II. 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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