aspirin – Morphine: decreases catecholamines which reduces myocardial O2 consumption – O2: may be discontinued after 6 hrs if saturation is normal – Nitroglycerin: give sublingually Q 5 min for 3 doses then advance to IV route – Aspirin: 325 mg to be chewed (clopidogrel if ASA allergy) – B-adrenergic antagonist: reduces myocardial damage and limits infarct size – ASA and heparin reduce risk of subsequent MI and cardiac death in pts with unstable angina – ACEI reduce short term mortality when started within 24 hrs of acute MI; prevents remodeling – Unstable angina + EKG changes give glycoprotein IIb/IIIa receptor inhibitor EKG changes in MI: ST wave elevation/depression and/or T wave inversion; Q waves indicate cardiac pathology (necrosis) Angina classifications: – Angina with unusually strenuous activity – Angina with more prolonged or slightly vigorous activity – Angina with usual daily activity – Angina at rest Causes of MI: atherosclerosis and plaque rupture, cocaine induced spasm, aortic dissection, embolus MI Clinical Presentation: pressure, squeezing, crushing, smothering, Levine sign, nausea, vomiting – Angina longer than 20-30 minutes is likely an MI Secondary Treatment – Reduce or address risk factors: male >40, HTN, smoking, DM, cocaine, hyperlipidemia, LV hypertrophy, family hx, chest trauma, postmenopausal, homocystinemia – Aspirin, nitrates and beta blockers have proven long term benefits – Statins decrease incidence of CV events; goal LDL is <70 – HTN should be treated to reduce mobidity and mortality – Recommend minimum of 30 min exercise on most days with weight management
Chest Pain Exercise ECG is most commonly used noninvasive procedure for evaluating whether the chest pain is due to angina. Myocardial stress imaging (scintigraphy , echo) is indicated if resting ECG makes an exercise ECG difficult to interpret – to confirm results of the exercise ECG or to localize the region of ischemia – to distinguish ischemic from infracted myocardium – to assess the completeness of revascularization following an intervention. • The electron beam CT can quantify coronary artery calcification, but is not helpful to evaluate angina. • Atypical Angina: pain that has the quality and characteristics of angina, or occurs with exertion, but not both. – chest heaviness not related to exertion or relieved by rest, or it pain with an atypical character (sharp or stabbing) but predictably brought on by exercise and relieved by rest. • Anginal equivalent: other symptoms of cardiac ischemia (eg, dyspnea) that is predictably precipitated by exertion and relieved by rest. • LV hypertrophy with strain, LBBB and ST-segment baseline abnormalities in the precordial leads abnormalities should get a thallium ETT rather than standard exercise treadmill test • Poor prognostic signs in an ETTfailure to complete stage II of a Bruce protocol, failure to achieve a HR > 120 beats/min (off β-blockers), onset of ST depression at a HR < 120 beats/min, ST depression > 2.0 mm, ST depression > 6 min into recovery, poor systolic BP response to exercise, angina or ventricular tachycardia with exercise and ST depression in multiple leads. Nitrates: • Tolerance is the most significant issue to consider when using nitrates for stable angina; develops rapidly with longacting nitrates • When using a patch, it is important to have intervals of 10 - 12 hrs w/o the patch to retain the effect. • Headache and fatigue may be important side effects β-blockers: • all are equally effective in treating angina • dose should be adjusted to achieve a heart rate of 50 - 60 beats/min.
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D-Dimer • useful in determining the risk for a DVT or PE. • A low result has a high negative predictive value for the presence of thrombus. • If the result were high, a confirmatory test would be appropriate.
Pneumonia • • • •
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infection of lung parenchyma; most common triggering mechanism is upper airway colonization Clinical: age, cough with green sputum, fever with chills, exposure, egophany, dullness to percussion Diagnosis: CXR is gold standard; cultures have low sensitivity – Absence of infiltrate does not rule out pneumonia Community Acquired Pneumonia (non hospital pts): – Strep pneumo, H. influenza (esp in COPD pts), and M. Catarrhalis are most common focal, lobar infiltrates – Mycoplasma, Chlamydia & legionella cause atypical pneumonia; more in adolescent/young adult Bilateral diffuse infiltrates Hospital Acquired Pneumonia – Risks are intubation, NG tube feeds, lung disease, multisystem failure – Pseudomonas, klebsiella, acinetobacter, gram+ cocci, staph aureus Abruptly worseningpneumococcal pneumonia Diarrhea + pneumonia legionellacan do urine antigen testing or direct fluorescent antibody Postinfluenza pneumoniastaph aureus Right lower lobe consolidationaspiration pneumonia Pneumonia Severity Index: assigns pts a risk category based on age, comorbid illness, specific exam and lab; high risk includes neoplastic disease, liver/renal disease, CHF, DM; physical bindings include tachypnea, fever, hypotension, tachycardia, AMS, low pH, low Na, low Hct, low O2 sat, high glucose, high BUN, pleural effusion on xray – Low risk classes treated as outpatient; high risk as inpatient Treat: fluoroquinolone or macrolide or beta-lactam for outpatient; IV beta lactam and IV macrolide for inpatient; get early follow up with CXR in 5-7 days; treat for 72 hrs in an afebrile patient, but at least 2 weeks if complicated or atypical pneumonia Complications: bacteremia, parapneumonic pleural effusion, empyema Prevention: – Pneumococcal vaccine for all >65, and all other adults with chronic illness – Influenza vaccine
Acute Bronchitis – Inflammation of the tracheobronchial tree often in the setting of a URI in the winter • Influenza, parainfluenza, adenovirus, rhinovirus, mycoplasma, Chlamydia
– No specific diagnostic criteria, but most have cough productive of purulent sputum of variable color – Treatment: no antibiotics unless it is pertussis; bronchodilator therapy, antitussives – Prolonged fever and consolidationpneumonia – Conjunctivitis and adenopathyadenoviral infection
CHF • • •
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Leading diagnosis among hospitalized pts >65; survival is 3-5 yrs; First priority is optimize O2 exchangegive O2 NC, dilate pulmonary vessels, decrease pre/afterload Lung fluid overload often causes anxiety and distress due to oxygenation struggleactivates sympathetic pathways & catecholamine responseworse heart failure w/tachycardia &peripheral vascular resistance – Suppress these triggers with morphine sulfate which is an anxiolytic and vasodilator – Give diuretics, ACE and BB to decrease preload and afterload and reduce cardiac remodeling Systolic dysfunction: dilated LV with impaired contractility Diastolic dysfunction: normal LV, impaired ability to relax, fill, and eject blood Symptoms: dyspnea on exertion, anxiety, orthopena, PND, cough with pink, frothy sputum – Right sided: venous congestion, N/V, distension, bloating, constipation, ab pain, decreased appetite, fluid retention, weight gain, edema, JVD, hepatojugular reflex, hepatic ascites, splenomegaly – Left sided: pulmonary congestion, DOE, PND, orthopnea, wheezing, tachypnea, cough, rales, S3 gallop, Cheyne-Stokes respiration, pleural effusion, pulmonary edema Framingham Heart Study: – need 2 major criteria- PND, JVD, rales, cardiomegaly, pulmonary edema, S3, CVP >15, circulation time of 25 sec, hepatojugular reflex, wt loss of 4.5 kg over 5 days of treatment. – Minor criteria- ankle edema, nocturnal cough, DOE, hepatomegaly, pleural effusion, decreased VC, tachycardia Elevated BNP and pr-BNP are sensitive and specific; BNP > 500 pg/mL; BNP < 80 pg/mL has a high (99%) negative predicative value and helps rule out CHF. ECHO is the gold standard diagnostic modality
CHF NYHA functional classification: • Class I: patients have no limitation of activity. • Class II: pts have slight limitations; comfortable at rest; fatigue, palpitation, dyspnea, angina w/ordinary activity • Class III: patients are also comfortable at rest, but less-than-ordinary activity causes symptoms. • Class IV: patients have symptoms at rest and increased symptoms with even minor activity. • •
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discontinuing alcohol use has been shown to improve function significantly. ACE inhibitors ↓symptoms, ↑quality of life, ↓hospitalizaTons, & ↓mortality in pts with NYHA class II - IV – slow progression to heart failure among asymptomatic pts with LV systolic dysfunction. – All pts with heart failure should be prescribed an ACE inhibitor unless they have a contraindication. β-Blockers are helpful, but not necessarily as a first-line agent. – β-Blockers inhibit the adverse effects of sympathetic nervous system activation in heart failure patients. – bisoprolol, metoprolol, and carvedilol can ↓symptoms, ↑quality of life, and ↓mortality. Nitrates & hydralazine can be used in pts who do not tolerate ACE inhibitors, as can ARBs. Some CCBs (nifedipine, diltiazem, and nicardipine) may worsen systolic dysfunction. metolazone can ↑diuresis in outpatient treatment of HF w/volume overload; Avoid prolonged therapy Spironolactone is usually considered for NYHA class III or IV pts or those with a serum K level < 5.0 mmol/L. ACE inhibitors and ARBs do not have the same effects on the neurohormonal pathways involved in CHF an ARB added to an ACE inhibitor ↓hospitalizaTon in pts with CHF, but does not ↓mortality. Outpatient treatment: Na restriction, weight reduction, ACE inhibitors are first line (unless pregnant, hypotensive, hyperK, renal stenosis/insufficiency), beta blockers (in non-acute setting), diuretics, aldosterone antagonists can be used in advanced heart failure, CCBs are contraindicated except for amlodipine, diltiazem, and verapamil.
Dizziness • • • • • • • • •
Vertigo rotational sensation, in which the room spins around the patient. Orthostasis lightheadedness upon arising, common with orthostatic hypotension. Presyncope feeling of impending faint. Disequilibrium sensation of unsteadiness or loss of balance; pt often thinks problem is in the feet Light-headedness is often vaguely described as a “floating” sensation. Dix-Hallpike maneuver is useful to distinguish central from peripheral causes of vertigo. peripheral vertigo latency time for onset of symptoms of vertigo or nystagmus is 3 - 10 sec; symptoms are severe; direction of the nystagmus is fixed; repeating the maneuver lessens the symptoms. central vertigo no latency to onset of symptoms, no lessening of symptoms with repeat maneuvers, the direction of the nystagmus changes, and the symptoms are of mild intensity. antihistamines are first-line therapysuppress the vestibular end-organ receptors and inhibit activation of the vagal response. Meclizine (Antivert), 25 mg Q 4-6 hrs and diphenhydramine (Benadryl), 50 mg orally Q 4 - 6 hrs
ENT • • •
Peripheral vertigo: inflammation, stimulation, destruction of hair cells, BPH, labrynthitis, vestubular neurotnitis, Meniere’s, acoustic neuroma Central vertigo: vascular insufficiency, MS, brain tumor Acoustic neuroma – unilateral tinnitus and hearing loss; symptoms are constant and slowly progressive. – vertigo, facial weakness, and ataxia can occur.
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Vestibular neuronitis – acute onset of severe vertigo lasting several days, with symptoms improving over several weeks
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Benign positional vertigo: dislodged otoliths in semicircular canals – symptoms with position changes only.
