Family Practice Notebook Updates

Aka: Family Practice Notebook Updates, FPN Updates, Family Practice Notebook Updates 2020, FPN Updates 2020

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II. Updates: February 2020

  1. COPD Management (lung, COPD)
    1. Corticosteroids are not uniformly effective in COPD
    2. Eosinophil Count >300 cells/ul (>4% of total WBC) predicts steroid responsiveness
    3. Eosinophil Count only has predictive value if off inhaled and Systemic Corticosteroids
    4. COPD may still respond to steroids despite low Eosinophil Count
  2. Electronic Prescriptions (manage, computer)
    1. Controlled substances must be E-Prescribed per Medicare Part D by 2021
  3. Apadaz (pharm, Analgesic)
    1. Benhydrocodone 4.08 mg, 6.12 mg and 8.16 mg is roughly equivalent to Hydrocodone 5, 7.5 and 10 mg
    2. Benhydrocodone is a prodrug enzymatically converted to Hydrocodone in gastrointestinal tract
    3. Submitted and declined by FDA to label as an Opioid Abuse Deterrent Agent
    4. Offers no benefit over other Opioids including Hydrocodone and not recommended
  4. Daytime Somnolence (psych, sleep)
    1. Pitolisant (Wakix) is released in 2020 for Daytime Somnolence for Narcolepsy
    2. A novel agent that is not a controlled substance, is active at CNS histamine receptors and appears to be as effective as Modafinil
    3. However, very expensive ($11,400 per month) andf many Drug Interactions as well as QT Prolongation
  5. CVA Prevention (neuro, prevent)
    1. Lowering LDL Cholesterol <70 mg/dl (compared with 95 mg/dl) decreases recurrent CV event in 3.5 years (NNT 42)
  6. Mucocele (ent, lip)
    1. Differential Diagnosis includes Lip Neoplasm, lip aneurysm and dermoid cyst
    2. Local removal techniques for typical Mucoceles including lesion unroofing, suturing, Cryotherapy and electrocautery
  7. Rickets (rheum, peds)
    1. Consider especially in exclusively Breast fed infants of darker skin and reduced sunlight exposure (esp. winter)
    2. Classic XRay Findings consistent with Rickets at metaphysis include Forearm/tibia cupping (scalloping) of metaphysis, fraying (tattered rope appearance) at metaphysis, widened metaphysis (splayed)
  8. Tonsillitis (ent, mouth)
    1. In addition to Group A Streptococcal Pharyngitis and Mononucleosis, consider Lemierre Syndrome or Fusobacterium Necrophorum
    2. Consider STD Causes (Gonorrhea, Acute HIV Infection, HSV)
    3. Consider airway emergencies (Peritonsillar Abscess, Retropharyngeal Abscess, Ludwig Angina, Epiglottitis, Bacterial Tracheitis
    4. Point-Of-Care GAS Nucleic Acid Amplification Test is a 15 minute test, with nearly perfect Test Sensitivity and requires no Throat Culture
  9. Lemierre Syndrome (ent, Pharyngitis)
    1. Infection by Fusobacterium necrophorium (Lemierre Syndrome), responsible for 10% of acute Pharyngitis cases in young adults and adolescents
    2. Occurs with contiguous infection from Pharyngitis (typically) or Dental Infection to lateral pharyngeal space, resulting in Septic Thrombophlebitis of Internal Jugular Vein
    3. Septic Thrombophlebitis of Internal Jugular Vein complicated by high morbidity and mortality, Septic pulmonary emboli, Carotid Artery erosion (with life-threatening bleeding)
  10. Functional Dyspepsia (gi, sx)
    1. Persistent chronic or recurrent Epigastric Pain, burning, early satiety or post-prandial fullness without structural cause
    2. Upper Endoscopy for Dyspepsia >1 month in over age 60 years (or significant Dyspepsia Red Flags) and then Antacid therapy (PPI, H2 Blocker)
