Family Practice Notebook Updates

Aka: Family Practice Notebook Updates, Family Practice Notebook Updates 2019, FPN Updates 2019, FPN Updates

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II. Updates: March 2019

  1. Adhesive Capsulitis (ortho, Shoulder)
    1. Diabetes Mellitus and Hypothyroidism are commonly associated with Adhesive Capsulitis
    2. Greatest improvements are made early, and although most patients will have near resolution after 1-2 years, persistent deficits are common
    3. Physiotherapy and Corticosteroid Injections are effective in combination
  2. Musculoskeletal Manipulation (sports, procedure, alternative)
    1. Uses various modalities: Counterstrain, Muscle Energy Technique, Soft Tissue Therapy, Spinal Manipulation
    2. May offer benefit in Neck Pain (with the rare 1:20,000 but devastating risk of vertebrobasilar dissection)
    3. May offer benefit in chronic Tension Headaches, but only small studies are available; no significant benefit in Low Back Pain (acute or chronic)
    4. No good evidence for benefit in infants and children, and generally recommended to avoid
  3. Hand Infection (ortho, id, hand)
    1. Superficial infections finger include Acute Paronychia, felon and Herpetic Whitlow
    2. Deep Finger Infections include Pyogenic Flexor Tenosynovitis and Fight Bite
  4. Hepatitis B (gi, liver, id, virus)
    1. Antivirals are indicated in chronic active Hepatitis B with inflammation and higher viral loads
    2. Prevent Hepatitis B perinatal transmission and after bloodborne exposure
  5. Functional Gastrointestinal Disorders (gi, sx, bowel)
    1. Bloating, Belching and Flatulence are common distressing functional complaints that have specific causes, evaluations and management strategies
    2. Common causes with established diagnostic criteria include Functional Dyspepsia, Irritable Bowel Syndrome and Functional Constipation
    3. Functional symptoms may be broken down into Belching (aerophagia), gastric bloating, Small Bowel bloating and bloating with Constipation
  6. Type II Diabetes Medications (endo, pharm, dm)
    1. Of the more than 40 medications available for Type II Diabetes, many show only modest improved A1c, despite high cost, and adverse effects
    2. Better alternatives likely exist for Gliptins and amylins
  7. Wilderness Trauma (er, sports, Trauma, wild)
    1. Most wilderness injuries are mild (sprains and strains, Lacerations, burns, gastrointestinal illness)
    2. Serious illness and injury are uncommon, but require a systematic approach with modified ATLS and evacuation considerations
    3. Spine evaluation, Pneumothorax evaluation, dislocation reduction, Fracture stabilization and Hemorrhage control are key to best outcomes
  8. Seat Belt Sign (er, exam, peds)
    1. Car Restraints significantly reduce the risk of injury and death, but must be used properly
    2. Car Seats should be used up to age 4 years old (rear facing until age 2 years)
    3. Booster Seats should be used from age 4-8 years old (until height >=57 inches)
    4. Premature use of the adult Shoulder-Lap belt risks neck extension and flexion injuries, head injuries, Chance Fractures, Abdominal Trauma
  9. NIH Stroke Scale (neuro, cv)
    1. Observe for mild changes (esp. facial droop which may be subtle)
    2. Patients may have severe symptoms (e.g. Vertigo in posterior CVA), yet have a low NIH stroke score
  10. Giant Cell Arteritis (neuro, Headache, cv)
    1. Consider Temporal Arteritis in any patient with Diplopia or Vision Loss (even when transient)
  11. Nerve Block (surgery, pharm)
    1. Ultrasound allows for much safer regional blocks (landmarks, visualize fluid dispersion)
    2. Anticoagulation is not a contraindication to Nerve Block
    3. Be aware of LAST Reaction and precalculate toxic dose levels
    4. Dilute anesthetic to lower concentrations and higher volumes for best effect
  12. Bupropion (psych, pharm, depression)
    1. Seizure risk in Overdose (treat with Benzodiazepines)
    2. QRS prolongation may also occur with Overdose (treat with serial doses of bicarbonate)
  13. MAO inhibitor (psych, pharm, depression)
    1. Some drugs we do not identify as MAO inhibitors include Linezolid, St. Johns Wort, Selegeline
    2. May cause Hypertension in Overdose or when taking tyramines; treat with phentolamine (alpha-adrenergic antagonist)
    3. May cause Hypotension in Overdose (treat with IV fluids and direct Vasopressors such as norepinephine)
    4. Risk of Serotonin Syndrome
  14. Massive Hemoptysis
    1. Intubating decompensating patients is challenging
    2. Attempt awake intubation under Ketamine, large bore suction (or via ET Tube) and place large ET (e.g. 8.5)
    3. Consider lung isolation (left or right mainstem Bronchus intubation)
    4. Emergently consult pulmonology, thoracic surgery, intervention radiology
  15. Sepsis (id, fever, Bacteria)
    1. In pregnancy, no Sepsis criteria accurately predicts status (SIRS, SOFA, MEWS, MOEWS, SOS)
    2. Blood Pressure, Heart Rate, Respiratory Rate are unreliable markers of serious infection or instability in pregnancy
    3. Lactic Acid cutoffs do not apply well to pregnancy, but higher Lactic Acids are associated with worse outcomes
  16. Postpartum Endometritis (ob, postpartum)
    1. Consider pelvic Thrombophlebitis in those who fail to improve with initial antibiotics
    2. Postpartum Endometritis with hematoma present may respond better to doxycyline AND Gentamicin, Cefoxitin or Unasyn
  17. Appendicitis (surgery, bowel)
    1. Mortality for mothers approaches 4% and for the fetus, up to 45%
    2. Atypical presentations are common in pregnancy; RUQ Abdominal Pain in 20%, Rectal Pain in 45%
  18. Neurologic Anatomy of the Eye (eye, anatomy, neuro)
    1. Completed 2 new diagrams: Extraocular Movement abnormalities and Pupillary defects

