//fpnotebook.com/
Family Practice Notebook Updates
Aka: Family Practice Notebook Updates, FPN Updates, Family Practice Notebook Updates 2022, FPN Updates 2022
- See Also
- Family Practice Notebook Updates 2021
- Family Practice Notebook Updates 2020
- Family Practice Notebook Updates 2019
- Family Practice Notebook Updates 2018
- Family Practice Notebook Updates 2017
- Family Practice Notebook Updates 2016
- Family Practice Notebook Updates 2015
- Family Practice Notebook Updates 2014
- Family Practice Notebook Updates 2013
- Updates: August 2022
- Brainstem CVA (neuro, cv)
- Added various Brainstem Syndromes (thanks to Dr. Sourabh Jain)
- Intracerebral Hemorrhage (neuro, cv)
- Updates
- Spinal Epidural Abscess (ortho, id)
- Updates
- Active Female (sports, gyn)
- Updates including to RED-S (replaces Female Athlete Triad), Exercise in Pregnancy
- Abdominal Pain in Pregnancy (surgery, ob)
- Updates including imaging the RLQ
- Preeclampsia Prevention (cv, ob)
- Consistent Exercise initiated in early pregnancy reduces the risk of developing Gestational Hypertension and Preeclampsia
- Blood Type (hemeonc, lab)
- Updates to Blood Type, INR, Clotting Pathway, Perioperative Anticoagulation
- Retropharyngeal Abscess (ent, mouth)
- Updates
- Intranasal Analgesics in Children (pharm, peds)
- Updates
- Esophageal Rupture (gi, esophagus)
- Updates
- Inflammatory Bowel Disease (gi, ibd)
- Updates
- Rectal Prolapse (gi, Rectum)
- Updated including reduction technique
- Low Back Pain (ortho, sx)
- Updates, including Low Back Pain Red Flags
- Patellar Fracture (ortho, knee)
- Updates
- Celiac Disease (gi, malabsorption)
- Updates
- Acute Pancreatitis (gi, Pancreas)
- Updates
- Acute Diarrhea (gi, Diarrhea)
- Updates
- Perirectal Abscess (gi, Rectum)
- Updates
- Pilonidal Abscess (gi, Rectum)
- Updates
- Urinalysis (urology, lab)
- Extensive updates to all components of the Urinalysis
- Alzeimers Disease (neuro, cognitive)
- PrecivityAD is a lab marketed for age 60 years old and older with Cognitive Impairment
- Combines 2 tests: ApoE Genotype and Abeta 42 to Abeta 20 ratio
- Generates a proprietary Amyloid Probability Score, estimating the likelihood for Alzheimers Disease
- Erythroderma (derm, hyperplasia)
- Updates
- Scrotal Swelling (urology, sx)
- Updates
- Infantile Hemangioma (derm, peds)
- Propranolol is FDA approved for age 5 weeks and older
- Well tolerated and very effective at facilitating Hemangioma involution when used in the first year of life
- Start in first months of life to prevent proliferation and continue for 6 months
- Dose: 1 mg/kg (max 2-3 mg/kg/dose) orally twice daily, given after feeding to prevent Hypoglycemia
- Depression Medical Management (psych, depress)
- Updates
- Covid19 (lung, id)
- Updates regarding Pxlovid including specific Drug Interactions
- Head Lice (derm, Parasite)
- Abametapir (Xeglyze) is another agent soon available to treat Head Lice
- pSOFA Score (id, fever)
- Added, thanks to Dr. Sourabh Jain
- APACHE Score (GI, Exam)
- Updated to link to APACHE 4 Calculator, thanks to Dr. Sourabh Jain
- Tirzeptatide (endo, pharm)
- Tirzeptatide (Mounjaro) is a GLP1-agonist, but also a GIP Agonist
- In combination with Metformin, reduces Hemoglobin A1C up to 2.3%
- Weight loss in Diabetes Mellitus patients may approach 25 pound loss in 10 months
- Same adverse effects and risks as with GLP-1 Agonists