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Meniere disease: endolymphatic hydrops increase pressure – Tinnitus, hearing loss (low frequency) – attacks of vertigo lasting for several hrs, associated with nausea, vomiting, hearing loss, and tinnitus – Treat with diuretics and salt restriction
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Know the Rhine and weber test
ENT
Temporomandibular joint dysfunction: – common cause of referred otalgia. – First-line therapies: NSAIDs, heat, mechanical soft diet, referral to the dentist if no improvement in 3-4 weeks. Otitis Media: – reddened TM, by itself, is not a sufficient finding to diagnose acute otitis media. – middle ear infection seen in kids usually due to URI; fever, ear pain, diminished hearing, vertigo, tinnitus, red TM • S. pneumo, H. influ, M. catarrhalis • Most resolve spontaneously though if prolonged or recurrent/severe, give amoxicillin – opaque TM (purulent effusion), bulging TM, impaired TM mobility When all 3 are present, PPV is near 90%. – Purulent discharge in ear canal may indicate perforation – Effusions may take 3 mo to resolve. Antibiotics not indicated for persistent effusions in the absence of acute otitis media. – amoxicillin is first-line therapy External Otitis: – infection of external auditory canal; inflamed, swollen, external ear canal with exudates & discharge; painful; TM uninvolved – must protect from additional moisture and avoidance of further mechanical injury from scratching. – Otic drops containing antibiotics and corticosteroids are very effective. – DM pts at risk for invasive external otitis (malignant) with pseudomonassurgical debridement and IV antibiotics – persistent otitis externa in an immunocompromised or diabetic should be referred for specialty evaluation. Pharyngitis: inflammation or irritation of the pharynx and/or tonsils; the majority is viral – Mycoplasma, Chlamydia, arcanobacterium are common in teens/young adults – GAS causes 15% of adult and 30% of pediatric cases; diagnose with rapid antigen test • If rapid antigen test is negative, do a throat culture (gold standard) – GAS : abrupt onset of sore throat, fever, tonsillar and/or palatal petechiae, tender cervical adenopathy, absence of cough • Post-strep glomerulonephritis and rheumatic fever are possible complications • Treat with Penicillin for 10 days or cephalosporins if penicillin allergy – Infectious Mono: adenopathy & hepatosplenomegaly, atypical lymphocytes in peripheral smear, restrict from activity Epiglottitis: manage airway patency first; tripod position, stridor, drooling, toxic
Eye Conditions Conjunctivitis • redness, irritation, tearing, discharge, photophobia, or itching; not usually painful • itching and bilateral symptoms are more specific for allergic conjunctivitis • Adenovirus is most common virus (85%) • Supportive treatment; topical antibiotics prevent bacterial superinfection, but no good evidence that it makes any impact. • topical corticosteroids are contraindicated Viral conjunctivitis a palpable preauricular lymph node is characteristic • eye drops for herpetic eye infections (corneal dendrites w/fluorescein staining); also use cold compresses Bacterial conjunctivitis purulent discharge, pain, photophobia, and a “gritty” sensation of the eye. • commonly caused by Streptococcus and Staphylococcus; ↑reports of conjuncTviTs caused by MRSA. • MRSA conjunctivitis is treated with the same drugs used to treat MRSA in other parts of the body Scleritis: • injection of the deeper scleral vessels. • ↓vision, deep boring eye pain, surrounding headache; associated w/autoimmune diseases like RA or Wegeners Episcleritis: mild irritation, and is not as intense as the syndrome described above. Corneal abrasion: associated with ↓vision, intense pain, and tearing, but is associated with trauma. Acute glaucoma: pain, ↓vision, and redness, but the affected pupil is usually dilated. Chalzion: sterile inflammation of meibomian gland; painful nodule Blepharitis: inflammation of eyelids, loss of eyelashes, scaling Dactrocystitis: occlusion of nasolacrimal duct Subconjunctival hemorrhage: benign bleeding of small bessels, painless Conjunctival hyperemia: diffuse erythema of conjunctiva Iritis: photophobia, sluggish pupil, cloudy cornea, pain, pupillary constriction
Sinusitis • • •
inflammation of the mucosa of the para-nasal sinuses irrespective of the cause. Predisposing factors: viral URI and allergic rhinitis. Bacterial: purulent rhinorrhea, purulent secretions in nasal cavity, tooth pain, & biphasic history (worsening of symptoms after an initial period of improvement) – S.pneumoniae is most common. – Others include H. influenzae, M.catarrhalis, & group A β-hemolytic strep
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Duration of illness < 7 days may be used as a negative diagnostic criterion. Sinus pain on palpation, lack of improvement w/decongestants; x-rays are not diagnostically valuable. Most with recurrent sinusitis have an underlying physiologic or anatomic abnormality that contributes to their problem. In pts clinically diagnosed with acute sinusitis, no significant difference between antibiotics and placebo use. In pts with sinusitis confirmed by CT scan, x-ray, or bacteriology, there has been demonstrated efficacy of antibiotics amoxicillin is considered the drug of choice in most countries.
Allergic Rhinitis • • • • • • • • • • •
IgE mediated response to extrinsic protein Mucus glands increase secretion, vasodilation, stimulation of sensory nerves Symptoms: sneezing, itching, rhinorrhea, postnasal drip, congestion, anosmia, headache, earache, tearing, red eyes, drowsiness Exam: allergic shiners, nasal crease, allergic salute, swollen blue/gray turbinates; conjunctivitis, dennie-morgan liens, cobble-stoning Treat: H1 blockers, nasal decongestant, oral decongestant, intranasal steroids, oral steroids, cromolyn, LTRAs Antihistamines: diphenhydramine, chlorpheniramine, hydroxyzine; side effects are dry mouth, dry eyes, blurred vision, urinary retention; 2nd gen have less SE: loratadine, fexofenadine, cetirizine Decongestants: constrict blood vessels; pseudoephedrine (α-adrenoreceptor agonest); may cause tachycardia, tremors, insomnia, rebound hyperemia, worsening of symptoms w/chronic use or discontinuation Corticosteroid nasal spray: effective long term management; reduce inflammatory mediators Oral corticosteroids: inhibit cell mediated immunity; long term steroid effects so only use short term DesensiTzaTon therapy: test for specific anTgens; inject dilute anTgen & gradually ↑concentraTon Anaphylaxis: give aqueous epinephrine 1:1000 in 0.2-0.5 mL dose subQ or IM + IV fluids Allergens may trigger asthma –rapid acting B2 adrenergic agonist albuterol is mainstay treatment – Mild intermittent: <2/wk,<2/mo; no daily meds other than short acting B rescue inhaler – Mild Persistent: 3-6/wk; 3-4/mo; give low dose inhaled steroid – Moderate persistent: daily; >5/mo; give low/med inhaled steroid + long acting B agonist – Severe persistent: continual/frequent; give high dose inhaled steroid, long acting B agonist; corticosteroid tablets/syrup if needed
Sore Throat • • • •
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Palatal petechiae either a group A streptococcal infection or infectious mononucleosis. posterior cervical adenopathy infectious mononucleosis Fever, chills, myalgias, and pain with swallowing, anterior adenopathy viral or bacterial pharyngitis. edema swollen uvula group A hemolytic streptococcal infection. – first-line treatment is amoxicillin. In the penicillin-allergic pt, a first-generation cephalosporin or macrolide. 20% of school age kids are carriers of group A β-hemolytic Strepcarriers do not need to be identified or treated, as they do not develop complications from infection and are not important in the spread Laryngitis with pharyngitis is generally associated with a viral infection, and only supportive care is needed. Centor Criteria for adults is a method for determining the probability of group A β-hemolytic strep – 1 point is given for each of the: tonsillar exudates, tender anterior cervical adenopathy, fever, lack of cough – most cost effective approach to pts who have all 4 criteria is to treat with antibiotics w/o laboratory testing. – If someone has 3 criteria, the chance of having a strep is 40%-60%, and a person with only 1 has 1%5% chance.
Pharyngitis RSV, adenovirus, parainfluenza, rhinovirus Herpangina tonsilar + palatal ulcerations; coxackie virus Group A Strep rheumatic fever, GN, rare in children < 3 Viral: rhinorrhea, cough, low grade fever Diphtheria gray membrane, tonsillitis, cervical lymph Kawasaki < 5 yrs, strawberry tongue, fever, rash on hands and feet • Monospot test positive after 5 days – 3 weeks; IgM may not be + for 2 weeks • Strep pneumo give 10 days of PNC or 1 IM injection
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Skin Rashes and Infections Acne: • cause is multifactorial: familial factors, follicular keratinization, androgens, and Propionibacterium acnes. • Contributory factors: certain medications, emotional stress, occlusion/pressure on the skin • Acne is not caused by dirt, chocolate, greasy foods or the presence or absence of any foods in the diet. • Topical agents are first line; topical retinoid + topical antibiotic 2nd line; add oral antibiotic if no improvement in 6 weeks • improvement occurs over a period of 2 - 5 months, and may take even longer for noninflamed comedones. • Topical retinoids applied in the evening, benzoyl peroxide & topical antibiotics (doxy) should be applied during the day • Isotretinoin indications: nodular acne, severe acne, moderate recalcitrant acne, resistant to other therapies – pregnancy must be prevented during its use. • tetracycline & isotretinoin cause pseudotumor cerebri, and should never be used together. Rosacea: • Stage I- persistent erythema, generally with telangiectasia formation. • Stage II - addition of papules and tiny pustules. • Stage III- erythema is deep and persistent, telangiectases are dense, and there may be a solid appearing edema of the central part of the face due to sebaceous Hyperplasia and lymphedema (rhinophyma and metophyma). • Management: topical metronidazole, antibiotics, and sodium sulfacetamide can work, but oral antibiotics are more effective than topical. Minocycline or doxycycline are very effective first-line therapies. Keratoacanthoma: • difficult to distinguish from basal cell cancers, nodular squamous cell cancers, or molluscum • characterized by rapid growth, achieving a size of 2.5 cm within a few weeks. Psoriasis: • often has nail involvement in addition to skin • For localized skin rashes, topical corticosteroids are appropriate therapeutic agent. • Topical pimecrolimus is effective for inverse psoriasis (perianal and genital regions) or on the face and ear canals • Oral retinoids & methotrexate treat generalized psoriasis, & help w/nails, but not first-line for localized rash
Skin Rashes and Infections Pityriasis rosea: • self-limited papulosquamous eruption; single herald patch (oval, slightly raised plaque with scale) followed in 1 - 2 wks with a generalized eruption. • spontaneously resolve in 6 to 12 weeks, and recurrences are uncommon. • The treatment is symptomatic, and includes antihistamines or corticosteroids to relieve itch. Impetigo: • well-demarcated erythematous lesions that, when disrupted, develop a secondary golden crust. • most cases are caused by S aureus followed by Strep. • responds well to topical antibiotics like mupirocin applied to the lesion and to the nares Folliculitis: • infection is generally caused by Pseudomonas aeruginosa or Pseudomonas cepacia. • condition is usually self-limited, and therefore reassurance is all that is necessary. HSV: • topical antiviral therapy or oral antiviral therapy. • Antiviral agents are more effective treating primary infections than recurrent infections. • Pulse dosing (treating at the first sign of outbreak) may shorten or reduce the severity of an eruption • Chronic suppression is best to ↓ frequency of symptomaTc recurrences and asymptomaTc viral shedding. • Acyclovir resistance is extremely rare. Valacyclovir & famciclovir have equal efficacy for cutaneous HSV Genital herpes: • treat each outbreak (episodic therapy) at first sign of outbreak or use daily antiviral therapy to prevent (suppressive therapy) • Suppressive therapy seems to reduce, not eliminate, asymptomatic viral shedding. • Suppressive therapy does not alter the natural course of infection and is not associated with antiviral resistance Herpes zoster: • AnTviral therapy is treatment of choice, and ↓ Tme for lesion healing and ↓ overall duraTon of pain if iniTated within 72 hours • In some cases, no benefit will occur if treatment starts after the 72 hour cutoff, but it should beinitiated regardless of time in pts > 50, those who are immunosuppressed, or those with eye involvement.
Skin Rashes and Infections Tinea capitis. • Systemic therapy is needed, but topical ketoconazole shampoo or selenium sulfide lotion may kill hair spores • Griseofulvin is treatment of choice, and should be used for 4 to 8 weeks. • Terbinafine, itraconazole, fluconazole, and ketoconazole can also be used. If fluconazole were to be used, the treatment duration would only be for 3 to 4 weeks, not 4 to 8 weeks. Tinea corporis/ringworm: • most commonly caused by Trichophyton rubrum. • well-demarcated plaque with central scaling; pruritic. Atopic dermatitis/eczema • rough, red plaques with flaking that can affect the face, neck, upper trunk, and behind the knees. • flexural surfaces are often involved; pruritus may be severe. • Papules, vesicles, scaling, crusting, lichenification • Steroids used for acute flares • Use emollients after bathing • Tacroliumus (and nonsteroidal immunomodulators) for short term treatment if severe • Most patients have the onset of eczema in childhood, and onset after the age of 30 is very uncommon. Molluscum contagiosum. • more common in white males, children in daycare/nursery (for kids it is not likely to be sexually transmitted) • poxvirus transmitted through direct skin-to-skin contact. • in adults and in the pubic region, they are sexually transmitted. • can occur in immunocompetent pts, but in pts who are immunocompromised, they are numerous and larger. • Most resolve spontaneously within months, but they can be treated with cryotherapy, cautery, or curettage.
