II. Updates: February 2018

  1. Penile Lesion (urology, penis, derm)
    1. Papulosquamous lesions include Psoriasis and pearly Papules
    2. Inflammatory lesions include Lichen Sclerosus, Lichen Nitidus, Lichen Planus
    3. Vascular lesions include Angiokeratomas
    4. Neoplastic lesions include Penile Carcinoma in Situ, penile squamous cell cancer
  2. Heel Pain (ortho, ankle, foot)
    1. Midfoot lateral pain includes Peroneal Tendinopathy and Sinus Tarsi Syndrome
    2. Midfoot medial pain includes flexor digitorum Tendinopathy or tibialis posterior Tendinopathy
    3. Posterior plantar Foot Pain includes Plantar Fasciitis, Heel Pad Syndrome, Tarsal Tunnel Syndrome, Calcaneal Stress Fracture
    4. Posterior Heel Pain includes Achilles Tendinopathy, Retrocalcaneal Bursitis, Haglund Deformity and in children, Severe Disease
  3. Colorectal Cancer Screening (gi, procedure, hemeonc)
    1. Standard Colorectal Cancer Screening starts at age 50, but for those meeting Family History criteria, start at age 40 (or 10 years before youngest relative)
    2. Specific screening protocols are defined for high risk syndromes: HNPCC, IBD, adenomatous polyposis, Peutz-Jeghers Syndrome, Sessile serrated polyposis
  4. Hemorrhoid (gi, Rectum)
    1. Fiber supplementation with adequate hydration is first-line management of Hemorrhoids
    2. Excise Thrombosed Hemorrhoids in the first 48-72 hours; Nifedipine or Nitroglycerin may be adjunctive for pain
    3. Most effective surgical interventions include Rubber Band ligation (grade I-III) and surgical excision (grade III-IV)
    4. Exercise caution when attributing rectal bleeding to Hemorrhoids (esp. in age >40 years or other Colon Cancer or Inflammatory Bowel Disease risks)
  5. Tremor (neuro, Tremor)
    1. Essential Tremor is the most common pathologic Tremor, an Action Tremor progressive with age, a diagnosis of exclusion made clinically
    2. Most Rest Tremors are Parkinsonism (although other causes include drug-induced and psychogenic can cause similar findings)
    3. Urgently refer children with Tremor
  6. Bullying (peds, behavior)
    1. Bullying is much more common than previously reported (each year, 20% in schools and 16% online)
    2. Start discussing Bullying at the 6 year old well child check
    3. Bullying victims commonly have Insomnia, Abdominal Pain, Headaches as well as Major Depression, Suicidality, poor school performance, Eating Disorders
  7. Hypothermia (er, environ)
    1. In Frostbite, do not massage or apply dry heat
    2. In Hypothermia, measure a core Temperature with a thermometer with adequate lower range, and consider Secondary Hypothermia causes
    3. In severe Hypothermia, ECMO continues to offer better outcomes when core Temperature is <28 C or if hemodynamic instability
  8. Abdominal Ultrasound (gi, rad)
    1. Several protocols exist for evaluating the Abdomen with Ultrasound including for free air, Small Bowel Obstruction and localizing Epigastric Pain
  9. STEMI (cv, cad)
    1. STEMI with Hypotension mayh be due to right ventricular infarct, Aortic Dissection, massive Pulmonary Embolism, Cardiac Tamponade, ventricular rupture
  10. Head Injury (er, neuro)
    1. Warfarin-related delayed CNS bleeding after Head Injury is uncommon (<2%) and typically does not warrant intervention
  11. Cardiac Arrest (er, exam)
    1. Consider a brief moment of silence at the end of code in which the patient expired
  12. Chlorine (er, toxin)
    1. Chlorine gas may form with use of cleaners (e.g. bleech solutions) and may cause ARDS and other life threatening lung injury