- Seborrheic Dermatitis (derm, dermatitis)
- Updates
- Collagen Supplement (pharm, alternative)
- Added
- Medical Precepting (manage, communication)
- Added
- Giapreza (cv, pharm)
- Updates
- Methotrexate Toxicity (rheum, pharm)
- Updates
- Social Media (prevent, computer)
- Updates, and a resource added to The Social Dilemma Movie
- Gastrointestinal Bleeding Management (gi, sx)
- Updated intubation management thanks to Dr. Sourabh Jain
- Cardiac CT Calcium Scoring (cv, rad)
- Updates
- Cachexia in Cancer (hemeonc, endo)
- Updates
- Updates: July 2022
- Sodium Nitrite Poisoning (er, toxin)
- Added
- Unknown Ingestion (er, toxin)
- Updated with precautions regarding newer combinations used in online Suicide kits
- Cellulitis (derm, Bacteria)
- Updates, including Necrotizing Fasciitis, severe Cellulitis empiric regimen
- Negative Pressure Wound Therapy (surgery, procedure)
- Added
- Community Acquired Pneumonia (lung, id)
- Extensive updates
- Monkeypox (id, virus)
- Added
- Clostridiodes difficile (gi, id)
- Updated antibiotic coverage
- Pneumococcal Vaccine (id, immunize)
- Another reminder that pneumococcal Vaccination has been simplified
- Prevnar 20 is sufficient alone in most adults with Pneumococcal Vaccine Indications
- Herd Immunity from Primary Series in children has markedly reduced invasive pneumococcus in elderly
- Superior Vena Cava Syndrome (cv, vessel)
- Updates to Superior Vena Cava Syndrome and to Generalized Edema Above the Diaphragm
- Splenic Rupture
- Spontaneous Splenic Rupture is seen in Infectious Mononucleosis (EBV) with Splenomegaly
- Spontaneous rupture accounts for 50% of Infectious Mononucleosis related Splenic Rupture cases
- Preoperative Examination in Children (surgery, exam)
- Added with extensive coverage
- Water Intoxication (renal, Sodium)
- Water Intoxication, beer potomania, Tea and Toast Syndrome share a similar mechanism for Hyponatremia
- Patient with excessive hypoosmolar fluid intake (free water, beer, tea) and low solute diet (low Sodium intake)
- Intake exceeds the renal capacity for free water excretion (50 to 100 meq/L or mOsm/L, specific gravity <1.003)
- Calcium Supplementation (renal, Calcium)
- Updated absorption
- Myasthenia Gravis (neuro, motor)
- Updates
- Cerebrovascular Accident (neuro, cv)
- Updates
- Finger Fracture (ortho, hand)
- Updates to Fractures including avulsion Fractures
- Finger Dislocation (ortho, hand)
- Updates
- Pelvic Fracture (ortho, hip)
- Updates
- Lumbar Surgery (ortho, surgery)
- Added
- Laceration Repair (surgery, derm)
- Scattered updates
- Regional Anesthesia (Surgery, Pharm)
- Multiple updates and revisions based on the excellent HQMedEd Regional Anesthesia course at HCMC
- Added 5 new diagrams for added blocks
- PENG Regional Anesthesia (Surgery, Pharm)
- Another method for Regional Anesthesia of the hip
- Axillary Nerve Block (Surgery, Pharm)
- Added
- Supraclavicular Brachial Plexus Block (Surgery, Pharm)
- Added
- Xylazine Toxicity (psych, cd)
- Adrenergic alpha-2 agonist (similar to Clonidine, Dexmedetomidine) with central acting decrease in sympathetic tone
- Used as a Sedative, Analgesic and centrally acting Muscle relaxant in veterinary medicine
- Street name, "Horse Tranquilizer", added to injection Drugs of Abuse (e.g. Fentanyl, Cocaine) to enhance euphoria
- Associated with Opioid Overdose deaths, and unresponsive to Naloxone
- Cannabinoid Hyperemesis (psych, cd)