Skin Cancer • • •
Reassuring features: <6mm, symmetric, uniform color, well-defined borders Risk factors: family hx, fair, burn easily, chronic exposure to toxic compounds, immunocompromised Superficial spreading melanoma: – – –
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Lentigo Maligna: – –
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Most common in African-Americans and Asians Found under the nails, on the soles of feet, palms of hands
Nodular: –
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Most often in the elderly on chronic, sun-damaged skin Least common of the 4 types; most common in Hawaii
Acral Lentiginous: – –
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Most common type in both sexes Spreads superficially along the top layers of skin before penetrating into deep layers Superficial, radial growth phase is slower than the vertical phase
Invasive at the time of diagnosis; Most aggressive type
Treat: if any of the ABCDE signs are present, excise completely with 2-3 mm margin; if pathology indicates malignancy, excise with 5 mm margin Tumor thickness is most important prognostic factor; <1 mm thick have low rate of metastasis Basal Cell Ca: most common; pearly papules w/central ulceration or telangectasias; rarely metastasize Squamous Cell Ca: higher rate of metastasis; irregularly shaped plaques/nodules w/raised borders, bleed easily; scaly, ulcerated
Musculoskeletal shoulder dislocation pain management and relocation • keep immobilized for 7 -10 days to allow for capsular healing. Then, start ROM exercises and strengthening • Younger pts may have ↑recurrence, & surgical referral should be entertained, but not necessary immediately • Rotator tendonitis discomfort w/abduction > 90; pain with throwing motion • Adhesive capsulitis chronic pain and stiffness; do exercise to increase ROM Iliotibial band syndrome: • most common cause of lateral knee pain in an athlete. • commonly seen in athletes with repetitive knee flexion activities like distance runners and cyclists. • pain or ache over lateral knee that worsens with activity, and on exam has pain and tightness over the IT band. • treat with strengthening the hip abductors, internal rotators, and knee flexors is generally treatment for Patellofemoral pain syndrome: • diffuse knee pain and a positive patellar grind test; generally does not occur acutely or after injury • most common diagnosis for patients with anterior knee pain presenting to their PCP • pain is worse with walking, running, ascending or descending stairs, or squatting or sitting for prolonged periods of time • Treatment is done primarily through strengthening the quadriceps muscles and hip rotators. ACL tear: • twisting injury, sense of instability, feeling of a “pop,” and immediate effusion while still able to bear weight. Meniscal injuries: • locking, catching, or giving way sensation; symptomatic treatment Medial collateral ligament sprains: • occurs after valgus stress to a partially flexed knee; pain over the medial aspect of the knee, but no joint swelling Ottawa ankle rules are a guide to use to determine if xray is indicated after ankle sprain. Films should be obtained if: • The pt is unable to walk four steps immediately after the injury and in the office. • There is tenderness over the distal 6 cm of the tibia or fibula, including the malleoli. • There is midfoot or navicular tenderness. • There is tenderness over the proximal fifth metatarsal.
Neck Pain • • • • • • • • • •
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Spondylosis or osteoarthritis Pain aggravated by movement, worse after activities, associated with a dull ache, limited ROM chronic mechanical problems tenderness to palpation on examination. cervical nerve root irritation radiation of symptoms, weakness, numbness, or paresthesias. whiplash injury history of an acceleration injury; get C-spine radiograph cervical dystonia (torticollis) neck would be laterally flexed and rotated. Physical therapy, stretching, gentle manipulation, cervical collars, ice/heat have all been used with some results evidence supporting those treatments is weaker than the evidence behind use of botulinim toxin. spinal stenosis: older individual with axial stiffness and paresthesias over several dermatomes (C7-T1). – CT scan is the best choice. Canadian cervical spine rules help determine who should receive radiography: 1. Is there one high-risk factor? High-risk factors: age >65, dangerous mechanism (high speed motor vehicle accident) or numbness/tingling in extremities. A yes to any of the above requires radiography. 2. Is there one low-risk factor? Low-risk factors: simple rear-end collision, if the pt was ambulatory at any time at the scene, if there was absence of neck pain at the scene, and if there was absence of C-spine tenderness on examination. A no to any of the above would require radiography. 3. Is the pt able to voluntarily actively rotate the neck 45° to the left and right regardless of pain? A “no”to that question would require radiography. Spurling test/neck compression test. – pt to bends head to the side & rotate head toward the side of pain while tester exerts downward pressure. – reproduces symptoms in the affected upper extremity in the case of nerve root injury. – high specificity, but low sensitivity for cervical radiculopathy. – Nonspecific mechanical pain should be considered if the maneuver results in neck discomfort only.
Back Pain • • • •
Inflammatory condiTons produce ↑pain & sTffness in the AM; mechanical disorders worsen during the day w/ activity. MRI is indicated for pain persisting > 6 wks despite normal radiographs and with no response to conservative therapy. Disk herniationassociated with radiation and neurologic symptoms. Spondylolisthesis: anterior displacement of vertebrae in relation to the one below – most common cause of low back pain in patients < 26, especially athletes.
• Back strain generally follows an inciting event; pain associated with movement. Treatment: • maintain usual activities, as dictated by pain. • prolonged bed rest & tracJon have not been shown to be effecJve in ↑return to usual activities sooner. • NSAIDs & muscle relaxants are effective for short-term symptomatic pain relief • Steroids can be considered in those who have failed NSAID therapy. • Low-dose TCAs can be useful in the treatment of chronic pain and do serve as adjuvants to other analgesics.
Joints Osteoarthritis: • Osteoarthritis: age >65, history of trauma, obesity, or repetitive joint use; deep, dull, achy pain • Gradual onset exacerbated by activity and decreasing with rest • Bony crepitus on passive ROM • Xray is normal at first, then develops bone sclerosis, subchondral cysts, osteophytes • Heberden nodes (at the DIP joints) and Bouchard nodes (at the PIP joints). • pauciarticular; pain is worse with activity and improved with rest. • often mild swelling, but warmth and an effusion are rare; Crepitus is common, as is malalignment of the joint. • Indications for joint replacement poorly controlled pain despite max therapy, malalignment, and ↓mobility • Fluid aspirated is generally clear joint fluid with a WBC count of 2000/mm 3 to 10,000/mm 3. • In RA, > 50% of the WBCs are PMNs, while in osteoarthritis, < 50% of the WBCs are PMNs. Rheumatoid Arthritis: • age 30-55 yrs; women>men; symptoms for >6 weeks • Morning stiffness Involves 3 or more joints; involves hand joints; symmetric arthritis; fatigue is common • Radiographic changes include erosions or decalcifications • Elevated ESR and CRP, anemia, thromobcytosis, low albumin, +rheumatoid factor • gradual, polyarticular and symmetric involvement of joints with morning stiffness that improves with activity • Hands and feet are usually involved first, but it may spread to larger joints. • symmetric swelling and tenderness are common, with associated rheumatoid nodules. • disease-modifying antirheumatic drugs (DMARDs) should be managed by rheumatologists and started early to avoid or delay joint deformity. • Extra-articular manifestations: seen at any stage of disease • nodules occur anywhere (usually subcutaneously along pressure points), vasculitis, dry eyes, dyspnea, or cough can all be seen. Cardiac, GI, and renal systems are rarely involved. When a neuropathy is present, it is generally because of a compression syndrome, not as an extraarticular manifestation • Treat: NSAIDs, glucocorticoids, anticytokines (infliximab, etancercept), sulfasalazine, methotrexate
Joint Pain Gout • • • •
increased risk men, EtOH consumption, after large meals, after trauma or surgery, thiazides abrupt in onset and monoarticular with pain at rest and with movement; any joint can be affected podagra- an abrupt, intense inflammation of the first MTP joint attacks often occur overnight, after an inciting event (excessive alcohol or a heavy meal). – Serum uric acid may be normal or low during an acute gout attack; use UA to monitor therapy but not to diagnose acute attack – Monosodium urate crystals, needle shaped, strong neg birefringence on polarizing microscopy • Ca pyrophaosphate crystals: rode shaped, rhomboid, weakly positive birefringence • Ca hydroxyapatite: cytoplasmic inclusions that are non-birefringent • Ca oxylate: bipryamidal, strongly positive birefringence; ESRD patients – Joint aspirate: WBC is 2000-60,000; <90% neutrophils; high proportion of PMN leukocytes. • Septic joint: WBC: 100,000 with >90% neutrophils – Treat: Acute attack colchicine, NAID, glucocorticoids; chronic probenecid or allopurinol • sed rate & C-reactive protein are both nonspecific. • crystals of pseudogout are rhomboid-shaped and demonstrate positive birefringement. • glucose levels fluid aspirated from a knee with gout or pseudogout would be normal. • short course of NSAID is one standard therapy for gout, another is a course of colchicine. • Colchicine, 1 tab Q 1-2 hrs until pain is controlled or side effects limit use (usual side effect is diarrhea). • Corticosteroids can provide quick relief, but should be reserved if initial therapy fails. • Allopurinol & probenecid are effective for prevention, but they can precipitate a flare. Septic Joint: • infections of only 1 joint; limited range of motion, effusion, fever • Steroid useS. Aureus • HIVpneumococcal, salmonella, H. Influenzae • IVDUstrep, staph, gram neg, pneudomonas • Treat: drainage with IV antibiotics (Vancomycin if MRSA)
Ankle Sprain Most ankle sprains are the result of inversion of the plantar flexed ankle – Grade I: stretching of ATFL w/pain and swelling but no mechanical instability or functional loss – Grade II: partial tear of ATFL and stretching of CFL; more pain, swelling, bruising; moderate joint instability, pain with weight bearing, loss of range of motion – Grade III: complete tear of ATFL and CFL with partial tear of PTFL; significant joint instability, loss of function, inability to bear weight • Lateral ankle, and anterior talofibular ligament are most commonly injured (then CFL and PTFL) • Ottawa Ankle Rules aid decision about x-rays (adult pts, normal mental status, within 10 days of injury) – 100% sensitivity in ruling out significant malleolar and midfoot fractures – Get x-ray if one of the following: >55 yrs, isolated patella tenderness; tenderness of head of fibula; inability to flex knee to 90 degrees; inability to bear weight for 4 steps • Anterior Drawer (ankle)tests anterior talofibular ligament for a tear • Inversion Stress testtests CFL; translation or palpable clunk of talus on tibia suggests tear • Squeeze testtests syndesmosis; syndesmotic injury if pain at anterior ankle joint • Lachman testexcessive translation ofa ACL with no solid end point suggests tear • Anterior Drawer (knee)tests ACL tear • Valgus Strestests MCL • Varus stresstests LCL • PRICE therapy: protection, rest, ice, compression, elevation; NSAID or acetaminophen for pain Shoulder: • Empty Can Testtests supraspinatus for rotator cuff injury or tear • External shoulder rotationtests infraspinatus/teres minor for rotator cuff injury or tear • Lift-off Testtests subscapularis for rotator cuff injury or tear •
GU Infections Bacterial Cystitis: • Urine culture indicated when acute bacterial cystitis is suspected and urinalysis is inconclusive • classic symptoms + negative dipstick or microscopic evaluationculture will confirm diagnosis. • 4 factors correlate with a diagnosis of acute bacterial cystitis: frequency, hematuria, dysuria, back pain. • 4 factors ↓ likelihood of UTI: absent dysuria, absent back pain, history of vaginal discharge, vaginal irritation • Women with any combination of the positive & negative symptoms have a more than 90% probability of a UTI. • 85% recurrent UTIsdevelop within 24 hours of sexual intercourse. • First treat with: voiding after intercourse, acidification of urine, discontinuing diaphragm • if this treatment doesn’t workprophylaxis is indicated for women with frequent infections. • Single-dose postcoital anTbioTc. If that does not ↓infecTons, daily single-dose antibiotic prophylaxis for 3 - 6 months. If symptoms reoccur after discontinuation, it may need to continue for 1 to 2 years. Urethritis: gradual onset. Pyelonephritis: fever, back pain Interstitial cystitis • chronic in nature and is generally not associated with back pain. • generally diagnosed through cystoscopy, based on presence of ulcerations and fissures in the bladder • When hematuria is present, interstitial cystitis should be suspected. Dysuria • Vulvovaginitis is a common cause of dysuria, but is associated with vaginal irritation or discharge. • Dysuria without pyuria is common. • In postmenopausal years, atrophy is a usual cause. • In younger women, ask about a bladder irritant (caffeine & acidic foods are common). • treat asymptomatic bacteriuria in pregnancy; treatment not indicated for other patients
Male GU Epididymitis: • sexually active males due to retrograde spread of prostatitis or urethral secretions through the vas deferens. • sexually active men < 35 yrsusually associated w/urethritis & caused by N.gonorrhoeae or C. trachomatis. • less commonly caused by Ureaplasma or Mycoplasma in this age group. • monogamous men > 35 more commonly due to enteric gram-neg rods (Enterobacter) assoc. w/prostatitis Testicular torsion • emergent surgical referral, as after 12 hrs w/o treatment, only a 20% chance that the testicle can be saved. • absent cremasteric reflex (pinch or brush the inner thigh ipsilateral testicle retracts toward inguinal canal) • If pain is relieved upon elevation of the testicle when pt is supine, Prehn sign is +. • This does not occur with testicular torsion. • The cremasteric reflex and Prehn sign are positive in cases of epididymitis, hernias, orchitis, or cancer. Spermatocele: • asymptomatic nodules, generally found attached to the spermatic cord. • No tests are necessary, unless the diagnosis remains unclear. Acute prostatitis: • most commonly seen in 30-50-y/o men, and symptoms include frequency, urgency, and back pain. • patient generally appears acutely ill, and has pyuria. • prostate examination would reveal a boggy, tender, and warm prostate.