  13. Ketorolac (pharm, Analgesic)
    1. Ketorolac 10 mg IV is as effective for analgesia as 15 or 30 mg
  14. Fever Without Focus Management Birth to 3 Months (id, peds)
    1. Well appearing febrile infants at 60 days of age have a 1.8% Prevalence of bacteremia
  15. Cannabinoid Hyperemesis Syndrome (psych, cd)
    1. Capsaicin cream applied to Abdomen (palm-sized amount) is effective
  16. Sudden Sensorineural Hearing Loss (ent, hearing)
    1. Prednisone 50-60 mg orally daily while awaiting ENT followup
  17. Traumatic Cardiopulmonary Arrest (er, cv)
    1. Unless medical Cardiac Arrest, immediate interventions (chest Ultrasound, Finger Thoracostomy) take precedence over CPR in Traumatic Arrest
    2. Consider Finger Thoracostomy instead of Needle Thoracostomy (both of which are best done at the 5-6th intercostal space axillary line)
  18. Oral Contraceptives (gyn, pharm)
    1. Even low dose Estrogen increases Breast Cancer risk by RR 1.2
  19. Biotin (pharm, Vitamin)
    1. Biotin supplementation for hair, nails... has little data of efficacy
    2. High dose Biotin (>5000 mcg) falsely lowers Thyroid Stimulating Hormone, Troponin and Procalcitonin
  20. Altitude sickness (er, environ)
    1. Consider prophlaxis with Diamox if traveling to >11,000 feet in one day (or 9000 if prior history of altitude sickness)
  21. Medications (pharm)
    1. Many new, expensive, copy-cat drugs
    2. Do we really need more GLP-1, SGLT2 Inhibitor agents for diabetes or biologics for Psoriasis or combo HIV agents?
    3. Who is working on new antibiotics or reasonably priced cancer regimens?
  22. Long Acting Beta Agonist (lung, Asthma, pharm)
    1. FDA takes away a black box warning on LABAs (apparently mortality was no worse than with Inhaled Corticosteroids)

III. Updates: January 2018

  1. Chronic Kidney Disease (renal, failure)
    1. Serum cystatin C may be used in place of Serum Creatinine to estimate Glomerular Filtration Rate
    2. Urine Albumin to Creatinine Ratio is the preferred method to evaluate for Proteinuria
    3. Use Urine Protein to Creatinine Ratio in severe Proteinuria (>300 mg/g)
  2. Pigmentation Disorder (derm, pigment)
    1. Several Hyperpigmentation disorders (e.g. Melasma, Solar Lentigines, Postinflammatory Hyperpigmentation) respond to tri-luma
    2. Start with Topical Corticosteroids for Localized Vitiligo, and UVB for generalized Vitiligo
    3. Sun protection and Sunscreen are a key to the management of Pigmentation Disorders
  3. Palpitations (cv, sx)
    1. Most Palpitations will be due to psychosomatic disorders, Atrial Fibrillation, SVT
    2. Every person with Palpitations should have an EKG at minimum
    3. Supraventricular Premature Complexes (SVPCs) are associated with risk of Atrial Fibrillation and cardiac events
  4. Hypertension Criteria (cv, htn)
    1. Once again ACC/AHA has moved the targets on Blood Pressure goals based on new studies
    2. Is this sound, given Blood Pressure reading inaccuracies, prescriber confusion, medication and lifestyle noncompliance
  5. Hypothyroidism (endo, Thyroid, pharm)
    1. Subclinical Hypothyroidism may be treated if TSH >10, persistent symptoms (Fatigue, Constipation, cold intolerance) or pregnancy
    2. Avoid desiccated Thyroid and Liothyronine (T3) in most cases
  6. Automobile Safety (prevent, car, pharm)
    1. Ilicit drugs and prescribed Benzodiazepines and other Sedative-Hypnotics, muscle relaxants, Opioids, Anticholinergics may cause Impaired Driving
  7. Opioid Dependency (psych, cd, pharm)