- Capsaicin cream may work on vanilloid receptors in Hypothalamus (similar to the action of a hot shower)
- Apply 0.075% Capsaicin cream as a thin film every 4 hours until symptoms resolve
- Apply cream to 15 x 25 cm or palm sized area periumbilical area using a gloved finger
- Peak effect in 20-30 minutes and lasts 3 hours
- Premature Ejaculation (urology, sx)
- Added
- Emergency Contraception (gyn, pharm)
- Mirena IUD (Levonorgestrel-releasing) has similar efficacy to Copper-T IUD for EC
- Intrauterine Device (gyn, Contraception)
- Studies support longer duration for IUD use
- Copper T-380A (Paragard) IUD: 10 years (studies support 12 years of use)
- Mirena: 7 year Levonorgestrel IUD (originally labelled for 5 years)
- Depo Provera (gyn pharm)
- Self-administered Depo Provera Subcutaneous (SQ) dosing is off label but supported by CDC, WHO
- Aspirin (pharm, Analgesic)
- Falling out of favor in the primary prevention of lower risk patients without Myocardial Infarction or stroke (NNT 250 for first CV event)
- Benefits may not outweigh the risks of GI Bleeding, Hemorrhagic CVA (NNH 200)
- Insect Repellent (id, pharm)
- Updated
- Agitation in Dementia (neuro, cognitive)
- Updated
- PDE5 Inhibitor (urology, pharm)
- Blurred Vision or Vision Loss (Retinal Detachment, Optic Neuropathy), with higher risk in atherosclerosis
- Vision Loss can be permanent and appears to occur with all PDE5 Inhibitors
- Incidence may be as high as 16 in 10,000
- Orexin Antagonist (urology, pharm)
- Added Quviviq (Daridorexant), another expensive sleep aid
- D-Dimer Discriminatory Values in Pulmonary Embolism (hemeonc, lab)
- Added PEGeD protocol related discriminatory values
- DVT Prevention in Travelers (hemeonc, prevent)
- Updates
- Iritable Bowel Syndrome
- Ibsrela (Tenapanor) is another expensive agent for Constipation dominant iritable bowel syndrome
- Soft Tissue Mass
- Added
- Plantar Fibromatosis (ortho, foot)
- Updates
- Nodular Tenosynovitis (ortho, hemeonc)
- Added
- Liposarcoma (hemeonc, Sarcoma)
- Added
- Dermatofibrosarcoma Protuberans (hemeonc, Sarcoma)
- Added
- Leiomyosarcoma (hemonc, Sarcoma)
- Added
- Rhabdomyosarcoma (hemeonc, Sarcoma)
- Updated
- Hypothyroidism (endo, Thyroid)
- TSH elevations are often transient in the elderly (often during non-Thyroid related acute conditions)
- Exercise caution when starting Thyroid Replacement in the elderly, and consider rechecking TSH after acute illness
- Thanks to Dr. Joe Weidner for the pearl
- Updates: June 2022
- Pediatric Constipation (gi, peds)
- Extensive updates
- Acute Radiation Syndrome (er, toxin)
- Added a thorough review of Radiation Syndrome
- First Seizure Evaluation (neuro, Seizure)
- Extensive updates
- Pediatric CVA (neuro, cv)
- Expanded differential diagnosis
- Telangiectasia (derm, exam)
- Added extensive review
- Subtalar Dislocation (ortho, foot)
- Added this high energy, rare foot dislocation
- Prevention of Kidney Disease Progression (renal, prevent)
- Limiting Dietary Sodium intake (e.g. <2300 mg/day) lowers Blood Pressure and decreases albuminuria
- Postpartum Care (ob, postpartum)
- Reviewed Postpartum Hemorrhage, Peripartum Cardiomyopathy, Cerebral Venous Thrombosis, Amniotic Fluid Embolism, Preeclampsia
- Sexually Transmitted Infection (id, std)
- Updates
- Mycoplasma Genitalium (id, std)
- Added
- Intimate Partner Violence (prevent, abuse)
- Updated
- Mycetoma (derm, id)