Female GU Candidiasis: • vaginal itch with white “cheesy” exudate. White plaques usually adhere to the vaginal wall. • KOH preparation shows multiple hyphae. • Treatment consists of topical azole applications or an oral one-time dose of fluconazole. • Recurrent yeast infections probably do not occur more frequently in diabetic or HIV +women, but may be more difficult to eradicate in this population Trichomonas vaginalis: • strawberry cervix; triangular cells with long tails, slightly larger than WBC. Bacterial Vaginosis: • Studded epithelial cells (clue cells) • treatment of choice is topical or oral metronidazole, with oral or topical clindamycin an acceptable alternative.
Vaginitis •
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Trichomonas vaginalis: – Motile, flagellated trichomonads and many WBCs; thinner green-yellow discharge with fishy odor; frothy discharge with erythematous cervix – Incubation is 3-21 days after exposure – Risks: multiple sexual partners, pregnancy, menopause – Treat: metronidazole 2g po in a single dose for patient and partner or 500mg BID x 1 week Vulvovaginal Candidiasis: – Thick, white discharge w/o odor; pruritis, edematous, erythema; pH 4-5; KOH prep shows budding yeast or pseudohyphase; fungal cultures not needed – Increased incidence in patients with DM, immunocompromized, hx of antibiotic use – Treat: 150 mg fluconozole single dose; or 10-14 days if complicated; do not need to treat partners unless symptomatic Bacterial Vaginosis – Overgrowth of anaerobic bacteria and G. Vaginalis – Associated with many sexual partners, though not an STD – Thin, homogenous discharge, pH >4.5, +KOH whiff test, clue cells on wet mount prep – Treat: oral and topical metronidazole or clindamycin; treat pregnant women to decrease incidence of preterm delivery Mucopurulent Cervictis: – 50% of gonococcal infections and 70% of chlamydial infections are asymptomatic – Diagnosis: gold standard is culture of cervical discharge – Treat: 125 mg ceftriaxone IM for gonorrhea or 500 mg cipro; Doxycyline 100 mg BID x 7 days for Chlamydia or single oral dose of azithromycin if compliance is a concern; treat partners PID: – Lower abdominal tenderness with adnexal and cervical motion tenderness, fever, discharge, elevated sed rate and CRP – Treat: if pregnant, HIV, or severe disease, should get inpatient therapy; oral- flouroquinolone for 14 days, or ceftiraxone IM single dose; if inpatient, give cefotetan 2g IV – Complications: tuboovarian abscess, chronic ab pain, infertility, ectopic pregnancy
Liver most important aspect of diagnosing alcoholic liver disease is the documentation of chronic alcohol abuse. • labs showing acute hepatocellular injury AST, ALT, LDH, and alkaline phos. • labs representing hepatic function (more suggestive of chronic disease)albumin, bilirubin, and prothrombin time. • Bleeding from varices is the most common cause of death in cirrhotic patients. • Absolute contraindications to liver transplant portal vein thrombosis, severe medical illness, malignancy, hepatobiliary sepsis, or lack of patient understanding. • Relative contraindications to liver transplant active alcoholism, HIV or hep B surface antigen +, extensive previous abdominal surgery, and a lack of a personal support system. Alcoholic hepatitis: • disproportionate ↑of AST compared to ALT with both values usually being < 300 IU/L. • ratio is generally greater than 2.0, a value rarely seen in other forms of liver disease •
Jaundice • childhood unconjugated hyperbilirubinemia hemolytic diseases (G6PD deficiency & spherocytosis), Gilbert disease and Crigler-Najjar syndrome. • childhood conjugated hyperbilirubinemiaviral hepatitis is most common; less commonwilson disease, galactosemia • Viral hepatitis accounts for up to 75% of jaundice in pts < 30, but only for 5% of jaundice in pts >60 yrs • Extrahepatic obstruction (gall stones, strictures, pancreatic cancer) accounts for > 60% of jaundice in pts > 60 yrs. • CHF accounts for around 10% of jaundice in pts > 60, and metastatic disease accounts for ~ 13% • obstruction suspected do ultrasound or CT scan • If dilated bile ducts, then ERCP or PTC. • bile ducts not dilated but likelihood of obstruction is low, evaluate for hepatocellular/cholestatic liver disease. • obstruction is still considered likely after a negative ultrasound or CT scan, MRCP is a reasonable next option.
Jaundice • • • •
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Prehepatic Jaundice: hemolysis of RBCs which overwhelms the liver’s ability to conjugate and clear the bilirubin; mostly unconjugaged Posthepatic Jaundice: obstruction to the flow of bile through bile ducts; bile duct stones, strictures, tumors; conjugated Acute onset of painless jaundice in person > 50 yrs should be worked up for pancreatic cancer Gilbert Syndrome: unconjugated hyperbilirubinemia – Congenital reduction of conjugation of bilirubin in the liver; level will increase during illness then recover; no further work up needed Hemolysis: unconjugated hyperbilirubinemia; often with anemia with red cell fragments or abnormalities Hepatitis A: fecal-oral transmission; contaminated food nad water, drugs, male-male sexual contact – Jaundice, fever, malaise, abdominal discomfort; self-limited; Incubation for 2-8 weeks; lasts 4-6 weeks – No specific treatment; just supportive care and symptomatic treatment – Vaccine available for those who are high risk – Prophylaxis for close contacts with immunoglobulin injection Hepatitis B: transmitted via contaminated blood or body fluids; – Incubation 6 weeks – 6 months; Acute symptoms are similar to hep a, but chronic hep b is highly related to the age of the patient – HBsAg is present in acute and chronic – HBeAAg are more infectious – Anti-HBs is seen in resolved infections and in those vaccinated – Anti-HBcAg IgM is diagnostic of acute infection – Measurable HBsAg with negative anti-HBcAg IgM is diagnostic of chronic Hep B – Acute Hep B is treated supportively, chronic Hep B pts may qualify for antiviral therapy – Vaccination is universally recommended Hepatitis C: most common cause of liver disease in the US; transmission via blood or body fluid – 60-85% will develop chronic infection with measurable levels of RNA – Chronic Hep C can lead to cirrhosis and hepatocellular carcinoma – Treat with antiviral therapy using ribavirin or interferon Alcohol Abuse: leads to conjugated hyperbilirubinemia by impairing bile acid secretion and uptake – AST is elevated more than ALT
Renal • most cases of chronic renal failure are caused by DM and HTN (60%) • serum creatinine can be normal in elderly people with chronic renal insufficiency, because they have less muscle mass. • best indicator of the presence of renal failure is the GFR. • ability to concentrate and dilute urine is retained until the GFR falls < 30% of normal. • hypoNa, hyperK, hyperP, and metabolic acidosis (↓plasma bicarbonate) occur in later stages of kidney disease. • anemia generally appears when the GFR falls below 60 mL/min. • ACE inhibitors help prevent the evolution of microalbuminuria to full blown proteinuria. • Renal replacement therapy (transplant or dialysis) is indicated for severe renal insufficiency (GFR <15 mL/min). • CKD higher risk for CVD; die primarily due to CVD, before reaching the need for dialysis.
Renal Failure • • • • • • • • • • • • • •
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First must assess volume status and see if kidneys recover with IV fluids Stage I: GFR 90-100 Stage II: GFR 60-89 Stage III: GFR 30-59 Stage IV: GFR 15-29 Stage V: GFR <15 or dialysis Elevated K treat with sodium polystyrene sulfonate, insulin + glucose, and retention enemas Anemiareduced EPO Edemalow albumin state Hyaline castslong term damage to kidneys Chronic renal failure: GFR < 60 for 3 or more months; decrease in nephrons and function – Is a CVD risk factor ESRD: irreversible loss of kidney function; GFR < 15 Causes: DM, HTN, glomerulonephritis Diagnostics: – >30 mg microalbumin per gram CR – Renal imaging and microscopic evaluation of urine Management: hydration, treat HTN, treat infection, no NSAIDs/aminoglycosides/radiocontrast – Keep BP < 130/80; use ACE or ARB, plus beta blocker, verapamil, or diltiazem if needed – Reduce protein excretion to <500-1000 mg/d, or 60% of baseline – Restrict dietary protein to 0.8-1.0 mg/kg/day – LDL < 100, and ideally <70 – Treat volume overload with Na restriction and loop diuretics – Treat metabolic acidosis with sodium bicarb to maintain concentration of 22 mEq/L – Oral phosphate binders if GFR < 25-30 – May treat with EPO before developing ESRD to reduce symptoms of anemia and CVD
Hematuria Bladder Carcinoma: • Painless hematuria without other symptoms is the most common presentation • Risks: male, smoking, aromatic amines often used in dye, paint, aluminum, textile, and rubber industries. Pseudohematuria: chemical agents, foods, vaginal bleeding; beets, blackberries, certain food dyes; chloroquine, metronidazole, phenytoin, rifampin, and sulfasalazine • Acute prostatitis and UTIs are usually associated with dysuria, fever, and urinary frequency and urgency. • Chronic prostatitis is associated with urinary symptoms as well. • Stones are associated with pain. • <40 yrs with hematuria, but a normal IV pyelogram, urine culture and cytologyperiodic monitoring, and reassurance • > 40 yrs w/hematuria and normal labs/pyelogramcystoscopy would be appropriate. • <20 yrs glomerulonephritis, UTI • 20-40 yrs UTI, stone, trauma, neoplasm • >40 yrs bladder cancer, stone, UTI, renal carcinoma, BPH
Hematuria •
asymptomatic hematuria – – – – – –
Glomerular Hematuria: associated with proteinuria, erythrocyte casts, dysmorphic RBCs Renal hematuria: associated with tubulointerstitial, renovascular, and metabolic disorders Interstitial nephritis: eosinophils in urine; often caused by analgesics or other drugs Urologic hematuria: tumors, calculi, infection, trauma, BPH Gross hematuria worry about malignancy; always needs a work-up Microscopic hematuriausually asymptomatic; no routine screening necessary •
Initial dispstick method should be confirmed by evaluation of urinary sediment
– Malignancy risk factors: smoking, benzene/aromatic amine exposure, hx of gross hematuria, >40 yrs, hx of urologic disorder, irritative voiding symptoms, hx of UTI, analgesic abuse, pelvic irradiation – Radiology: IVP for upper UT, ultrasound, CT (may lead to contrast nephropathy, give Nacetylcysteine), cystoscopy for lower UT – If negative work-upfollow for 3 yrs
Edema • many medications cause peripheral edema as a side effect. – Anti-HTN (CCBs), direct vasodilators, BBs, centrally acting agents, antisympathetics, rosiglitazone, hormones, corticosteroids, NSAIDs
• Bilateral edema + signs/symptoms of CHF (dyspnea, rales, JVD) get chest x-ray to rule in CHF, followed by an Echo. • If ascites is present liver function studies are needed. • check urinalysis If sediment is abnormal, nephritic syndrome or ATN is the likely diagnosis. • Unilateral edema lower extremity Doppler evaluation is indicated unless history of recent trauma/inflammation • Signs of inflammation/erythemacellulitis • chronic venous insufficiency knee-length elastic stockings; leg elevation throughout the day; limit prolonged standing
Thyroid Hashimoto Thyroiditis • -most common cause of thyroiditis, and most common cause of goiter in the US • -middle-aged women, generally presents with enlargement of thyroid, and often there is associated tenderness. • -TSH would be elevated, and the free T 3 and T 4 would be low. Subacute lymphocytic thyroiditisacute increase in thyroid size is seen, it is generally nontender. Subacute granulomatous thyroiditis follows a viral illness and is also associated with a mildly painful gland. Suppurative thyroiditis associated with fever, a swollen thyroid, and clinical manifestations of a bacterial illness. Subclinical hypothyroidism is distinguished by an elevated TSH and a normal free T 4. • -will progress to clinical hypothyroidism at a rate of 2% to 5% per year. • -Risk for progression: presence of thyroid autoantibodies, old age, a female gender, and a TSH level > 10 mIU/L. • -Invasive fibrous thyroiditis gradually increasing gland that is firm, but is nontender. Hyperthyroidism: • -elevated levels of thyroid hormones • -tachycardia is most commonly reported symptom, then fatigue, weight loss, tremor, anorexia, and increased sweating all occur with less frequency. • -Thyroid receptor antibodies are very specific and differentiate Graves disease from other causes of hyperthyroidism. • -Radionucleotide imaging is helpful in Graves, showing diffuse uptake. • -Once a thyroid nodule is found radionucleotide imaging. – If a nodule takes up radiotracer, it is termed a “hot” nodule. – Colloidal cysts and tumors do not take up tracer and are “cold” nodules. – Therefore, “hot” nodules are more likely benign. – Neurofibromas would also be cold.