III. Updates: February 2019

  1. Patellofemoral Pain Syndrome (ortho, knee)
    1. Exercises are the most effective management strategy
    2. Foot Orthotics may benefit over-pronators, but Knee Braces are unlikely to be of benefit
    3. Patellar Taping may have short-term benefit
  2. Neuropsychological Assessment (neuro, psych)
    1. Consider neuropsychological exam in Mild Cognitive Impairment, concern for driving risk, Decision Making Capacity Evaluation and after Traumatic Brain Injury
  3. Intravenous Drug Abuse (psych, CD)
    1. Drug Abuse Screening Test (or other CD screening) and offer CD treatment
    2. Screen for Viral Hepatitis, HIV Infection, Tuberculosis and immunize (Hepatitis B Vaccine, Hepatitis A Vaccine, Tetanus Vaccine)
    3. Be aware of the many complications from Injection Drug Use
    4. Consider HIV Preexposure Prophylaxis, dispense Naloxone to Opioid Abuse patients and review safer injection methods
  4. Renal Cell Carcinoma (urology, hemeonc)
    1. Incidental Renal Mass and persistent Microscopic Hematuria have replaced Renal Cell Carcinoma late presentations (palpable Renal Mass, flank pain, Gross Hematuria)
  5. Pediatric Gastroenteritis (gi, peds, Diarrhea)
    1. Oral Rehydration Solution (ORS) is preferred in moderate dehydration and well described protocols can avoid IV fluids in most cases
    2. Half-strength apple juice followed by preferred fluids is more effective than ORS in mild dehydration due to Diarrhea
  6. First Trimester Bleeding (ob, antepartum)
    1. Excluding Ectopic Pregnancy is top priority in pregnancy of unknown location
    2. Progesterone level <6 is consistent with non-viable pregnancy
    3. Gestational Sac should be seen on Transvaginal Ultrasound by 1800 to 3000
  7. Agitation (psych, behavior)
    1. Identify underlying cause (e.g. Cocaine, meth, Alcohol Withdrawal, Head Trauma, Hypoglycemia, Psychosis, Encephalitis)
    2. De-escalation is preferred in the agitated but non-dangerous patient
    3. Standard approaches exist for each of 3 Agitated Patients: agitated but cooperative, disruptive but not dangerous and Agitated Delirium
  8. Envenomation (er, derm)
    1. Anaphylaxis to Hymenoptera Stings (bees, hornets) are the most common cause of lethal Envenomation in the U.S.
    2. Snake Bite venom vacuum extractors are no longer recommended
    3. Do not use Tourniquets in Snake Bites
    4. Antivenoms may be life saving (e.g. Coral Snake bites, pit viper bites, Scorpion bites) but they risk Anaphylaxis
  9. Lacunar CVA (neuro, cv)
    1. Lacunar Infarcts are named for the latin ("small lakes"), and refer to the resorbed defects after stroke
    2. These strokes are from small penetrating vessels into the Thalamus, pons, Internal Capsule, corona radiata
    3. Several lacunar stroke syndromes exist (e.g. pure motor, pure sensory, ataxic Hemiparesis, Dysarthria-clumsy hand)
  10. Post-Cardiac Arrest Care (er, exam)
    1. Hypotension in post-arrest patients is common and critical to correct and maintain adequate perfusion for best outcomes
    2. Consider possible causes including the initial inciting event for the Cardiac Arrest
    3. Epinephrine is typically a reasonable choice for post-arrest Vasopressor
  11. Abdominal Compartment Syndrome (gi, cv)
    1. Rare condition with very high mortality if missed
    2. Abdominal pressures may be monitored through a Foley Catheter
  12. Local Anesthetic Systemic Toxicity (surgery, pharm)
    1. Toxicity increases with lipophilic drugs (esp. Bupivicaine, Ropivacaine)
    2. Withdraw before injection to prevent injection intravascularly, which can be lethal