    1. Naltrexone is revisted for maintenance of Opioid sobriety
  8. Topical Corticosteroids (derm, pharm)
    1. Once again, pharmaceutical companies have found a way to double prices on Generic Drugs (e.g. Topical Clobetasol)
  9. Long-acting Beta Agonist (copd, pharm)
    1. Trelegy Ellipta for severe COPD combines a LAMA, LABA and Corticosteroid
  10. Bronchiolitis (lung, Bronchi)
    1. Hypertonic Saline does not reduce hospitalization rates in Bronchiolitis
  11. Nonphysiologic Neonatal Jaundice (nicu, gi)
    1. Not much has changed in Hyperbilirubinemia management in the last couple of decades
    2. Use calculators (e.g. BiliTool.com) to assess the need for Phototherapy
    3. Consider secondary causes (e.g. Neonatal Sepsis)
  12. Idarucizumab (hemonc, pharm, coags)
    1. Idarucizumab reverses Dabigatran (Pradaxa) rapidly (minutes) and effectively
  13. Low Risk Chest Pain (cv, cad)
    1. Stress testing in Low Risk Chest Pain increases angiograms and revascularization without reducing MI related admissions
  14. Cardiac Arrest (er, exam)
    1. Bedside Ultrasound increases the delays to restarting Chest Compressions
  15. Delayed Sequence Intubation (lung, procedure)
    1. Prevent aspiration, by keeping CPAP or Bipap inspiratory pressures <15 cm H2O
    2. Small Ketamine doses in adults for DSI are sufficient (20-30 mg)
  16. Hyperemesis Gravidarum (ob, gi)
    1. Fewer labs needed (No Thyroid tests unless symptoms of Hyperthyroidism, Urine Ketones are not markers of illness severity)
    2. Metoclopramide and Ondansetron are first line Antiemetics
  17. Endotracheal Intubation Preoxygenation (lung, procedure)
    1. Oops Mnemonic (Levitan): Oxygen On, Apply 15 lpm by Nasal Cannula for Apneic Oxygenation, Pull Mandible forward, Sit patient up (to 20 degrees)
  18. Acromioclavicular Separation (ortho, Shoulder)
    1. Obtain comparison view of unaffected side, but weighted films are not needed
  19. Ankle Fracture (ortho, ankle, Fracture)
    1. Weber B Ankle Fracture stability is predicted by <2 mm posterior fragment displacement and only 2 Fracture fragments
  20. Noninvasive Urine Collection (urology, lab)
    1. Alternative techniques to stimulate urination in young children (pre-Toilet Training) are highly effective
    2. Quick-Wee Method (forceps with cold saline soaked gauze rubbed on suptrapubic area)
    3. Bladder stimulation technique (infants <1 month), with infant suspended by axilla, tap on Bladder, than circular massage low back
  21. Brown Recluse Spider Bite (er, derm, bite)
    1. Immediately ice bite wounds to deactivate toxin
    2. Skin necrosis starts at 72 hours after bite
    3. NOT RECLUSE mnemonic is used to exclude brown recluse bites as wound cause in endemic areas
  22. Informed Consent (neuro, cognitive)
    1. Provider performing the procedure should also perform the Informed Consent
  23. Otitis Externa (ent, ear)
    1. Combine topical antibiotic with a Topical Corticosteroid (e.g. cipro-hc, cipro-dex, Ofloxacin and Dexamethasone)
  24. Insulin Dosing in Type 2 Diabetes (endo, pharm)
    1. Updated protocol for initiating basal Insulin only and advancing to basal and Bolus Insulin (Insulin augmentation)
    2. Updated protocol for initiating and advancing to basal and Bolus Insulin (Insulin replacement)
  25. Ear Pain (ent, sx, ear)
    1. Consider referred Ear Pain, esp. cancer risk, CAD risk and Temporal Arteritis risk
  26. Pityriasis Rosea (derm, hyperplasia)
    1. Likely HHV-6 (Roseola) and HHV-7 mediated rash, which may respond to Acyclovir

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