- Added
- Psoriasis (derm, hyperplasia)
- Updates to management
- Foreign Body Granuloma (surgery, derm)
- Added a brief summary of this complication of retained Skin Foreign Body
- Vasomotor Symptoms of Menopause (gyn, sx, endo)
- A few updates and corrections to SNRIs
- Deep Vein Thrombosis (hemeonc, cv)
- Created a deep vein image
- Post-Thrombotic Syndrome (hemeonc, cv)
- Review of topic, diagnosis, grading, management and prevention
- Tendinopathy (sports, ortho)
- Updated Peroneal Tendinopathy, Posterior Tibial Tendinopathy, Anterior Tibial Tendinopathy
- Added Ankle Anatomy diagram (Muscles and tendons)
- Joint Pain (rheum, sx)
- Added additional evaluation guidance
- Down Syndrome (neuro, Disability)
- Updates to the Health Maintenance of adults with Down Syndrome
- Insulin Pump (endo, pharm)
- Updates
- Metabolic Syndrome (endo, dm)
- Updates
- Type 2 Diabete Mellitus (endo, dm)
- Indications to add SGLT2 Inhibitor or GLP-1 Receptor Agonist (which are associated with lower mortality)
- Established cardiovascular disease or Chronic Kidney Disease (esp. SGLT Inhibitor)
- Four or more Cardiovascular Risk Factors
- Peanut Allergen Powder (ent, pharm)
- Updates
- Traveling with Medications (id, travel)
- Updates
- Decubitus Ulcer Prevention (surgery, derm)
- Updates
- Parkinson's Disease Management (neuro, Tremor)
- Updates
- Spinal Cord Injured Patient (prevent, hme)
- Regular Physical Activity improves aerobic capacity, balance and walking ability
- Improves Activities of Daily Living, global function, Major Depression and sleep quality
- Prevention of Ischemic Stroke (neuro, prevent)
- Updates
- Condom (gyn, Contraception)
- Updates
- Chest XRay (lung, rad)
- A few additions including spine sign
- Tobacco Cessation (psych, cd)
- Behavioral interventions are effective (with or without pharmacotherapy)
- Individual or group counseling
- Guaranteed financial incentives
- Text message-based counseling
- Hydrocarbon Ingestion (er, toxin)
- Expanded on Hydrocarbon definitions, examples, pathophysiology, evaluation and management
- Atrial Fibrillation Synchronized Cardioversion (cv, ekg)
- Electrical Cardioversion results in earlier discharge compared with chemical cardioversion for CHADS 0 to 1
- Thiazide Diuretic (cv, pharm)
- Chlorthalidone is more potent than Hctz (lowers SBP 10 mmHg more)
- Hctz immediate release only covers daytime Hypertension
- Lung Cancer (lung, hemeonc)
- Extensive updates to Lung Cancer, Non-Small Cell Lung Cancer, Small Cell Lung Cancer
- Also updates to Lung Nodule (approach changed in 2017) and Lung Cancer screening (approach changed in 2021)
- Prostate Cancer Screening (urology, hemeonc)
- MyProstateScore (MPS) is two urinary biomarkers: Prostate CancerAntigen 3 (PCA3), TMPRSS2:ERG Gene Fusion
- Consider in patients referred for Prostate biopsy
- Cost of $760 is not covered by medicare or medicaid
- COPD Pulmonary Rehabilitation (lung, sports)
- Virtual Pulmonary Rehab or Telerehabilitation (phone call, phone app, computer, video conference)
- As effective as in-person rehab in reducing breathlessness and increasing walk distance in COPD
- Livedo Reticularis (rheum, exam)
- Added, with updates to Polyarteritis Nodosa and Takayasu Arteritis
- Lateral Canthotomy (eye, procedure)
- Updates
- Hypopyon (eye, exam)
- Expanded on differential diagnosis including Pseudohypopyon
- Also Added endogenous Bacterial endophthalmalitis
