II. Updates: January 2019

  1. Health Maintenance in Adults (prevent, hme)
    1. Screen high risk adults with Ultrasound of AAA, Lung Cancer Screening CT Chest
    2. HPV Vaccine is indicated up to age 26 in men and women (age 45 years in high risk patients)
  2. School Absenteeism (peds, behavior, school)
    1. Truancy is common in U.S. with 14% of students missing more than 10% of school days (18 days)
    2. Truancy is associated with social problems, risky behavior, low academic achievement, school drop out, lower future income
    3. Prevention of Truancy includes pre-kindergarden attendance and addressing specific risk factors and attendance barriers
  3. Migraine Prophylaxis (neuro, Headache)
    1. Prophylaxis is indicated for 4 Headaches per month or 8 Headache days per month, refractory debilitating attacks or complicated Migraine
    2. First-line prophylaxis agents include Divalproex, Topiramate and some Beta Blockers (Metoprolol, Propranol, Timolol)
  4. NSTE-ACS Protocol (cv, cad)
    1. Obtain serial EKGs and Troponins in high clinical suspicion Chest Pain despite non-diagnostic initial findings
    2. Observe EKG for ST depression, T Wave inversion, T Wave flattening
    3. Atypical Chest Pain presentations are common in older women including Dyspnea, weakness, Nausea, Vomiting, Palpitations, Syncope
  5. Inborn Errors of Metabolism (endo, metabolism)
    1. U.S. Universal Newborn Screening differs between states, but typical panels screen 25 inborn error conditions
    2. In suspected inborn errors or metabolism, stop feedings and start D5 or D10 infusion
    3. Consider Inborn Errors of Metabolism in the differential diagnosis of Sepsis
  6. Urine Drug Test (psych, lab)
    1. Immunoassays area Screening Tests with many false negatives and false positives; confirmation tests are available via reference lab
    2. Typical poppy seed intake does not cause false positive Opioid tests and typical Marijuana second hand smoke does not cause positive tests
  7. Downhill Skiing (sports, Skiing)
    1. Start range of motion soon after knee and Shoulder injuries
    2. Evaluate knee injuries for important Fractures (Tibial Plateau Fracture, Tibial Spine Avulsion Fracture)
    3. Lateral talar process Fracture is the most common significant ankle injury in the snowboarder
  8. Labial Fusion (gyn, peds, vagina)
    1. Labia minora fuses in prepubescent girls, blocking the vaginal introitus
    2. Avoid manually separating the fused labia (painful, and typically refuses)
    3. Practice good hygiene with daily baths and frequent diaper changes
    4. Apply daily, a small amount of Topical Estrogen cream to affected labia minora
  9. Urethral Prolapse (urology, peds, Urethra)
    1. Erythematous, friable Urethra
    2. Do not manually reduce
    3. Apply daily, a small amount of Topical Estrogen cream to Urethra
  10. Vaginal Injury in Girls (gyn, peds, vagina, Trauma)
    1. Most cases will be accidental, but observe for signs of pediatric sexual abuse and Nonaccidental Trauma
    2. Blunt injury is typically a superficial Skin Tear between labia majora and minora
    3. Deep Lacerations from blunt injury may require Consultation for repair
    4. Sharp injuries are uncommon, but risk of penetrating injuries (esp .blood in introitus) - consult gynecology, surgery
  11. Carbon Monoxide Poisoning (er, toxin)
    1. Hyperbaric oxygen may be indicated for moderate to severe exposure, esp. if neurologic symptoms are present
  12. Aortic Dissection (cv, aorta)
    1. Symptoms: Chest Pain, back pain or Abdominal Pain that is abrupt onset, severe intensity, ripping or tearing pain
    2. Signs: Pulse deficit or SBP differential, new murmur of Aortic Insufficiency, Hypotension
  13. Thoracic Aortic Aneurysm (cv, aorta)
    1. Relatively uncommon (approximately 15,000 cases per year in U.S.)
    2. Surgical repair is indicated in asymptomatic patients at 4 to 5.5 cm depending on underlying risks (e.g. Marfan Syndrome)
  14. Workplace Violence (prevent, abuse)
    1. Healthcare is second only to law enforcement as a site for Workplace Violence
    2. Emergency department is a frequent site of Workplace Violence
  15. Ultrasound guided peripheral IV
    1. Standard of care is to use a probe cover and single-use sterile gel
  16. Medical Malpractice (manage, legal)
    1. Most common pediatric lawsuits are for Meningitis, arm Fractures, Appendicitis, Testicular Torsion
    2. Age 0 to 2 account for 50% of pediatric Malpractice cases
  17. Penetrating Neck Trauma (er, ent)
    1. Do not be distracted by wound when performing primary Trauma survey and ensuring airway and Hemorrhage Management
  18. Cellulitis (derm, Bacteria)
    1. Aside from Necrotizing Fasciitis and Sepsis, oral antibiotics are preferred and as effective as IV antibiotics
  19. Hyperlipidemia Management (cv, lipid)
    1. Statins are still the only first-line agent for Hyperlipidemia Management, with the only decision high intensity or low intensity
    2. LDL Cholesterol goal for the highest risk patients continues to be 70 mg/dl, and the only indication to add a second agent (e.g. Zetia)
  20. Asthma (lung, Asthma, pharm)
    1. Despite its potential risk, Primatene Mist is back on the OTC market
    2. Educate patients regarding the risk of misuse, and stick with Albuterol as the rescue Inhaler
  21. Angiotensin Receptor Blockers (cv, htn, pharm)
    1. Valsartan, Irbesartan, Losartan are all in the midst of recalls due to a contaminant with cancer risk
  22. SGLT2 Inhibitor (endo, dm, pharm)
    1. Jardiance reduces overall mortality (NNT 39) and cardiovascular death (NNT 45) over 3 years
    2. Other SGLT inhibitors (e.g. Invokana, Farxiga) have weaker CV benefits
    3. SGLT2 Inhibitors are also associated with significant adverse effects (UTI, amputations, Euglycemic ketoacidosis, Acute Kidney Injury)
  23. MRSA (id, emerging, Bacteria)
    1. Most patients do not require MRSA decolonization (instead, prevent spread)
    2. Decolonization is indicated for 2 MRSA Infections at different sites over a 6 month period despite proper hygiene
  24. Opioid Dependence (psych, cd)
    1. Wisdom Tooth Extraction is often an entry for young adults to get hooked on Opioids
  25. Amiodarone (cv, ekg, pharm)
    1. So many Drug Interactions and potential adverse effects, but still loved by many cardiologists
  26. Deep Vein Thrombosis Prevention (hemeonc, coags, prevent, surgery)
    1. DVT Prophylaxis for 10-14 days after knee replacement, 35 days after hip surgery
    2. Also consider DVT Prophylaxis after hospital discharge if prior VTE, extremely limited mobility
    3. Most other patients do not need DVT Prophylaxis after hospital discharge, and serious bleeding risk is typically higher than the DVT Risk

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