II. Updates: January 2020
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Cirrhosis (gi, liver)
- Viral Hepatitis has surpassed Alcohol as most common Cirrhosis cause, and NAFLD is steadily increasing
- Biopsy has largely been replaced in fibrosis staging due to noninvasive techniques (biomarkers, calculators, transient elastography)
- Ultrasound screening every 6-12 months for Hepatocellular Carcinoma
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Amblyopia (eye, peds)
- 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
- Early recognition and treatment is key (ideally before 3-5 years old) and photoscreening with an iphone is an effective strategy
- Ophthalmology referral indications have been expanded
- After correction of primary eye disorders (e.g. Congenital Cataracts), patching, glasses and Atropine drops obscuring the good eye, are the main treatment strategies
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Nasotracheal Intubation (lung, procedure)
- Nasotracheal Intubation is rarely done outside of Angioedema and other tenuous airway management in which an awake intubation is preferred
- Complications include Nasopharyngeal Hemorrhage, Retropharyngeal Perforation (may occur with Blind Nasotracheal Intubation), Post-Intubation Otitis Media
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Otitis Media Prevention (ent, ear, id)
- Antibiotic prophylaxis for Otitis Media has not been recommended for 1-2 decades due to Antibiotic Resistance (esp. pneumococcus)
- Recommended prevention includes PrevnarVaccine, Influenza Vaccine yearly, avoiding passive smoke, propped bottles and Pacifiers, and Allergic Rhinitis management
- Consider Tympanostomy Tubes for three Otitis Media episodes in 6 months OR 4 episodes in 1 year AND Last episode within prior 6 months
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Cutaneous Larva Migrans (derm, Parasite)
- Serpiginous formation of Papules, typically on the legs after barefoot walking on soil, sand in Southeastern United States
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Acute Parotitis (ent, Salivary)
- Distinguish the hot, swollen, tender Parotid Gland (Acute Parotitis) from the cold, swollen, minimally tender Parotid Gland (chronic Parotitis)
- Acute Parotitis may be Bacterial (esp. Staphylococcus aureus) or viral (mumps, EBV, parainfluenza, Influenza)
- Chronic Parotitis may be due to Sarcoidosis, Sjogren's Syndrome, Diabetes Mellitus, Cirrhosis
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Chronic Hypertension in Pregnancy (cv, ob, htn)
- PIH risk with chronic Hypertension is 20-50%
- Aspirin 81 mg daily starting in second trimester and continuing until delivery is recommended
- Antihypertensives and their indications are reviewed
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Diphtheria (ent, mouth, id)
- Diphtheria is Vaccine preventable, yet it continues with worldwide cases including rare cases in the U.S.
- Mortality from Diphtheria is as high as 50% in untreated cases (5-10% with treatment)
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Foodborne Illness (gi, Diarrhea)
- Suspect preformed toxin (Staphylococcus aureus, b cereus, Scombroid Fish Poisoning) when onset <6 hours after ingestion
- Although most Foodborne Illness is self limited, life threatening illness may occur with Listeria, Vibrio and Botulism
- Consider parasitic causes when onset >1 week
- Food handlers and healthcare workers should not return to work until symptoms have resolved for 48 hours
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Parental Consent to Treat Minor Children (neuro, cognitive)
- 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
- However, younger children do not typically have the ability to understand their medical options and make decisions
- 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
- 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
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Scoliosis (ortho, t-spine)
- Scoliosis screening is not recommended by USPTF and AAFP, but is recommended by AAP and AAOS
- Scoliosis XRay for Cobb Angle is indicated based on Scoliosis Examination (Forward Bending Test, Scoliometer)
- BMI <85%: Scoliometer measurement 7 degrees or more of trunk rotation (~20 degree Cobb Angle)
- BMI >85%: Scoliometer measurement 5 degrees or more of trunk rotation (~10 degree Cobb Angle)
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Atrial Fibrillation Acute Management (cv, ekg)
- In complex presentations of Atrial Fibrillation with rapid ventricular rate, consider compensatory Tachycardia for secondary cause (Alcohol Withdrawal, decompensated COPD, Sepsis, CHF exacerbation)
- Although immediate cardioversion is indicated in unstable primary Atrial Fib RVR, it may be harmful in secondary cause
- 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
- 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)
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Myxedema Coma (endo, Thyroid)
- Consider in the elderly, hypothermic patient with Altered Level of Consciousness
- Consider triggers (e.g. Sepsis, cold exposure, Amiodarone or Lithium)
- ABC Management, IV Thyroxine (and consider T3 IV) and supportive care (e.g. IV crystalloid)
- Mortality is very high (approaches 30-60%)
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Lymphoma (hemeonc, lymph)
- Extensive updates on Hodgkin's Lymphoma and Non-Hodgkin's Lymphoma
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Anorectal Conditions (gi, exam)
- Multiple topics updated including Perianal Pruritus, Anal Fissure, Functional Rectal Pain, Fecal Incontinence
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Bariatric Surgery (endo, surgery)
- Sleeve Gastrectomy is responsible for 60%, and Roux-En-Y 18% of the nearly 230,000 bariatric surgeries per year
- Complications include anastomotic leak, Internal Hernia, Pulmonary Embolism, Vitamin Deficiencies (including Acute Thiamine Deficiency)
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Coronary CT Angiography (cv, rad)
- 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)
- However, in Low Risk Chest Pain, there is high risk of False Positive tests and unnecessary cardiac catheterization
- CCTA has a Test Specificity at best of 90%, or 100 patients in 1000 tested with a False Positive result
- CCTA could subject 100 Low Risk Chest Pain patients to invasive catheterization to find 2-3 true positives
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Salicylate Toxicity (pharm, Analgesic, adverse, toxin)
- Salicylate Overdose, especially chronic toxicity in the elderly, is under-recognized
- Consider Salicylate Toxicity in the patient with Altered Level of Consciousness and Tachypnea
- Respiratory Alkalosis precedes Metabolic Acidosis with Anion Gap
- Chronic Salicylate Toxicity presents with greater symptoms at lower Salicylate levels and noncardiogenic pulmonary edema
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Hyperkalemia Management (renal, Potassium)
- When using Glucose and Insulin Infusion, risks of Hypoglycemia include pretreatment Glucose <150, no diabetes, weight <60 kg, female gender, Renal Failure
- Consider decreased Regular Insulin dose (0.1 unit/kg up to 5-10 units IV) instead of a full 10 units IV for everyone
- Administer dextrose with Insulin if Serum Glucose <250 mg/dl and esp. if risks and consider second dextrose bolus or infusion
- Monito Glucose for 4-6 hours
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Echocardiogram (cv, rad)
- Extensive updates to the Echocardiogram content with more to come after attending a 1 week course at GCUS
- Eight new diagrams covering measurements, color-doppler and pulse-wave doppler added with more to come