- Macular Degeneration
- VEGF Inhibitor Ocular Implant containing Ranibizumab (Susvimo) is inserted via a small incision in pars plana and Sclera
- Similar to VEGF Inhibitor Intravitreal Injections that require reservoir refill via needle only every 24 months
- As effective as intravitreal injection, but with Endophthalmitis risk (1.7%) is higher with implants than with injection (0.5%)
- Conjunctival Hemorrhage, hyperemia ad Iritis are common initial adverse effects in first month
- Hypertrophic Cardiomyopathy (cv, Myocardium)
- Extensive updates to diagnosis, evaluation, management including specific guidelines in pregnancy, athletes, pilots, truck drivers
- Covid19 Monoclonal Antibody (lung, pharm)
- Bebtelovimab is a Monoclonal Antibody effective in omicron variants
- PreHevbrio (id, immunize)
- Three Antigen recombinant Hepatitis B Vaccine indicated as a Hepatitis B Vaccine option in non-pregnant adults
- This Tri-Antigenic Vaccine Appears more immunogenic than other, single Antigen preparations
- However, associated with more local pain, as well as myalgias, Headache, Fatigue than with the other preparations
- As with most other Hepatiis B Vaccines, administer in 3 doses at 0, 1, and 6 months
- Ventricular Tachycardia (cv, ekg)
- Additional features that make Ventricular Tachycardia more likely than SVT with aberrancy
- Right bundle branch morphology of the QRS (RSR' or "rabbit ears")
- Fusion Beats (supraventricular and ventricular waves fuse to form an irregular QRS)
- Intravenous Contrast for Abdominopelvic CT (surgery, rad)
- Updates
- Low Back Pain Management (ortho, l-spine)
- Antispasmodics/Muscle relaxants once again show no benefit and increased adverse effects
- Hospital Support for Lactation (ob, Lactation)
- Infant Carrier may increase the rate of Breast Feeding at 6 months
- Updates: May 2022
- Urethral Stricture (urology, Urethra)
- Added complete review including diagnosis and management
- Oral Lesion (dental, mucosa)
- Updated Aphthous Ulcer, Oral Candidiasis, Geographic Tongue, Hairy Tongue, Herpes Labialis, Leukoplakia, Torus Palatinus, Oral Lichen Planus
- Venous Thromboembolism (hemeonc, cv)
- Extensive updates with a focus on recurrent VTE management
- Added two decision rules: HERDOO2 Model and Orbit Bleeding Risk Score
- Also updated Breakthrough VTE
- Sleep Disorders (psych, sleep)
- Extensive updates
- Sexually Transmitted Infection (id, std)
- Extensive Updates to Sexually Transmitted Infection, especially regarding gonorrohea and Chlamydia
- Include pharyngeal and rectal GC, Ch testing when indicated
- Ulcerative Colitis (gi, ibd)
- Extensive updates
- Ivabradine (cv, pharm)
- CHF agent - updated Drug Interactions, adverse effects, contraindications
- Cascades of Care (manage, legal)
- Extra tests beget more tests
- Shingles Vaccine (id, immune)
- Shingrix is now recommended for Immunocompromised patients, age >19 years
- Alcoholic Hepatitis (gi, liver)
- Extensive updates
- Lung Abscess (lung, id)
- Extensive updates
- Near-Hanging (er, ent)
- Extensive Updates
- Myocarditis (cv, id)
- General updates to the diagnostic approach
- Nasal Fracture (ent, nose)
- Updates on imaging approach (skip the xray)
- Hepatitis B Vaccine (id, immune)
- Hepaitis B Vaccine is recommended for all unvaccinated adults ages 19 to 59 years
- Fever in the Returning Traveler (id, fever)
- Extensive updates