Hyperthyroid Graves Disease • Symptoms: warm, moist skin, sweating, vasodilation, resting tremor, enlarged thyroid, weight loss, tachycardia, upper eyelid retraction, ophthalmopathy, elevated BP, widened pulse-pressure • Thyroid storm: sudden release of thyroid hormone; fever, confusion, restlessness, psychoticlike behavior • Cause: IgG Abs bind to TSH receptors on thyroid glandgland hyperfunctioning; autonomous thyroid nodule may also secrete thyroixine • Diagnosis: elevated free thyroxine, low TSH; T-99m scan shows diffuse hyperactivity with large uptake in Graves, and patchy uptake with overall reduced activity in thyroiditis • Treat: propylthiouracil (prevents peripheral conversion)and methimazole (inhibits organification), and/or B-blockers; radioactive iodine (ideal if not pregnant) – 40% who receive radioactive iodine become hypothyroid – Medication side effect is agranulocytosis • Hypothyroidism: – lethargy, weight gain, hair loss, dry skin, slowed mentation, constipation, cold intolerance, depressed affect – May be confused with Alzheimer’s in older patients – Most commonly due to Hashimoto thyroiditis – Low free thyroid levels, and high TSH; secondary hypothyroidism have low TSH – Treat with thyroid hormone replacement (Levothyroxine) • Nodular Thyroid Disease: – Increased malignancy in children, <30 or >60, hx of irradiation, family hx – Functional adenomas are rarely malignant; malignancyirregular margins, vascular, microCa – Hyperfunctioning nodules are treated with surgery or ablation – Nonfunctioning nodules >1cm require biopsy (FNA) • Follicular cell malignancy cannot be distinguished from its benign equivalent – Malignant nodulesthyroidectomy followed by radioactive ablation
Hypercalcemia • •
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Corrected serum Ca = (normal Albumin – Pt’s albumin) x 0.8 x serum Ca PTH, calcitonin and 1,25 dihydroxyvitami D3 (calcitriol) regulate Ca – Thyroid parafollicular cells make calcitonin to lower Ca levels through renal excretion and opposing osteoclast activation; this excretes Ca and P – PTH promotes osteoclast activation, mobilizing Ca from bone and Ca resorption at the kidneys – PTH also increases calcitriol levels which promote Ca and P absorption from GI tract Symptoms: kidney stones, bone pain, arthritis, osteoporosis, poor concentration, weakness, fatigue, stupor, coma, abdominal pain, constipation, nausea, vomiting, pancreatitis, short QT, arrhythmias Common causes of hypercalcemia: – Primary hyperparathyroidismsporadic, familial, MEN I or II; usually due to an adenoma – Malignancysolid lung, squamous ca of head/neck, renal, breast, multiple myeloma, prostate; tumor secretes PTH-rP or via direct osteolysis – Hypervitaminosis Aincreased bone resorption – Immobilizationincreased risk when underlying disorder of high bone turnover (paget’s) – Hypervitaminosis Dincreased calcitriol leads to increased GI absorption of Ca and P – Granulomatous TB, sarcoidosis, hodgkins; extrarenal conversion of 25 OH D3 to calcitriol – Milk alkali syndromeexcessive intake of Ca containing antacids – Medications thiazides, lithium; reduced urinary excretion or increased PTH – RhabdomyolysisCa released from injured muscle – Adrenal insufficiencyincreased bone resorption and increased protein binding of Ca – Thyrotoxicosisincreased bone resorption – Familial hypocalciuric hypercalcemiadefect in Ca sensing receptor Treat: hydration, avoid thiazides, physical activity, avoid inactivity, parathyroidectomy
CVA/TIA • • •
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First get a brain CT without contrast, as well as blood sugar, electrolytes, renal function, drug screen If more than 3 hrs since the attack, patient is not a candidate for thrombolytic therapy TIA: focal neuro deficit lasting less than 24 hrs, often less than 1 hr; increased risk for subsequent stroke – Risk factors: HTN, DM, age, sex, race, heart disease, smoking, hyperlipidemia – 95% are due to atherothromboembolism, cardiogenic embolism, and small vessel disease Stroke: sudden onset of focal neuro deficit, lasting >24 hrs – MCAaphasia, contralateral hemiparesis, sensory loss, spatial neglect, contralateral impaired conjugate gaze – ACAfoot and leg deficits with cognitive and personality changes – Vertibrobasilarmotor or sensory loss in all 4 limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria, dysphagia – Cerebellumipsilateral limb ataxia and gait ataxia Initial treatment: supplemental oxygen, cardiac monitor, cautiously treat HTN, antipyretic if febrile – Give anti-HTN if systolic >220 or diastolic >120; or, if pt is suitable for thrombolytic treatment, give anti-HTN to reduce systolic <185 and diastolic <110; IV labetalol, nicardipine, and sodium nitroprusside are often used – Pts with non-hemorrhagic stroke should get aspirin in the first 48 hrs – Give DVT prophylaxis if not getting tPA – Pts should get rtPA if they can be treated in the first 3 hrs • Contraindications: recent surgery, trauma, MI, use of anticoagulants, uncontrolled HTN • Risk of hemorrhage is 5% Prevention: quit smoking, reduce EtOH, treat HTN as per JNC-7 guidelines, LDL <100, tight diabetic control, aspirin – Carotid endarterectomy can reduce risk of stroke in pt with history of TIA/CVA and carotid artery stenosis; indicated if >70% stenosis, or for symptomatic patients with 50-70% stenosis • Warfarin anticoagulation is useful for pts with a.fib, ischemic stroke caused by MI and LV thrombus, cardiomyopathy, rheumatic mitral valve disease, prosthetic heart valves
Tremor Parkinson Disease: • tremor is typically seen at rest and inhibited by movement • glabella tap reflex is tested by percussing the pts foreheadorbicularis oculi muscle contracts causing both eyes to blink. The blinking normally stops after 5 to 10 repeated taps, but persistence of blinking is called Myerson sign and is common among patients with PD. • MAO B inhibitors (selegiline) ↓morbidity and mortality in PD and delay functional impairment and disease progression. Other therapies provide symptomatic relief only, and do not modify disease progression. Essential tremor: • bilateral, usually symmetric and either postural (elicited by holding the arm against gravity) or kinetic (more apparent during purposeful movement). Intention tremor: • Its amplitude will increase during visually guided movements.
Delerium, Dementia, AMS • history of HTN think of multi-infarct dementia, rather than delirium (focal neurologic deficits and papilledema) • in dementia, the level of consciousness is not clouded, but disorientation may occur later in the illness. • abrupt onset of a mental status change is consistent with delirium. • narcotic excesspinpoint pupils • DTsdilated pupils and sympathetic outflow • EtOH withdrawlhyperalert confusion • Amphetamine withdrawal psychomotor slowing. Alzheimer’s Disease: • ↑age is the strongest risk factor. By 65, 1% meets diagnostic criteria, and the prevalence doubles every 5 years • Family hx is risk factor- individuals with a first-degree relative with the disease are 4x more at risk • other risk factors: female gender, low levels of education, CV risk factors, and a history of head trauma. • Remote memories are well-preserved initially; ability to recall new information is lost early in the illness. • Difficulty with word-finding is also noted early. • ↓ability to recognize & draw complex figures is an early sign of problems, as is loss of the ability to calculate. • Social propriety and interpersonal skills often remain strikingly preserved until late in the illness. • no labs to independently confirm a diagnosis of Alzheimer disease. • Structural imaging is important to rule out other causes as well and may include either a CT scan or an MRI. • MMSE, the clock drawing test, or other brief screening tools may be most useful in the diagnosis. • 3 cholinesterase inhibitors for treatment: donepezil (Aricept), galantamine (Reminyl), & rivastigmine (Exelon). • ↓ metabolism of acetylcholinesterase, thereby prolonging its action at cholinergic synapses. • modest improvements in cognition, behavior, ADLs, and global measurements of functioning. • they do not change the progression of neurodegeneration. • donepezil modest clinical improvement but no difference in rate of institutionalization or progression • Pts with advanced disease have benefit from Memantine, with or without concomitant use of an acetylcholinesterase inhibitor. Lewy Body Dementia: begins similarly to Alzheimers, but pts develop complex visual hallucinations and spontaneous signs of parkinsonism
Dementia •
Alzheimer’s Disease: most common cause of dementia – – – – – –
Definitive diagnoses by neuritic plaques and neurofibrillary tangles on autopsy Gradual onset and progression of cognitive dysfunction in more than 1 area of mental function Should use a validated test, like the MMSE, to confirm presence of dementia Depression in elderly can present with symptoms of memory disturbance = pseudodementia Hypothyroidism, B12 deficiency, and neurosyphilis can also present like Alzheimer’s Treatments: cholinesterase inhibitors • • •
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Mild-moderate: Donepezil, Galantamine, Rivastigmine Alzheimer’s dementia: Tacrine – must monitor liver enzymes Severe: Memantine
Vascular Dementia: multi-infarct dementia is the second most common cause of dementia – Symptoms related to amount and location of neuronal loss – Sudden onset and progresses in a stepwise fashion
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Other illnesses associated with Dementia – Parkinson disease, normal pressure hydrocephalus, lewy body dementia, chronic alcohol abuse, sedative use, anticholinergic use, hypothyroidism, B12 deficiency, neurosyphilis, hypoNa, AIDS
Syncope • Hct, serum creatine kinase, glucose, ECG, carotid massage, orthostatic BP, & evaluation of pulses should be done • Additional testing Holter monitor, Echo, ambulatory loop ECG, & tilt table testing yields a diagnosis in 5% of patients. • Tilt table testing is recommended in pts with unexplained recurrent syncope if cardiac causes have been ruled out. • An abnormal result suggests vasovagal syncope. • Psychiatric eval should be considered if the tilt table is normal, especially if associated with other psychiatric symptoms (anxiety, depression, fear, or dread). • Carotid Dopplers and MRI of the brain should be reserved for people with bruits or focal neurologic signs. • Stress testing is indicated if there is high risk for, or symptoms of, ischemic disease.
Geriatrics •
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Hearing screening: 1/3rd of those >65 and ½ of those >85 have some hearing loss; whispered voice test – Presbycusis, noise-induced hearing loss, cerumen impaction, otosclerosis, central auditory processing disorder • most common cause of hearing loss in the elderly; age related sensorineural hearing loss associated with selective high frequency loss & difficulty with speech discrimination – Noise induced: tinnitus, difficulty w/ speech discrimination, problems hearing background noise – Otosclerosis: autosomal dominant; progressive conductive hearing loss – CAPD: difficulty understanding spoken language but may be able to hear sounds well 25% of patients > 65 have impairments in IADL or ADLs – IADLs: transportation, shopping, cooking, telephone, managing $, taking meds, cleaning, laundry – ADLs: bathing, dressing, eating, transferring from bed to chair, continence, toileting Vision screening: Snellen chart or Jaeger card is most sensitive and specific screening – Vision loss: presbyopia, macular degeneration, glaucoma, cataract, diabetic retinopathy – Age related macular degeneration is the leading cause of severe vision loss in elders; atrophy of cells in central macular region of retinal pigment epithelium, resulting in loss of central vision – Cataract disease: most common cause of blindness worldwide Fall Assessment: leading cause of nonfatal injury Cognitive screening: prevalence of dementia doubles every 5 yrs after 60 Clock draw and three item recall Depression screening: two question screen Nutrition screening: serial weight measurements and inquiry about changing appetite HTN screening: heart and CV disease are leading causes of death; thiazides are drugs of choice Stroke prevention: stroke incidence doubles with each 10 yrs; greatest risks are HTN and a.fib Cancer screening: colon and breast cancer screening until life expectancy is below 5-10 yrs Osteoporosis screening: CaCO3 and Vit D reduce osteoporotic fractures; DEXA scan if >65 Immunizations: >65 get annual influenza & 1 pneumococcal shot; booster of tetanus & diphtheria shot; Zoster
HIV/AIDS •
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PCP pneumonia is an AIDS defining illness in someone with HIV – Nonproductive cough, fever, dyspnea that worsen over a few days to weeks; febrile, tachypnic, hypoxic – Bilateral interstitial infiltrates on xray; ground glass appearance – Commonly seen with candidiasis, diarrhea, Kaposi sarcoma, wasting syndrome – Give prophylactic treatment with TMP-SMX in pts with CD4<200 Initial HIV exposure: nonspecific symptoms, low grade fever, fatigue, myalgias; known as seroconversion syndrome; most experience clinical latancy for 6-9 months after primary infection Category A: asymptomatic HIV, primary HIV, persistent generalized lymphadenopathy Category B: symptomatic conditions indicative of defect in cell mediated immunity – Bacillary angiomatosis, ITP, candidiasis, listeriosis, PID, cervical dysplasia, peripheral neuropathy, oral hairy leukoplakia, herpes zoster Category C: AIDS defining illnesses are present; CD4 <200 with or w/o symptoms is considered a diagnosis of AIDS – Bronchi/trachea/lung/esophagus candidiasis, invasive cervical cancer, coccidiodomycosis, etrapulmonary crptococcus, intestinal cryptosporidiosis, CMV, HIV encephalopathy, HSV chronic ulcers/bronchitis/pneumonitis/esophagitis, disseminated/extrapulmonary histoplasmosis, intestinal isosporiasis, Kaposi sarcoma, burkitt lymphoma, immunoblastic lymphoma, brian lymphoma, MAC, mycobacterium TB, PCP, recurrent pneumonia, PML, recurrent salmonella septicemia, toxoplasmosis of brain, wasting syndrome Diagnosis: positive ELISA tests should be confirmed by western blot – HIV RNA levels, CD4 levels should be monitored – Do initial screen for STDs, Hep B and A vaccine should be given, get PPD, Pap smear Treat: give annual influenza vaccine; offer pneumococcal vaccine if CD4 <200 – Live virus vaccines are contraindicated in HIB pts and their close contacts – Prophylaxis against PCP with TMP-SMX when CD4 <200 – MAC prophylaxis with azithromycin or clarithromycin if CD4<50
HIV • • • • • • • • • • • •
Health care workers should be tested for HIV ASAP after needle stick and therapy should be initiated using at least 2 meds to which the source would unlikely be resistant. window period of several weeks - 4 months between infection and seroconversion when tests may be negative. During this time, pts may be viremic & infectious, but not have sufficient levels of antibodies to result in + tests. If there is strong clinical suspicion, plasma HIV RNA should be ordered. More HIV infected women die of cervical cancer than from AIDS Pap testing every 6 months. In HIV-infected individuals, 5 mm is considered a positive test. Prophylaxis against MAC should be instituted once CD4 count drops < 75 to 100 lymphocytes/mm Prophylaxis against PCP should be considered once CD4 count drops < 200 lymphocytes/mm 3. Prophylaxis for fungal disease, herpes simplex and zoster is not generally done. CMV prophylaxis can be instituted in those with CMV IgG positivity and with CD4 counts < 50 lymphocytes/mm 3, but it is generally not done because ganciclovir (the primary prophylactic agent) can cause neutropenia. PCP: treatment of choice is TMPSMX for 3 weeks. corticosteroids improve course of pts with moderate to severe PCP with O2 sat < 90% or a PaO 2 < 65 mm Hg.
