Practice Management Book


Family Practice Notebook Updates

Aka: Family Practice Notebook Updates, Family Practice Notebook Updates 2018, FPN Updates 2018, FPN Updates
  1. See Also
    1. Family Practice Notebook Updates 2017
    2. Family Practice Notebook Updates 2016
    3. Family Practice Notebook Updates 2015
    4. Family Practice Notebook Updates 2014
    5. Family Practice Notebook Updates 2013
  2. Updates: March 2018
    1. Nutrition Guidelines (pharm, nutrition)
      1. Healthy Kitchens, Healthy Lives conferences emphasizes delicious, plant forward food choices
      2. Vegetables and fruits should be 50% of diet and whole grains 25%
      3. Replace red meat with nuts, legumes, fish and poultry; limit dairy, and use monounsaturated fats
    2. Sexual Assault of Male Victim (prevent, abuse)
      1. Woods lamp is ineffective at visualizing semen (but UV light is effective)
    3. Migraine Headache (neuro, Headache)
      1. NSAIDS are first-line for mild-moderate Migraines and Triptans are first-line for mild-moderate Migraines
      2. Dopamine antagonists (e.g. reglan, Compazine) are preferred Antiemetics in Migraine Headache
      3. Acetaminophen and metoclopramide are preferred agents in pregnancy
      4. Acetaminophen, NSAIDs and Triptans are preferred in children
    4. Testicular Cancer (urology, hemeonc, Testes)
      1. Testicular Cancer screening is not recommended in asymptomatic men (USPTF)
      2. Testicular Cancer peaks at age 30-34 years
      3. Thorough update of staging, management and surveillance
    5. Vitamin D (pharm, Vitamin)
      1. Vitamin D Deficiency is defined as Vitamin D <12-20 ng/ml
      2. Vitamin D screening is not routinely recommended
      3. Vitamin D testing or supplementation is not indicated in Major Depression, Fatigue, Osteoarthritis or Chronic Pain
    6. Opioid Use Disorder (psych, cd)
      1. Buprenorphine is a common partial Opioid agonist used in Medication-Assisted Treatment
      2. Combined Buprenorphine/Naloxone agents are preferred over Buprenorphine alone for lower abuse potential
      3. Buprenorphine prescribers requires special DEA licensing
    7. Colorectal Cancer (gi, hemeonc)
      1. Follow-up after resection is typically every 3-6 months for 2-3 years, then every 6 months until 5 years post-resection
      2. CEA is tested at each follow-up visit
      3. CT chest, Abdomen and Pelvis is done every year for 5 years in Stage 3-4, and high risk Stage 1-2
      4. Colonoscopy is at 1 and 3 years after resection and then every 5 years (unless advanced adenoma is found)
    8. Intimate Partner Violence (prevent, abuse)
      1. Screen all patients with atypical presentations for abuse regardless of gender, race, age or LGBT
      2. Provide abuse victims with the resources and help they are willing to accept, with an open offer for additional help as they are willing to accept it
      3. Help patients develop a safety plan (emergency shelter and point person, emergency bag, important papers)
    9. Electrocardiogram (cv, exam)
      1. Do not rely on computerized EKG Interpretation (aside from interval measurement)
      2. There is no standardization for software quality across EKG manufacturers and accuracy varies widely
      3. Computer interpretations miss STEMIs in up to 23-41% of cases
      4. Atrial Fibrillation is a frequent false positive on computer interpretations
    10. Vaginitis (gyn, vagina)
      1. Symptoms do not distinguish Vaginitis cause (history, exam and labs are best used for accurate diagnosis)
      2. Single DNA tests (e.g. BD Affirm) are available to test for Trichomonas, Bacterial Vaginosis and candida infection
      3. DNA Testing is preferred for Trichomonas diagnosis, and can be added to DNA probe and liquid pap
      4. Bacterial Vaginosis treatment in pregnancy improves symptoms, but does not lower risk of Preterm Labor
    11. Drug Activity in Women (pharm, gyn)