- Intraosseous Line (er, procedure)
- Added image for access sites
- Analgesic Overuse Headache (neuro, Headache)
- A few updates
- Monkshood Poisoning (er, toxin)
- Added
- Tetrahydrocannabinol (psych, cd)
- Delta-8 THC is a synthetic, chemically similar to THC (delta-9), but with risk of life threatening toxicity
- Myasthenia Gravis (neuro, motor)
- Updates
- Tick Borne Illness (er, derm)
- Updates
- Alpha Gal Reaction (ent, allergy)
- Added
- Powassan Encephalitis (neuro, id)
- Added
- Southern Tick Associated Rash Illness
- Added
- Gabapentin (neuro, pharm)
- Updates
- Agitated Delirium (psych, behavior)
- Updates
- Scaphoid Fracture (ortho, wrist)
- Short Arm Cast WITHOUT thumb appears as effective as Thumb Spica Cast, and with better hand function while casted
- Elbow Ossification Centers (ortho, anatomy)
- Added image for Elbow Ossification Centers (CRITOE Mnemonic)
- Homeopathy (pharm, alternative)
- Solutions so dilute, they may lack even a single molecule of "active" ingredient, but could have harmful contaminants
- Who knows? Not the consumer, and not the FDA or USP, since these are unregulated
- Peptic Ulcer (gi, pud)
- Glycopyrolate was originally used in the 1960s for peptic ulcers to reduce gastric secretions
- However, since that time, much more effective medications are available (e.g. H2 Blockers, Proton Pump Inhibitors)
- Yet, in 2022 Dartisla ODT was released at $500/90 tablets, a 10 fold markup over generic glycopyrolate
- Avoid glycopyrolate (including Dartisla ODT) in Peptic Ulcer Disease (we have much better. less expensive treatments)
- Fluoride Supplementation (pharm, mineral)
- Added dental varnish (had been included in Oral Health in Children)
- Delayed Antibiotic Prescription (pharm, id)
- Example: Acute Sinusitis <10 days of symptoms (to start if symptoms refractory to non-antibiotics at >10-14 days)
- Delayed Antibiotic Prescriptions result in decreased antibiotic use, without adverse outcomes
- Covid19 (lung, id)
- Added AAP Return to Play guidelines for child and teen athletes following Covid 19 infection
- Preparticipation Physical Evaluation (sports, exam)
- Added Electrocardiogram precautions
- Alcohol Intoxication (psych, cd)
- General updates
- Hepatitis B Serology (gi, lab)
- Added another Serology interpretation table
- Langerhans Cell Histiocytosis (hemeonc, marrow)
- Rare condition presenting in young children age<3 with atypical, refractory Seborrheic Dermatitis or Eczema
- Plenity (endo, pharm)
- Updated
- Mild Closed Head Injury (er, neuro)
- I-Stat TBI Plasma detects 2 markers of intracranial injury (UCH-L1, GFAP)
- May be used to risk stratify to Head CT Imaging in adults within 12 hours of Closed Head Injury with GCS 13 to 15
- CT Indicated if UCH-L1 > 327 pg/ml, or GFAP >22 22 pg/ml
- Test Sensitivity 97.6% for intracranial Head Injury and Negative Predictive Value 99.6%
- Bacterial Meningitis (neuro, id)
- Updated decision rules
- Alopecia Areata (derm, hair)
- Updated
- Zinc Deficiency (pharm, minerals)
- Updated Zinc Deficiency and Zinc
- Clinical Practice Guideline (manage, research)
- Updated with pitfalls, resources
- Updates: April 2022
- Sacroiliac Joint Dysfunction (ortho, L-spine)
- Extensive updates
- Pediatric Murmur (cv, exam, peds)
- Extensive updates to Heart Murmur, Systolic Murmur, Diastolic Murmur, Congenital Heart Disease and Pediatric Murmur
- Prevnar 20 (id, immunize)