Ethics – Emancipation: person younger than 18 petitions to be declared a legal adult • Live apart from parents, self-sufficient, married, pregnant or a parent, in the military, declared so by judicial system
– Mature Minor/Judicial Bypass: minor may consent to receive care w/o parent consent if deemed mature by the judicial system – Ethical Principles: autonomy, beneficence, nonmaleficence, justice
Growth Charts • • • • • • • • • • • • • • • •
concern should be raised when a child drops > 2 %ile brackets on a growth curve and does not maintain at that area. In the US, the majority of FTT is 2ndary to inadequate nutrition & a dietary history is most likely to reveal the cause. Albumin has a long half-life and is a poor indicator of recent undernutrition. Prealbumin is ↓in acute inflammaTon and undernutrition and is therefore insensitive. Organic disease, including hypothyroidism, is found in < 10% of cases of FTT. IgA levels are sensitive to undernutrition and would be ↓in FTT. FTT + diarrhea and recurrent respiratory infectionscystic fibrosis must be considered FTT + wet burps/emesis/cough get esophageal pH probe. FTT + diarrhea or melenainflammatory bowel disease may be considered, and a hemoccult test would be necessary. FTT + diarrhea, ab pain, foul-smelling stoolslactose intolerance may be considered; lactose tolerance test FTT + projectile vomiting, ab distention, palpable masspyloric stenosis; get ultrasound familial short stature growth curve shows simultaneous changes in height and weight. FTT & constitutional growth delayweight ↓first, then height. hypothyroidismheight velocity slows first and may plateau before weight changes. breast-fed infantsweight ↓relaTve to peers aZer 4 to 6 months, but catches up aZer 12 months. Hospital admission is indicated for FTT if: hypotension, bradycardia, severe malnutrition.
Well Child Care • • • • • •
FTT: weigh below 3rd-5th %, or deceleration of growth across 2 major growth %iles in short time All states require PKU and congenital hypothyroidism screening Lead screening: once at 9-12 mo and once at age 2 Begin to measure blood pressure at age 3 Car seat rear facing until 20 lbs & 1 yr old; forward facing seat 20-40 lbs; booster seat until 4 ft/60 lbs Developmental Milestones: – – – – – – – – – – –
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1 mo: reacts to pain, responds to noise, regards human face; eye contact 2 mo: eyes to midline, head prone, vocalizes, social smile, recognizes parent 4 mo: eyes past midline, rolls over, laughs/squeals, regards hand 6 mo: sits unsupported, transfers objects, rolls prone to supine, babbles, recognizes strangers 9 mo: pincer grasp (10), crawl, cruises, mama/dada, bye-bye, starts to explore 12 mo: walks, throws, 1-3 words, 1 step command, stranger/separation anxiety 2 yr: walk up/down stairs, copies line, runs, kicks ball, 2-3 word phrases, ½ understood speech, refers to self by name, pronouns, parallel play 3 yr: copies circle, tricycle, 3 numbers, sentences, ¾ understood, 3 colors, group play, play simple games, knows gender, knows first and last name 4 yrs: body parts, copies cross/square, hops, throws overhand, completely understood, uses past tense, tells a story, social interaction 5 yrs: copies triangle, catches ball, dresses self, writes name, count 10 objects 6 yrs: draws person, ties shoes, skips, identifies left and right
Strabismus: asymmetric light reflex, refer to ophthalmologist
Abdominal/Vomiting Pain (Peds) • First steps: IV fluid hydration, surgery consult, ab xrays, NG tube; possible contrast study • Intussusceptions: intermittent severe pain with gradual and slow bowel telescoping; bilious vomiting; currant jelly stools; sausage shaped mass; mass if often at the ileocecal junction; barium enema will be diagnostic and therapeutic • Pyloric stenosis: olive shaped mass palpable in the RUQ; projectile vomiting between 3-6 wks; nonbilious vomiting after meals; peristaltic waves across upper abdomen; GI contrast shows double track sign • Malrotation: 60% are less than one month; bilious vomiting and abdominal pain; get an upper GI series; beaklike appearance of contrast medium; surgery is treatment • Foreign bodies: flat disk batteries need immediate intervention; most objects will come out in stool • Poisoning: another cause of vomiting and ab pain in children
Limping and Pain (Peds) • •
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Antalgic gait: when stance phase of gait is shortened, usually because of pain during weight bearing SCFE: most common nontraumatic hip pathology in adolescents; separation of growth plate with the femoral head being posteriorly displaced; treat by surgically pinning the femoral head – Common in obese adolescent males – Pain with internal rotation of the hip; obligate external rotation on passive flexion Septic Arthritis: monoarticular and associated with systemic signs; children lay with their hip flexed, abducted, and externally rotated; joint must be aspirated; GBS, staph aureus, strep pyogenes; purulent aspirate with WBC > 50,000 Toddler’s Fracture: spiral fracture of the tibia that results from twisting while the foot is planted; tibial tenderness and normal knee and upper leg Congenital dysplasia of the hip: painless limp from the time the child learns to walk Transient synovitis: self limited, often after a viral infection; low grade or no fever; normal WBC, normal ESR; pain with internal rotation of the hip and overall ROM limited by pain; yellow-clear aspirate with WBC < 10,000 Legg-Calve-Perthes: avascular necrosis of the femoral head in children 4-8; more common in boys; gradual onset of hip, thigh, or knee pain and limping; collapse, flattening, and widening of the femoral head; treatment is conservative; high risk of developing degenerative arthritis
Non-Asthma Wheezing (Peds) • • •
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Acute wheezinginfectious or mechanical obstruction Chronic wheezing anomalies of tracheobronchial tree, CV disease, GERD, immunologic disorder Bronchiolitis: most common cause of acute wheezing in children < 2yrs, esp infants 1-3 mo – RSV accounts for 70%; the rest are parainfluenza, adenovirus, mycoplasma, metapneumo – Diagnosis is clinical, and includes rhinorrhea, wheezing, cough, irritability, dyspnea – Supplemental O2 and supportive care are the modes of treatment – Nebulized epinephrine, ipratropium or corticosteroids may be helpful – RSV Ig can be given before RSV season for children younger than 2 born prematurely Croup: most common airway obstruction in children ages 6 mo – 6 yrs – Inflammation of the subglotting region that produces barking cough, hoarseness, stridor – Parainfluenza, RSV, rhinovirus, enterovirus, influenza viruses – Runny nose and low grade fever prodrome – Steeple sign on radiology – Give coolmist therapy, corticosteroids, nebulized epinephrine Epiglottitis: bacterial infection of supraglottic tissue usually in children younger than 5 yrs – H. influenza, strep pneumo, staph aureus, beta hemolytic strep – Child looks toxic with fever, severe sore throat, muffled speech, drooling, dysphagia – Tripod position with neck hyperextended – Thumb sign on xray; CBC shows leukocytosis, neutrophilia, bandemia – Treat with airway management and antibiotics Foreign body airway obstruction: most common from 6mo – 3 yrs – Weak cough, inability to speak or cry, high pitched sounds or no sounds during inhalation, cyanosis, choking, vomiting, drooling, wheezing, blood-streaked saliva, unilateral wheezing, decreased breath sounds, stridor – Do not to a blind finger sweep; may attempt opening the airway with head tilt
Fever and Rash (Peds) •
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Roseola: – HHV6, infects most children before age 3; fever and mild respiratory symptoms that last for 5 days, followed by an erythematous maculopapular rash that suddenly appears; rash disappears in 1-2 days and no treatment is usually necessary Varicella: – fever and rash which develops in clusters; exanthema is often papules or vesicles on an erythematous base; dewdrops on a rose petal; vesicles progress to shallow, crusted erosions; confirmed with Tzanck smear or DNA probe; antiviral therapy may shorten disease course if given within 72 hrs of onset Erythema Infectiousum: – parvovirus B19/fifth disease: infects children under 10 yrs in the winter and spring; rash starts as confluent erythematous macules on the face and spares the nose and periorbital regions; slapped cheek appearance; rash lasts 2-4 days followed by lacy pruritis exanthema on the trunk and extremities lasting 1-2 weeks; may be given to fetus during pregnancy, resulting in hydrops Group A Beta-Hemolytic Strep: – can cause strep pharyngitis, rheumatic fever, glomerulonephritis; rash of scarlet fever starts 2 days after onset of sore throat; rash is punctuate, raised, erythematous eruptions that feel like sandpaper; rash starts on upper trunk and spreads to the rest of the trunk and extremities; strawberry tongue is common; rash fades and desquamation occurs 4-5 days after the first appearance of rash; confirm infection with rapid antigen testing or culture and treat with PCN Neisseria Meningitidis: – high fever, hypotension, altered mental status, meningeal irritation; rash often starts as an erythematous maculopapular eruption that progress to form petechiae; prophylaxis for close contacts with rifampin Rocky mountain spotted fever: – acute, life-threatening infection caused by rickettsia rickettsii, transmitted by tick; acute fever, headache, myalgia, fatigue; the classic exanthema is a macular, popular or petechial eruption that starts on the wrists and ankles; low WBCs, low platelets, elevated liver enzymes; treat with doxycycline Lyme Disease: – erythema migrans develops 3-30 days after infection; expanding erythematous macule with a central clearing looking like a bully’s eye; treat with oral doxycycline
Childhood Enuresis • • • • • • • • • •
spontaneous nocturnal voiding into bed/clothes at least 2x/week for 3 consecutive months in a child who is at least 5 yr Primary monosymptomatic enuresis: bed-wetting w/o history of nocturnal continence & no other symptoms. cause is unknownfelt to be due to ↓producTon of nocturnal ADH. associated with a maturational delay; 25% of 5-year-olds are enuretic. Family history is important1 parent enuretic, 40% likelihood child will be. If both parents, 70% risk. Enuresis alarms have been shown to be an effective treatment for nocturnal enuresis. Frequent nighttime wakening may be effective, but compliance is a barrier to effectiveness. DDAVP can also be effective, but relapse rate is high once the medication is discontinued. Secondary monosymptomatic enuresis: recurrence of bed-wetting after at least 6 months of nocturnal continence. Non-monosymptomatic: bed-wetting associated w/urgency, frequency, straining, pain, chronic constipation, encopresis
Breast Changes •
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Fibrocystic Changes: most common benign condition of the breast. – ↓caffeine and methylxanthines, or using evening primrose oil may ↓symptoms – Cysts: range in size from 1 mm to > 1 cm in size. Fibroadenomas: rubbery, smooth, well-circumscribed, nontender, and freely mobile. Mastitis: occurs with nursing, and is characterized by inflammation, edema, and erythema in areas of the breast; – continue nursing, and start antibiotic that covers streptococcal & staphylococcal infections. Mammograms: Up to 15% of breast cancers are mammographically silent. palpable mass deserves further workup, even if the mammogram is negative do an ultrasound to determine if the mass is cystic or solid, and possible biopsy. Aspiration of the mass may be appropriate, but biopsy is still necessary if the mass is palpable after aspiration, if the fluid is bloody, or if the mass reappears within 1 month. Spontaneous, unilateral discharge is most suspicious for breast cancer; bloody, serous, serosanguineous, or watery discharge deserves a workup as well. abnormality seen on a mammogram is classified using the breast imaging reporting and data system (BI-RADS). – BI-RADS classification 0 means that the test was incomplete, and additional testing should be conducted ASAP – BI-RADS 1 & 2 mean that the mammogram is benign, and routine screening can be conducted at usual intervals. – BI-RADS 3 indicates the lesion is probably benign, but diagnostic mammogram should be performed in 6 mo – BI-RADS 4 and 5 are suspicious for, and highly suggestive of, cancer (respectively) and tissue diagnosis is needed Gynecomastia: benign enlargement of the male breast. – may be asymptomatic or painful, bilateral, or unilateral; Most cases resolve within 1 year. – commonly occurs around puberty, and if so, requires only a history, physical, exam, and reassurance – Outside puberty, assessment of hepatic, renal, and thyroid functions may help uncover a cause. – Sex hormones are only tested if progressive enlargement is noted.