    3. For those <60 years old, start with avoidance of Gastric Irritants and FODMAPS, and consider H. pylori testing before starting Antacids
  11. Systemic Glucocorticoids (endo, pharm)
    1. Even short course Corticosteroids are associated with increased serious adverse effects (e.g. Fracture, VTE, Sepsis, AVN)
    2. Systemic Corticosteroids are not recommended in Acute Bronchitis (aside from Asthma, COPD) and mild-moderate acute Pharyngitis (aside from Peritonsillar Abscess)
    3. Systemic Corticosteroids are also not recommended in Acute Sinusitis and Allergic Rhinitis
  12. Muscle Weakness (neuro, sx, motor)
    1. Differentiate weakness from pain-related disuse, Asthenia, Fatigue, Dyspnea, as well as Frailty and Sarcopenia of advanced age
    2. Categorize the findings as unilateral or bilateral, proximal or distal, upper or Lower Motor Neuron, and pure motor or combined sensory and motor
    3. Consider Medication Causes of Myositis, Neuropathy, Myopathy, and toxic-metabolic causes
  13. Apical Four Chamber Echocardiogram View (cv, rad)
    1. Added echo measurements including RVSP, VTI
  14. Monteggia Fracture (ortho, elbow)
    1. Proximal ulna Fracture AND Radial Head Dislocation typically from Fall on Outstretched Hand WITH extended elbow AND Hyperpronated Forearm
    2. Risk of Radial Nerve injury (including posterior interosseous nerve which branches from Radial Nerve); perform a careful Hand Neurovascular Exam (esp. extension of thumb, wrist and MCP joint)
    3. Closed reduction AND Long Arm Splint immobilization for stable, non-displaced Fractures
    4. Emergent orthopedic consult for displaced Monteggia Fracture Dislocations (unstable)
  15. Intubation Associated Sinusitis (ent, sinus)
    1. Most common with Nasotracheal Intubation and Nasogastric Tube, but also occurs with orotracheal intubation
    2. Common cause of unexplained fever in ICU patients
    3. Obtain CT Sinus, Gram Stain and Culture of sinus aspirate (by ENT) and MRSA Nasal PCR
    4. Consider Invasive Fungal Sinusitis (immunocompromised patients), which rapidly progresses over hours and requires emergent surgical management
  16. Lamictal (neuro, pharm)
    1. Anticonvulsant used commonly in Bipolar Disorder
    2. In Overdose, risk for life threatening arrhythmia with QRS Widening, Serotonin Syndrome, as well as the more common sedation
    3. Seziures may also occur in Overdose, esp. in children
  17. Ophthalmic Anti-inflammatory Agent (eye, pharm)
    1. Updated Ocular NSAIDs
    2. Added topics Ophthalmic Corticosteroid and Ophthalmic Cyclosporine (Ophthalmic Calcineurin Inhibitor, Restasis)
  18. Nocardia (derm, id)
    1. Weakly Gram Positive rod that forms fungus-like filaments and is found in soil
    2. Causes Pneumonia, CNS Abscess and disseminated Nocardiosis, and in 20% of case causes Skin Infection including Nodular Lymphangitis
  19. Beers List (geri, pharm)
    1. A few assorted updates to the list
  20. Health Maintenance in Adolescents (prevent, peds, teen)
    1. Updated Health Maintenance in Adolescents, Adolescent History (HEADSS Screening) and added Social Media Use in Adolescents
  21. Clostridium difficile (gi, id)
    1. Continues to increase in Incidence, and in mortality
    2. Vancomycin has been the first-line drug recommendation for C. difficile since 2018
    3. Stool odor is not sensitive nor specific for c. diff
  22. Chronic Wound (surgery, derm, Trauma)
    1. Chronic Wounds are divided into Arterial Ulcer, Venous Ulcer, diabetic ulcer and Pressure Ulcer