      1. Women are higher risk for Torsades, Opioid-induced respiratory depression, insufficient Propofol dosing
    12. Musculoskeletal Injuries in Women (sports, gyn)
      1. Women athletes are higher risk for ACL Tears, PFS, Patellar Subluxations, Stress Fractures, elbow and Shoulder Dislocations and Concussions
    13. Sulfonylurea Drug Interactions Causing Hypoglycemia (endo, pharm)
      1. Sulfonyureas (esp. Glyburide) are a risk for Hypoglycemia
      2. Drug Interactions (e.g. Fluoroquinolones, Clarithromycin, sulondamides, fibrates) can increase the risk of drug-induced Hypoglycemia
    14. Mediastinal Widening (lung, rad)
      1. Emergent causes include Aortic Dissection, Aortic Rupture, Pneumomediastinum, thoracic aortic aneurysm, Vertebral Fracture with hematoma
      2. Other causes include lung or mediastinal mass or adenopathy, Hiatal Hernia, Atelectasis, Thymus or Thyroid mass or anatomic variant
      3. Imaging technique (rotation, supine position, AP view, poor inspiration) commonly results in wide mediastium appearance
    15. Procedural Sedation and Analgesia (surgery, anesthesia)
      1. Ketamine is the preferred procedural anesthetic in children with the least adverse effects
    16. MMR Vaccine (id, immunize)
      1. MMR Vaccine booster (3rd dose) is indicated in outbreaks if directed by local public health (esp. in dormitories, barracks)
      2. As always, avoid MMR in pregnancy and immunocompromised
      3. Give a second dose, if never immunized (or unknown status), at 4 weeks after the first
    17. Urinary Tract Infection in Pregnancy (urology, ob, id)
      1. Cephalexin, Cefuroxime, and Fosfomycin (expensive) may be used in any trimester (as well as Amoxicillin, which has higher resistance)
      2. Nitrofurantoin should not be used in late third trimester (Hemolytic Anemia risk) and may be very weakly associated with heart defects, Cleft Lip
      3. Trimethoprim-Sulfamethoxazole may only be used in second and early third trimester
    18. Steroid-Induced Hyperglycemia (endo, pharm)
      1. Blood Glucose will typically increase with Systemic Corticosteroids
      2. Most diabetes patients do not require significant changes to regimen when on short courses of Corticosteroids
      3. Risk of Hypoglycemia as steroid is tapered outweighs benefit of transiently increased regimen
      4. Closer monitoring and tighter Glucose management on Corticosteroids in Type I Diabetes Mellitus, uncontrolled Type 2 Diabetes Mellitus
    19. Rhabdomyolysis (renal, failure)
      1. Rhabdomyolysis is divided into exertional (typically benign) and non-exertional (worse outcome)
      2. Initial Creatinine kinase level does not predict outcome unless >40,000
      3. Acute Kidney Injury is associated with a worse outcome
      4. Aggressive fluid hydration is key within first 6 hours (urine out >250 cc/h), but crystalloid type and alkalinization have not been shown to matter for outcome
    20. Influenza (id, virus)
      1. Avoid Elderberry and Oscillococcinum (unlikely to be helpful)
    21. Low Back Pain Management (ortho, L-Spine)
      1. Valium does not add benefit over Naprosyn alone for Low Back Pain
      2. Most will improve within 3 months of Acute Low Back Pain onset (but 20% will still have a functional deficit)
    22. Tympanic Membrane Perforation (ent, ear)
      1. Do not use cortisporin with a perforated Ear Drum
      2. ENT referral for most cases, esp. for large perforation, suspected ossicle disruption, Vertigo
      3. Use antibiotic drops (e.g. Ofloxacin, Ciprofloxacin) which are at 100x oral concentrations, for associated Otitis Media with or without oral antibiotics
    23. Neonatal Circulation Assessment (nicu, exam, cv)
      1. Minimize blood loss in newborns
      2. Newborn Blood Volume: 85 ml/kg
      3. Newborn weighing 4 kg has only 340 ml total Blood Volume
      4. Every 34 ml (slightly more than 2 Tbs or 1 oz) is 10% of total Blood Volume