Breast Disease • •
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Breast cancer risks: family hx of breast cancer, early age menarche, late age menopause, nulliparity, first birth after age 30, HRT use, obesity, physical inactivity, EtOH use Palpation of a new breast mass should prompt a FNA – Clear, yellow or green fluid that results in complete resolution is diagnostic of a benign cyst and pt can follow up in 4-6 wks to evaluate for recurrence of the lesion – Bloody fluid, a mass that doesn’t resolve, or a lesion that recurs requires more evaluation; Diagnostic mammography is the next test Ultrasound can be used to determine if the lesion is solid or fluid filled and can assist with aspirating cystic lesions – Masses found to be solid or complex should be biopsied Core needle biopsies are done using ultrasound or mammographic guidance Breast pain: not a common presentation of breast cancer – Cyclic mastalgia: diffuse, bilateral and related to menstrual cycle – Noncyclic mastalgia: unilateral and more common in postmenopausal – Nonmammary pain: pain not from the breast, but usually from the chest wall – Life style changes such as smoking cessation, caffeine elimination, stress reduction, primrose oil will help with breast pain; severe pain can be treated with danazol Nipple Discharge: usually benign; discharge that is spontaneous, persistent, bloody, from a single duct, associated with a mass, is more likely to represent a pathologic process – Most common non-benign causes are intraductal papilloma, duct ectasia, cancer, infection – Pt should get mammogram – Treatment of most unilateral, spontaneous or bloody nipple discharge is surgical excision of the terminal duct involved Galactorrhea: hypothyroidism, hyperprolactinemia, pituitary adenoma, medications, pregnancy
Menstrual Cycle Irregularity •
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Normal menstruation: estrogen production by the ovaries is regulated by the hypothalamus and pituitary; estrogen builds up the endometrial lining; after ovulation, the corpus luteum produces progesterone, which compacts the endometerium; if conception does not occur, the production of progesterone abruptly decreases, resulting in sloughing of endometrium Amenorrhea: absence of menstrual bleeding for 6 or more months w/o pregnancy Menometororrhagia: heavy menstrual flow or prolonged duration of flow at irregular intervals – Abnormal bleeding with irregular cycles is known as dysfunctional uterine bleeding and implies an abnormality with the hypothalamic-pituitary-ovarian axis – This is more common shortly after menarche and only require watchful waiting at that time – Continuous estrogen stimulation can lead to endometrial hyperplasia and carcinoma which may present as irregular uterine bleeding Menorrhagia: excessive menstrual flow, or prolonged duration >7 days at regular intervals – Ovulation is occurring – Leiomyomata (fibroids) are a common cause of this problem – If volume of menstrual bleeding is reduced but there is regular ovulation, think about asherman syndrome, which is scarring of the uterine cavity caused by trauma from uterine curettage Metrorrhagia: bleeding occurring at irregular intervals Poly/oligo menorrhea: cycles < 21 or >35 days apart, respectively PCOS clinical picture: obese, hirsute woman with ongoing weight gain and irregular menses – Insulin resistance and androgen excess with anovulatory menstrual cycles – Can induce menstruation by giving progesterone or OCPs – Treat with lifestyle modification- diet, exercise, weight loss Endometrial Cancer: risk factors are a history of anovulation, obesity, nulliparity, over age 35, use of tamoxifen, or unopposed exogenous estrogen – Work up: transvaginal ultrasound, endometrial biopsy; hysteroscopy with D and C can be therapeutic If the work up for abnormal bleeding does not reveal malignancy, anovulatory bleeding is usually responsive to treatment with OCPs or progestin
Menstrual Cycle Irregularity Primary amenorrhea: • No menses at 16 in presence of normal secondary sex characteristics; no menses at 14 in the absence of secondary sex traits • usually the result of a genetic or anatomic abnormality (gonadal dysgenesis, Turner syndrome) • amenorrhea + ↑testosterone & DHEA-S CT of adrenal glands & ultrasound of ovaries to rule out neoplasm. • Primary amenorrhea w/normal secondary sex characteristics & normal initial labs progestin challenge test. • When no withdrawal bleedingeither inadequate estrogen production or outflow tract obstruction. • No withdrawal bleeding after estrogen-progestin challenge outflow obstruction or anatomic defect. Hypothalamic failure: anorexia nervosa, excessive exercise, chronic or systemic illness, severe stresssuppression of hypothalamic GnRH Pituitary failure • -inadequate GnRH stimulation; history of head trauma, shock, infiltrative processes, pituitary adenoma, or craniopharyngioma. Polycystic ovarian syndrome: • -primary amenorrhea; generally associated with normal breast development. • -androgen excess, and symptoms include irregular or absent menses, hirsutism, acne, and virilization Constitutional delay of puberty: common in boys; uncommon in girls, clinically very hard to distinguish from other more common causes. Secondary Amenorrhea: • Pregnancy is the most common cause • Polycystic ovarian syndrome is common and is responsible for ~ 30% of the cases of secondary amenorrhea. Anovulatory Bleeding: • caused by continuous unopposed endometrial estrogen stimulation; progesterone from the corpus luteum is not secreted • most common cause of dysfunctional uterine bleeding in women < 20, accounting for ~ 95% of cases. Postmenopausal Bleeding: needs an endometrial biopsy to rule out endometrial cancer.
Pap Smear Results • • • • • • • • •
ASCUS repeat in 4 - 6 months & 1 year, HPV testing, or colposcopy. If the HPV testing is negative, the pt is low risk for cancer, and Pap can be repeated in 1 year. ASCUS + HPV testing is positive colposcopy (if over 33 yrs) or wait for infection to clear (if under 33 yrs) ASCUS, HPV testing unavailable colopscopy or repeat the Pap smear in 4 -6 mo. If repeat Pap has results of ASCUS or higher, a colposcopy should be performed. If the repeat is normal, Pap should be repeated again in 4-6 mo. If next repeat Pap is negative, frequency of testing can return to normal. If you perform a colposcopy and no CIN is found, Pap should be repeated in 12 mo and the frequency of testing can return to normal. If patient is postmenopausal and not taking estrogen, Pap can be repeated 1 wk after a course of vaginal estrogen (4 wks). If the smear remains abnormal, colposcopy can be considered. ASCUS, favoring LSILcolposcopy. atypical glandular cells (AGUS) colposcopy, or endometrial biopsy if the atypical cells are of endometrial origin
Pelvic Pain Ovarian cysts: • unilateral dull pain that can become diffuse and severe if the cyst ruptures. • smooth mobile adnexal mass with peritoneal signs if the cyst ruptures. PID: • fever, vaginal discharge, dysuria; gradual in onset and bilateral. • Treatment should provide coverage for N.gonorrhoeae, C.trachomatis, anaerobes, and enteric gram-neg rods ceftriaxone 250 mg IM + doxycycline 100 mg BID for 14 days with or w/o metronidazole 500 mg BID for 14 days. • Inpatient treatment w/parenteral antibiotics for pregnant women, pts with severe illness with fever & vomiting, and where surgical emergencies can’t be ruled out; may be necessary for those who fail outpatient regimen Ectopic pregnancy: • pain is colicky, and may radiate to the shoulder if there is a significant hemoperitoneum. • Nausea, a symptom of pregnancy, is a diagnostic clue. Ovarian Mass • 80 % of ovarian masses in girls < 15 years are malignant. • any adnexal mass should be evaluated by transvaginal ultrasound and referral for surgical removal. • In many women of childbearing years, adnexal masses are commonly cysts. • If the pain is not acute or recurrent, palpable cysts < 6 cm may be monitored with repeat pelvic exam.