    2. Check ABI (which may be inaccurate in Diabetic Foot Ulcer) before applying compression
    3. Broad-based review with added topics including Arterial Ulcer and Chronic Wound Infection
  23. Suicidality (psych, depression)
    1. Added the Columbia Suicide Severity Rating Scale (C-SSRS) and Modified MSPS Suicide Risk Assessment, as well as safety plan information
    2. Expanded on the approach to the disposition of the suicidal patient
  24. Enterostomy Tube (gi, procedure)
    1. Added more pearls on G-Tube, J-Tube complication management
  25. Pediatric Intubation (lung, procedure)
    1. Added pearls on pediatric airway management
  26. Scalp Laceration (surgery, derm, wound)
    1. Control Hemorrhage, repair the galea if torn and keep hair out of the wound closure
  27. Amnotic Fluid Embolism (ob, cv)
    1. Experimental protocol (A-OK Amniotic Fluid Embolism Protocol) includes Atropine, Ondansetron, Ketorolac
  28. Digoxin Toxicity (cv, pharm)
    1. Although Digoxin Toxicity is much less common now, several Herbals contain toxic levels of cardiac glycosides (e.g. pong-pong) and may be lethal
  29. Hypertensive Encephalopathy (cv, htn, neuro)
    1. Ill appearing patients with Altered Level of Consciousness and Severe Hypertension
    2. Contrast with severe, but asymptomatic Hypertension (other than mild Headache) which is not Hypertensive Encephalopathy

III. Updates: January 2020

  1. Cirrhosis (gi, liver)
    1. Viral Hepatitis has surpassed Alcohol as most common Cirrhosis cause, and NAFLD is steadily increasing
    2. Biopsy has largely been replaced in fibrosis staging due to noninvasive techniques (biomarkers, calculators, transient elastography)
    3. Ultrasound screening every 6-12 months for Hepatocellular Carcinoma
  2. Amblyopia (eye, peds)
    1. Effects up to 6% of children and is the most common cause of monocular Vision Loss in children and causes irreversible blindness in nearly 3% of adults
    2. Early recognition and treatment is key (ideally before 3-5 years old) and photoscreening with an iphone is an effective strategy
    3. Ophthalmology referral indications have been expanded
    4. After correction of primary eye disorders (e.g. Congenital Cataracts), patching, glasses and Atropine drops obscuring the good eye, are the main treatment strategies
  3. Nasotracheal Intubation (lung, procedure)
    1. Nasotracheal Intubation is rarely done outside of Angioedema and other tenuous airway management in which an awake intubation is preferred
    2. Complications include Nasopharyngeal Hemorrhage, Retropharyngeal Perforation (may occur with Blind Nasotracheal Intubation), Post-Intubation Otitis Media
  4. Otitis Media Prevention (ent, ear, id)
    1. Antibiotic prophylaxis for Otitis Media has not been recommended for 1-2 decades due to Antibiotic Resistance (esp. pneumococcus)
    2. Recommended prevention includes PrevnarVaccine, Influenza Vaccine yearly, avoiding passive smoke, propped bottles and Pacifiers, and Allergic Rhinitis management
    3. Consider Tympanostomy Tubes for three Otitis Media episodes in 6 months OR 4 episodes in 1 year AND Last episode within prior 6 months
  5. Cutaneous Larva Migrans (derm, Parasite)
    1. Serpiginous formation of Papules, typically on the legs after barefoot walking on soil, sand in Southeastern United States
  6. Acute Parotitis (ent, Salivary)
    1. Distinguish the hot, swollen, tender Parotid Gland (Acute Parotitis) from the cold, swollen, minimally tender Parotid Gland (chronic Parotitis)