    24. Alcohol Intoxication (psych, cd)
      1. Hypoglycemia, abnormal Vital Signs or chemical Sedation needed are markers of underlying Critical Illness in the intoxicated patient
    25. Appendix Ultrasound (surgery, rad)
      1. AppendicitisUltrasound accuracy is improving
      2. Test Sensitivity is as high as 92% in radiology (80% at ED bedside)
      3. Test Specificity is as high as 97% in radiology (92% at ED bedside)
    26. Surfer Spine (sports, water)
      1. Atraumatic Spinal Myelopathy from cord infarction is an uncommon condition seen primarily in warm water Surfing (e.g. Hawaii) by amateur surfers
      2. May be associated with prolonged hyperextended position
      3. Presents with sudden onset of back pain, bilateral leg weakness, Paresthesias
  3. Updates: February 2018
    1. Penile Lesion (urology, penis, derm)
      1. Papulosquamous lesions include Psoriasis and pearly Papules
      2. Inflammatory lesions include Lichen Sclerosus, Lichen Nitidus, Lichen Planus
      3. Vascular lesions include Angiokeratomas
      4. Neoplastic lesions include Penile Carcinoma in Situ, penile squamous cell cancer
    2. Heel Pain (ortho, ankle, foot)
      1. Midfoot lateral pain includes Peroneal Tendinopathy and Sinus Tarsi Syndrome
      2. Midfoot medial pain includes flexor digitorum Tendinopathy or tibialis posterior Tendinopathy
      3. Posterior plantar Foot Pain includes Plantar Fasciitis, Heel Pad Syndrome, Tarsal Tunnel Syndrome, Calcaneal Stress Fracture
      4. Posterior Heel Pain includes Achilles Tendinopathy, Retrocalcaneal Bursitis, Haglund Deformity and in children, Severe Disease
    3. Colorectal Cancer Screening (gi, procedure, hemeonc)
      1. Standard Colorectal Cancer Screening starts at age 50, but for those meeting Family History criteria, start at age 40 (or 10 years before youngest relative)
      2. Specific screening protocols are defined for high risk syndromes: HNPCC, IBD, adenomatous polyposis, Peutz-Jeghers Syndrome, Sessile serrated polyposis
    4. Hemorrhoid (gi, Rectum)
      1. Fiber supplementation with adequate hydration is first-line management of Hemorrhoids
      2. Excise Thrombosed Hemorrhoids in the first 48-72 hours; Nifedipine or Nitroglycerin may be adjunctive for pain
      3. Most effective surgical interventions include Rubber Band ligation (grade I-III) and surgical excision (grade III-IV)
      4. Exercise caution when attributing rectal bleeding to Hemorrhoids (esp. in age >40 years or other Colon Cancer or Inflammatory Bowel Disease risks)
    5. Tremor (neuro, Tremor)
      1. Essential Tremor is the most common pathologic Tremor, an Action Tremor progressive with age, a diagnosis of exclusion made clinically
      2. Most Rest Tremors are Parkinsonism (although other causes include drug-induced and psychogenic can cause similar findings)
      3. Urgently refer children with Tremor
    6. Bullying (peds, behavior)
      1. Bullying is much more common than previously reported (each year, 20% in schools and 16% online)
      2. Start discussing Bullying at the 6 year old well child check
      3. Bullying victims commonly have Insomnia, Abdominal Pain, Headaches as well as Major Depression, Suicidality, poor school performance, Eating Disorders
    7. Hypothermia (er, environ)
      1. In Frostbite, do not massage or apply dry heat
      2. In Hypothermia, measure a core Temperature with a thermometer with adequate lower range, and consider Secondary Hypothermia causes
      3. In severe Hypothermia, ECMO continues to offer better outcomes when core Temperature is <28 C or if hemodynamic instability
    8. Abdominal Ultrasound (gi, rad)
      1. Several protocols exist for evaluating the Abdomen with Ultrasound including for free air, Small Bowel Obstruction and localizing Epigastric Pain
    9. STEMI (cv, cad)