    3. Intralipid is the antidote for life threatening LAST Reactions
  13. Newborn Stool Color (gi, nicu, bowel, blood)
    1. In the ill appearing young infant with blood in the stool, consider NEC, malrotation with Midgut Volvulus, Hirschsprung's enterocolitis, Vitamin K Deficiency
    2. In well appearing young infants, with intermittent inconsolable crying, consider intussception
    3. In well appearing young infants, consider Allergic Colitis of Infancy, Anal Fissure, red food or fluid intakes
    4. Acolic stool requires an emergent evaluation for Biliary causes including biliary atresia
  14. Urticaria (ent, derm, allergy)
    1. Differentiate acute hives (<6 weeks) which often has a cause identified from chronic hives (>6 weeks) which often is idiopathic
    2. Consider allergic causes, acute infections, autoimmune causes
    3. Antihistamines are most beneficial (in non-Anaphylaxis), and allergists often use Zyrtec 10 mg orally TWICE daily
    4. Other adjunctive medications include H2 Blockers, leukotriene modifiers, steroids
  15. Acute Flaccid Myelitis (id, neuro)
    1. Viral prodrome followed by Flaccid Paralysis with or without Meningitis, but no encephalopathy
    2. Enterovirus D68 and A71 are identified as common causes
    3. Treated with IVIG and recovery is most often incomplete, with residual deficits
  16. Ulnar Neuropathy at the Wrist (ortho, wrist, neuro)
    1. Consider in differential in a C7-T1 radiculopathy differential
    2. Nerve injury may also cause Ulnar Neuropathy at the Elbow
  17. Brachial Plexus (ortho, anatomy)
    1. At least 38 defined variations exist
  18. Saturday Night Palsy (ortho, Shoulder, neuro)
    1. Radial Nerve injury at the axilla (stereotypically when intoxicated with arm over a chair or bench back rest) resulting in a Wrist Drop
  19. Suprascapular Nerve Injury (ortho, Shoulder, neuro)
    1. Nerve exits high in the Brachial Plexus and can be impinged with overhead overuse (Volleyball Player's Shoulder)
  20. Thoracic Outlet Syndrome (ortho, brachial)
    1. Adson's Test and Elevated Arm Stress Test (EAST) are 2 tests used to identify Thoracic Outlet Syndrome
  21. Fluoroquinolone (id, pharm, Bacteria)
    1. Add aortic complications (Aortic Dissection, aortic aneurysm, Aortic Rupture) to the list of Fluoroquinolone complications
    2. Another reason to avoid in the elderly, vascular disease patients, smokers, Marfan Syndrome, Ehlers Danlos
  22. Acute Kidney Injury (renal, failure)
    1. ACE Inhibitors and ARBs are typically stopped in Acute Kidney Injury
    2. Outcomes appear improved if ACE/ARBs are restarted after Renal Function returns to baseline in high risk conditions (Systolic Dysfunction, recent MI, CKD)
    3. When reintroducing ACE/ARB, start at low dose and slowly increase
  23. Acute Gastroenteritis (gi, Diarrhea)
    1. Lactobacillus (Probiotic) does not significantly modify the Gastroenteritis course
  24. Warfarin Protocol (hemeonc, pharm)
    1. Do not use DOACs for Warfarin bridging (use Lovenox or other LMWH)
    2. Exception: May overlap DOAC and Warfarin when switching from DOAC to Warfarin
  25. Dosing Changes (pharm)
    1. Vitamin D units have been expressed in IU, and will now be in mcg (1000 IU = 25 mcg)
    2. Folic Acid will now be in Dietary Folate Equivalents (DFE), for example, Folate 400 mg = 600 mg DFE
  26. Expensive Medications (pharm)
    1. More expensive medications to extend patents (Tolsura) or me-too (Aemcolo)

IV. 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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