    2. Acute Parotitis may be Bacterial (esp. Staphylococcus aureus) or viral (mumps, EBV, parainfluenza, Influenza)
    3. Chronic Parotitis may be due to Sarcoidosis, Sjogren's Syndrome, Diabetes Mellitus, Cirrhosis
  7. Chronic Hypertension in Pregnancy (cv, ob, htn)
    1. PIH risk with chronic Hypertension is 20-50%
    2. Aspirin 81 mg daily starting in second trimester and continuing until delivery is recommended
    3. Antihypertensives and their indications are reviewed
  8. Diphtheria (ent, mouth, id)
    1. Diphtheria is Vaccine preventable, yet it continues with worldwide cases including rare cases in the U.S.
    2. Mortality from Diphtheria is as high as 50% in untreated cases (5-10% with treatment)
  9. Foodborne Illness (gi, Diarrhea)
    1. Suspect preformed toxin (Staphylococcus aureus, b cereus, Scombroid Fish Poisoning) when onset <6 hours after ingestion
    2. Although most Foodborne Illness is self limited, life threatening illness may occur with Listeria, Vibrio and Botulism
    3. Consider parasitic causes when onset >1 week
    4. Food handlers and healthcare workers should not return to work until symptoms have resolved for 48 hours
  10. Parental Consent to Treat Minor Children (neuro, cognitive)
    1. In adults, substituted judgment is based on knowing a patient's opinions and values and the surrogate acts on what they believe the adult patient would want
    2. However, younger children do not typically have the ability to understand their medical options and make decisions
    3. Instead, parents and surrogates practice what they interpret as best interests of the child, although "Best interest" is often difficult to determine, and may reasonably vary from one surrogate to another
    4. Nonmaleficence ("do no harm") may be a more manageable way to judge surrogate decision making, in which the clinician should consider whether surrogate decision making risks significant child harm
  11. Scoliosis (ortho, t-spine)
    1. Scoliosis screening is not recommended by USPTF and AAFP, but is recommended by AAP and AAOS
    2. Scoliosis XRay for Cobb Angle is indicated based on Scoliosis Examination (Forward Bending Test, Scoliometer)
    3. BMI <85%: Scoliometer measurement 7 degrees or more of trunk rotation (~20 degree Cobb Angle)
    4. BMI >85%: Scoliometer measurement 5 degrees or more of trunk rotation (~10 degree Cobb Angle)
  12. Atrial Fibrillation Acute Management (cv, ekg)
    1. In complex presentations of Atrial Fibrillation with rapid ventricular rate, consider compensatory Tachycardia for secondary cause (Alcohol Withdrawal, decompensated COPD, Sepsis, CHF exacerbation)
    2. Although immediate cardioversion is indicated in unstable primary Atrial Fib RVR, it may be harmful in secondary cause
    3. If Hypotension is due to Atrial Fibrillation with rapid rate, expect the patient to be cool; contrast with Sepsis with vasodilation, in which the patient's skin will be warm
    4. Expect typical rates for Atrial Fibrillation rapid ventricular response (130-140 if younger, 110 if older); Heart Rate of 160 suggests compensatory Tachycardia for secondary cause (e.g. Sepsis)
  13. Myxedema Coma (endo, Thyroid)
    1. Consider in the elderly, hypothermic patient with Altered Level of Consciousness
    2. Consider triggers (e.g. Sepsis, cold exposure, Amiodarone or Lithium)
    3. ABC Management, IV Thyroxine (and consider T3 IV) and supportive care (e.g. IV crystalloid)
    4. Mortality is very high (approaches 30-60%)
  14. Lymphoma (hemeonc, lymph)
    1. Extensive updates on Hodgkin's Lymphoma and Non-Hodgkin's Lymphoma
  15. Anorectal Conditions (gi, exam)
    1. Multiple topics updated including Perianal Pruritus, Anal Fissure, Functional Rectal Pain, Fecal Incontinence
  16. Bariatric Surgery (endo, surgery)
    1. Sleeve Gastrectomy is responsible for 60%, and Roux-En-Y 18% of the nearly 230,000 bariatric surgeries per year
    2. Complications include anastomotic leak, Internal Hernia, Pulmonary Embolism, Vitamin Deficiencies (including Acute Thiamine Deficiency)
  17. Coronary CT Angiography (cv, rad)
    1. CCTA is an option evaluation of Low Risk Chest Pain patients in the prediction of short-term significant coronary event (risk 0.2-0.3% or 2-3 per 1000)
    2. However, in Low Risk Chest Pain, there is high risk of False Positive tests and unnecessary cardiac catheterization
    3. CCTA has a Test Specificity at best of 90%, or 100 patients in 1000 tested with a False Positive result
    4. CCTA could subject 100 Low Risk Chest Pain patients to invasive catheterization to find 2-3 true positives
  18. Salicylate Toxicity (pharm, Analgesic, adverse, toxin)
    1. Salicylate Overdose, especially chronic toxicity in the elderly, is under-recognized
    2. Consider Salicylate Toxicity in the patient with Altered Level of Consciousness and Tachypnea
    3. Respiratory Alkalosis precedes Metabolic Acidosis with Anion Gap
    4. Chronic Salicylate Toxicity presents with greater symptoms at lower Salicylate levels and noncardiogenic pulmonary edema
  19. Hyperkalemia Management (renal, Potassium)
    1. When using Glucose and Insulin Infusion, risks of Hypoglycemia include pretreatment Glucose <150, no diabetes, weight <60 kg, female gender, Renal Failure
    2. Consider decreased Regular Insulin dose (0.1 unit/kg up to 5-10 units IV) instead of a full 10 units IV for everyone
    3. Administer dextrose with Insulin if Serum Glucose <250 mg/dl and esp. if risks and consider second dextrose bolus or infusion
    4. Monito Glucose for 4-6 hours
  20. Echocardiogram (cv, rad)
    1. Extensive updates to the Echocardiogram content with more to come after attending a 1 week course at GCUS
    2. Eight new diagrams covering measurements, color-doppler and pulse-wave doppler added with more to come

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