      1. STEMI with Hypotension mayh be due to right ventricular infarct, Aortic Dissection, massive Pulmonary Embolism, Cardiac Tamponade, ventricular rupture
    10. Head Injury (er, neuro)
      1. Warfarin-related delayed CNS bleeding after Head Injury is uncommon (<2%) and typically does not warrant intervention
    11. Cardiac Arrest (er, exam)
      1. Consider a brief moment of silence at the end of code in which the patient expired
    12. Chlorine (er, toxin)
      1. Chlorine gas may form with use of cleaners (e.g. bleech solutions) and may cause ARDS and other life threatening lung injury
    13. Ketorolac (pharm, Analgesic)
      1. Ketorolac 10 mg IV is as effective for analgesia as 15 or 30 mg
    14. Fever Without Focus Management Birth to 3 Months (id, peds)
      1. Well appearing febrile infants at 60 days of age have a 1.8% Prevalence of bacteremia
    15. Cannabinoid Hyperemesis Syndrome (psych, cd)
      1. Capsaicin cream applied to Abdomen (palm-sized amount) is effective
    16. Sudden Sensorineural Hearing Loss (ent, hearing)
      1. Prednisone 50-60 mg orally daily while awaiting ENT followup
    17. Traumatic Cardiopulmonary Arrest (er, cv)
      1. Unless medical Cardiac Arrest, immediate interventions (chest Ultrasound, Finger Thoracostomy) take precedence over CPR in Traumatic Arrest
      2. Consider Finger Thoracostomy instead of Needle Thoracostomy (both of which are best done at the 5-6th intercostal space axillary line)
    18. Oral Contraceptives (gyn, pharm)
      1. Even low dose Estrogen increases Breast Cancer risk by RR 1.2
    19. Biotin (pharm, Vitamin)
      1. Biotin supplementation for hair, nails... has little data of efficacy
      2. High dose Biotin (>5000 mcg) falsely lowers Thyroid Stimulating Hormone, Troponin and Procalcitonin
    20. Altitude sickness (er, environ)
      1. Consider prophlaxis with Diamox if traveling to >11,000 feet in one day (or 9000 if prior history of altitude sickness)
    21. Medications (pharm)
      1. Many new, expensive, copy-cat drugs
      2. Do we really need more GLP-1, SGLT2 Inhibitor agents for diabetes or biologics for Psoriasis or combo HIV agents?
      3. Who is working on new antibiotics or reasonably priced cancer regimens?
    22. Long Acting Beta Agonist (lung, Asthma, pharm)
      1. FDA takes away a black box warning on LABAs (apparently mortality was no worse than with Inhaled Corticosteroids)
  4. Updates: January 2018
    1. Chronic Kidney Disease (renal, failure)
      1. Serum cystatin C may be used in place of Serum Creatinine to estimate Glomerular Filtration Rate
      2. Urine Albumin to Creatinine Ratio is the preferred method to evaluate for Proteinuria
      3. Use Urine Protein to Creatinine Ratio in severe Proteinuria (>300 mg/g)
    2. Pigmentation Disorder (derm, pigment)
      1. Several Hyperpigmentation disorders (e.g. Melasma, Solar Lentigines, Postinflammatory Hyperpigmentation) respond to tri-luma
      2. Start with Topical Corticosteroids for Localized Vitiligo, and UVB for generalized Vitiligo
      3. Sun protection and Sunscreen are a key to the management of Pigmentation Disorders
    3. Palpitations (cv, sx)
      1. Most Palpitations will be due to psychosomatic disorders, Atrial Fibrillation, SVT
      2. Every person with Palpitations should have an EKG at minimum
      3. Supraventricular Premature Complexes (SVPCs) are associated with risk of Atrial Fibrillation and cardiac events
    4. Hypertension Criteria (cv, htn)
      1. Once again ACC/AHA has moved the targets on Blood Pressure goals based on new studies
      2. Is this sound, given Blood Pressure reading inaccuracies, prescriber confusion, medication and lifestyle noncompliance
    5. Hypothyroidism (endo, Thyroid, pharm)
      1. Subclinical Hypothyroidism may be treated if TSH >10, persistent symptoms (Fatigue, Constipation, cold intolerance) or pregnancy
      2. Avoid desiccated Thyroid and Liothyronine (T3) in most cases