OCPs • • • • • • •
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may cause small ↑in BP; risk ↑with age. Once disconTnued, BP usually returns to normal within 3 months. androgenic (hair growth, male pattern baldness, nausea) & estrogenic (nausea, breast tenderness, fluid retention). Weight gain is thought to be common, but multiple studies have failed to show it to be statistically significant side effect most cited as the reason for stopping use is irregular bleedingcommon in first 3 mo 3x risk of venous thromboembolism. protective effect against ovarian cancer and endometrial cancer. If an active pill is missed, and no intercourse has occurred in 5 days, 2 pills should be taken immediately & a backup method used for 7 days. If intercourse occurred in the previous 5 days, emergency contraception should be used immediately & pills restarted the following day. A backup method should be used for 5 days. Progestin-only pills: – ovulation suppression, cervical mucus thickening, endometrium alteration, & tubal transport inhibition. – effectiveness of this method is dependent on consistency of use. – no hormone-free period with these pills, and they should be taken every day. – do not ↑risk for thromboembolism, and the WHO has reported this to be safe for women with a history of VTE, PE, DM, obesity, or HTN. – Nursing women can use this pill, but there is FDA approval for use in others as well. OCPs containing estrogen and progestin components are contraindicated in smokers > 35 yrs, because of ↑risk of thromboembolic events. An intravaginal ring or transdermal patch that releases estrogen & progestin is contraindicated in smokers > 35 Women who use IUDs are at higher risk for acquiring a STD and developing PID as compared to women who use barrier or other hormonal birth control methods, and patients should be screened carefully
Contraceptives •
Hormonal contraceptives – – –
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Contraindicated if >35 and a smoker, thromboembolic disease, cerebral vascular disease, coronary occlusion, impaired liver function, breast cancer, abnormal vaginal bleeding, congenital hyperlipidemia OCPs offer significant protection against ovarian cancer, endometrial cancer, Fe deficiency anemia, PID, and fibrocystic breast disease Minipill reduces cervical mucus and causes it to thicken
Depo-Provera: injectable progestine every 14 weeks Transdermal: similar to OCPs Intravaginal Ring Spermicide used alone: when used with a condom, failure rate is similar to OCPs Condoms: effective at preventing STDs Diaphragm: spermicide must be placed inside the diaphragm for it to be effective; leave for 6 hrs IUD: alters the uterine and tubal fluids, inhibits transport of sperm through mucus and uterus; high risk of PID; recommended for women in mutually monogamous relationships; contraindicated if recent/recurrent endometritis, PID, or STD, pregnancy, anatomically distorted uterine cavity, HIV; complications include perforation, septic abortion, ectopic pregnancy Natural Family Planning: measure basal body temp, cervical mucus changes Emergency contraception: high doses of COPS within 72 hrs decrease pregnancy risk by 74%; mifepristone is effective after 72 hrs; 2 oral doses of levonorgestrel (plan b)
Emergency Contraception • should be used within 72 hrs of intercourse, well before implantation (5-7 days after intercourse). • limited hormonal exposure, and have not been shown to increase the risk of VTE, stroke, or MI. • no medical contraindications • do not disrupt an already implanted pregnancy and do not cause birth defects. • Progestin ECPs prevent 85% of expected pregnancies, and combined ECPs prevent 75%
L&D • •
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ROM: visualize fluid, pH >6.5 in vaginal fluid on Nitrazine paper, ferning on air-dried microscope slide First stage of labor: onset of labor until cervix is completely dilated – Latent phase- contractions become stronger, longer lasting more coordinated – Active phase- starts at 3-4 cm of cervical dilation and goes at 1.2-1.5 cm / hr Second Stage of labor: from complete cervical dilation until delivery of the fetus – Normally lasts less than 2 hrs in nulliparous, and <1 hr in parous Third stage of labor: after delivery of baby and ends with delivery of the placenta; <30 minutes Progress of labor is determined by: Power, passenger, pelvis Fetal Heart Rate: normal is 110-160 – Bradycardia: maternal hypothermia, meds, heart block, fetal distress – Tachycardia: maternal fever – Acceleration: increase in HR >15 beats/min for >15 sec – reassuring – Deceleration: early coincides with contraction/increased vagal tone by compression of the fetal head; late decels are after contractions and show uteroplacental insufficiency/maternal hypotension, epidural anesthesia, oxytocin, HTN, DM; variable decels are due to umbilical cord compression during contractions Cardinal Movements: Flexion, Internal Rotation, extension, external rotation Variability: – Decreased in sleep, CNS depressants, neuro abnormality, prematurity, acidemia GBS: – Penicillin in labor; alternatives- ampicilin, cephalothin, erythromycin, clindamycin, vancomycin
Prenatal Care • • • • • • • •
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First prenatal visit: CBC, HBsAg, HIV, RPR, UA, UC, rubella, blood type, Rh, Pap, GC/Chlam Naegele’s rule: subtract 3 mo and add 7 days to first day of LMP Follow-up visits every 4 weeks until 28 wks, then every 2 weeks from 28-36 wks, then every week Ultrasound not required if uncomplicated; accurate within 1 wks in 1st tri; 2 wks in 2nd tri; 3 wks in 3rd Radiation exposure: risk for baby only if >5 rads (dental xray is 0.00017 rads) Folic acid: low risk women should take 500 micrograms; 1mg if high risk; 4mg if previous child with NTD Use methyldopa and CCB to treat HTN; avoid ACE, ARB, thiazide in first 2 trimesters Trisomy screening: ideally between 16-18 wks – Triple screen: 65% sen; 95% sp- tests hCG, estriol, AFP – Quadruple screen: adds inhibin; 80% sen Amniocentesis: 15 weeks; 0.5% risk of spontaneous abortion CVS: 10-12 wks; 1-1.5% risk of spontaneous abortion; may be associated with limb defects Gestational DM: screen at 24-28 wks with 1hr glucose challenge – If >135, do 3 hr GTT 28 weeks: repeat RPR, Hb/Hct, give RhoGAM if necessary GBS: screen at 35-37 wks via swab of lower vagina, perineal area, rectum – Give intrapartum Abx if positive, or if previously positive in past pregnancy Flu and tetanus toxoid can be given during pregnancy; varicella and rubella not during pregnancy Assumption of Fetal Maturity – Heart tones documented for 20 wks by nonelectonic fetoscope, or 30 wks by Doppler – 36 wks since positive bHCG – US measurement of crown rump length at 6-11 wks supports gestational age of 39 wks – US at 12-20 wks confirms gestational age of 39 wks
Postpartum Care • • • • • •
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Postpartum= 6-12 weeks after delivery of placenta Breast feeding benefits: rapid return of uterine tone, reduced bleeding, faster weight loss, reduced ovarian and breast cancer, convenience, low cost Breast feeding contraindications: HIV, active herpes, acute/active Hep B – Breast feeding women should use the progestin-only minipill for hormonal contraception In women not breast-feeding, menstruation begins by the 3rd postpartum month Breast engorgement occurs 1-3 days after delivery Hemorrhage: – Early if within 24 hrs of delivery; late if >24hrs – 6 weeks after delivery – Most commonly caused by uterine atony, lacerations/inversion, retained placenta, coagulopathy – Uterine atony is most common causegive IV oxytocin and do bimanual massage • Methylergonovine is 2nd line but contraindicated in HTN • Prostaglandin F2alpha is third line, but contraindicated in asthma Fever: – Often a sign of endometritis treat with broad spectrum antibiotics – UTI, atelectasis, wound infections, VTE Mood disorders – Maternity blues: develop in the first week and resolve by 10th day postpartum • Tearfulness, sadness, emotional lability – Postpartum depression: onset within 4 weeks of delivery and seen up to a year later • Same symptoms as major depression; high recurrence rate in future pregnancies • Treat with SSRIs – Postpartum Psychosis: manic or delusional behavior within a few days to weeks of delivery
Psych PTSD • reexperiencing a traumatic event. • Alcohol and drugs are commonly used by the patient to self-treat. • Antidepressants can ameliorate symptoms; sertraline & paroxetine have FDA indications for treatment. • Alprazolam can be used, but there is significant concern for dependency problems. Anorexia + Bulemia: • Both disorders involve self-evaluation that is unduly influenced by body weight and/or shape. • binge eating or purging are characteristics of bulimia; there is a binge eating/purging subtype of anorexia • Both bulimics and binge eating/purging subtypes of anorexics may use diuretics, enemas, and laxatives. • Both engage in inappropriate behaviors to prevent weight gain. • bulimics sense a lack of control over eating during binging; anorexics often feel a strong sense of control. ADHD: • 50% to 75% of kids will continue to exhibit symptoms into adulthood. • In adults, ADHD may be more subtle, and symptoms may changeDeficits in executive function tend to be more salient (poor organization or time management) and hyperactivity may be replaced by restlessness. • hyperactivity and impulsivity tend to peak between the ages of 6 and 10, inattention remains relatively stable through the lifespan of the illness. • Hyperactivity is the most problematic feature for children with ADHD because it tends to be most disruptive and socially unacceptable. • treating ADHD in adolescents actually ↓the risk of substance abuse when compared to children not treated. • Oppositional behavior and conduct disorders may be comorbid, but are not necessarily features of ADHD. Nefazodone should not be used in patients with liver disease. Hypertension is a relative contraindication to venlafaxine. Patients experiencing hypersomnia and motor retardation should avoid nefazodone and mirtazapine. Patients who report agitation and insomnia should avoid bupropion and venlafaxine. Mirtazapine and tricyclic antidepressants are less preferred for patients with obesity. Bupropion is contraindicated for patients with seizure disorder.
Depression • • • • •
At least 5 of the following for a 2 week period: depressed mood/loss of interest or pleasure plus: weight change, sleep change, psychomotor change, fatigue/loss of energy, worthlessness, decreased concentration, suicidal thoughts Causes clinically significant distress or impairment of functioning; not due to another cause Also consider- hypothyroidism, anemia, EtOH, sedatives, narcotics, cocaine, steroids Depressed pts with CVD have a greater chance of dying of a heart attack Treat: pharmacotherapy with psychotherapy is most effective – –
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Treatment failure is usually due to medication noncompliance, inadequate duration of therapy, or inadequate dosing Treat at least 6-9 months after first episode of depression
SSRI: increase serotonin by blocking presynaptic reuptake; takes 4-6 weeks before therapy works; side effects are sexual dysfunction, weight gain, GI disturbance, fatigue, agitation SNRI: act on serotonin at low doses and NE at high doses; second line if SSRIs fail TCA: affect reuptake of NE and serotonin; side effects of sedation, dry mouth, dry eyes, urinary retention, weight gain, sexual disturbance, potentially fatal in overdose MAOIs: increase serotonin and NE released during nerve stimulation; need tyramine restricted diet to avoid hypertensive crisis Buproprion: contraindicated in seizure disorder or eating disorders; no sexual side effects Trazodone: side effect of priapism; good to use as a sleep aid
Alcohol and Substance Abuse • • •
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Tolerance: increased amount or diminished effect Withdrawal: withdrawal syndrome or need of substance to avoid withdrawal symptoms Dependence: Substance taken in larger amounts or over more time than intended, Persistent desire or unsuccessful efforts to cut down or control, Great deal of time spent in activities necessary to obtain substance or recover from effects, Important social, occupational, recreational activities given up or reduced because of substance, Use is continued despite knowledge of having a persistent or recurrent problem caused by it Substance abuse: if patient does not meet criteria for substance dependence and one or more of the following are evidentfailure to fulfill major role obligations, recurrent use in physically hazardous situations, legal problems, continued use despite persistent or recurrent social/interpersonal problems caused or made worse by the substance CAGE: Cut down? Annoyed? Guilty? Eye-opener? – 72-91% sensitive, 77-96% specific for answering 2 or more with “yes” At-Risk Drinking: men age 65 or younger with >4 standard drinks in a day or <14 in a week; men>65 and all women with >3 drinks in a day or >7 in a week Standard Drink: 14 g EtOH: 1 12 oz beer, 1 5 oz glass of wine, 1 shot spirits Substance induced depression: depression arises in association with EtOH intoxication or withdrawal – Antidepressant medication is likely to be ineffective, if not harmful, to a pt with EtOH problem – If symptoms persist >4 wks after EtOH discontinuation, consider other causes of depression EtOH withdrawal: tremulousness, insomnia, anxiety, depressed mood, GI upset, palpitations, sweating – Seizures can occur with in 6-48 hrs – Hallucinations can occur within 12-48 hrs – DTs occur within 48-72 hrs- hallucination, agitation, tremor, sleeplessness, sympathetic hyperactivity – Benzodiazepines are the drug of choice for managing EtOH withdrawal Intervention: 5-10 min discussion with Dr. can lead to significant reduction in risky drinking
Alcohol and Substance Abuse EtOH: • Elevated GGT is shown to be more sensitive than an elevated MCV, ALT, or AST. • specificity is low; it is ↑in nonEtOH liver disease, DM, pancreatitis, hyperthyroidism, HF, & anticonvulsant use. • ratio of AST:ALT may help distinguish between alcohol and nonalcoholrelated liver diseases • Ethyl glucuronide (EtG) urine test detects recent EtOH consumption, but says nothing about the level of consumption or abuse. Its value is in the monitoring of those patients who are committed to abstinence. • An ↑MCV is 96% specific for alcohol abuse with a 63% predicTve value. • Naltrexone: helpful for both opiate addiction and alcohol addiction; saturates opiate receptor sites and leaves them unavailable for opiate attachment. • For EtOH abuse, naltrexone works by ↓the reinforcing effect of EtOH (not allowing pts to become drunk) • Disulfiram: negative reaction to ingested alcohol, regardless of the form; flushing, nausea, and vomiting; alcohol in cough medicines, mouthwashes, and other forms must be avoided • Acamprosat: most effective at reducing EtOH relapse.; affects both GABA and glutamine neurotransmission with greater and longer lasting effects than naltrexone Cocaine: • Stopping cocaine use does not produce a significant physiologic withdrawal. • Intoxication with cocaine does produce elevated HR and BP. • cocaine withdrawal extreme fatigue and significant depression. Relapse is common during the crash Opiates: • withdrawal is not life-threatening in otherwise healthy adults, but can cause severe discomfort. • Early symptoms: lacrimation, rhinorrhea, yawning, and diaphoresis. • Restlessness & irritability occur later, with bone pain, nausea, diarrhea, abdominal cramping, and mood lability.
Smoking •
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5As approach to tobacco use and cessation – Ask about tobacco use – Advise to quit through clear personalized message – Assess willingness to quit – Assist to quit – Arrange follow-up and support Buproprion: blocks uptake of norepinephrine and/or dopamine; contraindicated in patients with eating disorders, MAO use, or seizure disorder; start meds 1-2 wks before quite date; use for 7-12 wks Nicotine-replacement therapy increases the chance that a smoker will quit. Varenicline: selective nicotinic receptor partial agonist. side effects include nausea, insomnia, and abnormal dreams. It is safe in persons with seizure disorders, Varenicline is taken for 1 week before the quit date, and therefore can be taken while a person is still smoking.
Family Violence – physical violence, sexual, intimidation, emotional, psychological, economic control, isolation from others – Look for numerous bruises of varying ages, metaphyseal corner fractures, cigarette burns – Do a full x-ray bone scan and ophthalmologic exam – All elder and child abuse must be reported. – Child abuse not reported by a physician is a crime – A spiral fracture of the tibia is known as a toddler’s fracture and is a common injury
Adverse Drug Reactions and Interactions
(low yield) – Medications with high first pass hepatic clearance may be particularly susceptible to adverse events caused by alterations in hepatic metabolism – CYP1A2: induced by tobacco; drugs that depend on 1A2 are theophylline and imipramine – CYP2C9, 2D6, 2C19 have evidence of genetic polymorphism and different individuals have different rates of metabolism – 2E1: alcohol effects this isoenzyme; can produce a hepatotoxic metabolite of acetaminophen – Probenecid decreases renal excretion of penicillin, resulting in an increased level and therapeutic effect – Creatinine clearance: (140 – age ) x (ideal body weight in kg) ( 0.85 for women) / 72 x serum creatinine