    6. Automobile Safety (prevent, car, pharm)
      1. Ilicit drugs and prescribed Benzodiazepines and other Sedative-Hypnotics, muscle relaxants, Opioids, Anticholinergics may cause Impaired Driving
    7. Opioid Dependency (psych, cd, pharm)
      1. Naltrexone is revisted for maintenance of Opioid sobriety
    8. Topical Corticosteroids (derm, pharm)
      1. Once again, pharmaceutical companies have found a way to double prices on Generic Drugs (e.g. Topical Clobetasol)
    9. Long-acting Beta Agonist (copd, pharm)
      1. Trelegy Ellipta for severe COPD combines a LAMA, LABA and Corticosteroid
    10. Bronchiolitis (lung, Bronchi)
      1. Hypertonic Saline does not reduce hospitalization rates in Bronchiolitis
    11. Nonphysiologic Neonatal Jaundice (nicu, gi)
      1. Not much has changed in Hyperbilirubinemia management in the last couple of decades
      2. Use calculators (e.g. to assess the need for Phototherapy
      3. Consider secondary causes (e.g. Neonatal Sepsis)
    12. Idarucizumab (hemonc, pharm, coags)
      1. Idarucizumab reverses Dabigatran (Pradaxa) rapidly (minutes) and effectively
    13. Low Risk Chest Pain (cv, cad)
      1. Stress testing in Low Risk Chest Pain increases angiograms and revascularization without reducing MI related admissions
    14. Cardiac Arrest (er, exam)
      1. Bedside Ultrasound increases the delays to restarting Chest Compressions
    15. Delayed Sequence Intubation (lung, procedure)
      1. Prevent aspiration, by keeping CPAP or Bipap inspiratory pressures <15 cm H2O
      2. Small Ketamine doses in adults for DSI are sufficient (20-30 mg)
    16. Hyperemesis Gravidarum (ob, gi)
      1. Fewer labs needed (No Thyroid tests unless symptoms of Hyperthyroidism, Urine Ketones are not markers of illness severity)
      2. Metoclopramide and Ondansetron are first line Antiemetics
    17. Endotracheal Intubation Preoxygenation (lung, procedure)
      1. Oops Mnemonic (Levitan): Oxygen On, Apply 15 lpm by Nasal Cannula for Apneic Oxygenation, Pull Mandible forward, Sit patient up (to 20 degrees)
    18. Acromioclavicular Separation (ortho, Shoulder)
      1. Obtain comparison view of unaffected side, but weighted films are not needed
    19. Ankle Fracture (ortho, ankle, Fracture)
      1. Weber B Ankle Fracture stability is predicted by <2 mm posterior fragment displacement and only 2 Fracture fragments
    20. Noninvasive Urine Collection (urology, lab)
      1. Alternative techniques to stimulate urination in young children (pre-Toilet Training) are highly effective
      2. Quick-Wee Method (forceps with cold saline soaked gauze rubbed on suptrapubic area)
      3. Bladder stimulation technique (infants <1 month), with infant suspended by axilla, tap on Bladder, than circular massage low back
    21. Brown Recluse Spider Bite (er, derm, bite)
      1. Immediately ice bite wounds to deactivate toxin
      2. Skin necrosis starts at 72 hours after bite
      3. NOT RECLUSE mnemonic is used to exclude brown recluse bites as wound cause in endemic areas
    22. Informed Consent (neuro, cognitive)
      1. Provider performing the procedure should also perform the Informed Consent
    23. Otitis Externa (ent, ear)
      1. Combine topical antibiotic with a Topical Corticosteroid (e.g. cipro-hc, cipro-dex, Ofloxacin and Dexamethasone)
    24. Insulin Dosing in Type 2 Diabetes (endo, pharm)
      1. Updated protocol for initiating basal Insulin only and advancing to basal and Bolus Insulin (Insulin augmentation)
      2. Updated protocol for initiating and advancing to basal and Bolus Insulin (Insulin replacement)
    25. Ear Pain (ent, sx, ear)
      1. Consider referred Ear Pain, esp. cancer risk, CAD risk and Temporal Arteritis risk
    26. Pityriasis Rosea (derm, hyperplasia)
      1. Likely HHV-6 (Roseola) and HHV-7 mediated rash, which may respond to Acyclovir

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