- Pneumococcal Vaccine recommendations by CDC have changed every few years and are confusing
- Pneumococcal Vaccination is recommended for over age 65 years and those with risk factors
- As of 2022, Prevnar 20 ALONE replaces other Pneumococcal Vaccines
- If Prevnar 13 or Vaxneuvance are used for conjugate Vaccine, then also give Pneumovax 23 (at interval)
- Telemedicine Diabetes Mellitus Evaluation (endo, exam, dm)
- Provider and nurse diabetes Telemedicine visits improve outcomes and glycemic control (esp. Type 2 Diabetes)
- Remote Glucose monitoring is among the most effective Telemedicine strategies
- Corticosteroid (endo, pharm)
- Added Corticosteroid tapering indications (>3 weeks of use, disease flare expected on stopping)
- Also added physiology related information
- Thalassemia (hemeonc, Hemoglobin)
- AFP Journal has an excellent review of Thalassemia in March 2022 issue
- Article brings into focus the management and complications of Thalassemia based on transfusion dependent or not
- Extensive updates to a topic that I feel I understand much better after reading this article
- Also completed a Hemoglobin diagram
- Fever Without Focus Management Birth to 3 Months (id, peds)
- Extensive updates to the well appearing febrile infant protocol that changed in fall of 2021
- Medications in Lactation (ob, pharm)
- Updated Medications in Lactation and Breast Feeding Problems for the Mother
- Menstrual Cycle (gyn, exam)
- Extensive additions to the physiology of the Menstrual Cycle including a new diagram
- Intussusception (surgery, gi)
- Updates
- Monteggia Fracture (ortho, elbow)
- Do not miss the Radial Head Dislocation!
- Added image for Forearm Fracture dislocations (GRUM)
- Narrow Pulse Pressure (cv, exam)
- May predict circulatory collapse in Trauma with Hemorrhage
- Prehospital Narrow Pulse Pressure predicts severe Trauma and need for aggressive Resuscitation
- Interpret in combination with Trauma Evaluation and other markers (Hypotension, Shock Index)
- Septic Olecranon Bursitis (ortho, id)
- Bursa Aspiration for Gram Stain and culture has been historically recommended in all cases of Septic Bursitis
- However, based on new ED based study, empiric antibiotic management without aspiration may be a safe and effective strategy
- Health Care Associated Infection (id, prevent)
- Updates to CAUTI, CRBI, VAP, C. difficile, Surgical Site Infection, Antibiotic Resistant Infection
- Insulin (endo, pharm)
- Added additional information about Insulin U-500
- Hyperparathyroidism (endo, Parathyroid)
- Extensive updates to Hypercalcemia and Hyperparathyroidism
- Also updated Hypocalcemia and Hypoparathyroidism
- Hypopituitarism (endo, pituitary)
- Added
- CT Angiography in Gastrointestinal Bleeding (gi, rad)
- Preferred test when Lower GI Bleed patient cannot undergo endoscopy, with significant Lower GI Bleeding
- Cerebral Venous Thrombosis (neuro, cv)
- Updated risk factors, precautions, presentation, management
- Cerebral Arteriovenous Malformation (neuro, cv)
- Added, and also added Arteriovenous Malformation
- Cerebral T Waves (cv, ekg)
- Associated with large Intracranial Hemorrhage (also seen in cerebral edema, Ischemic CVA, PRES)
- Typically in precordial leads, and T Inversion may be >20 mm
- May be associated with Prolonged QTc
- Altered Level of Consciousness in Children (neuro, peds)
- Added with an extensive protocol and differential diagnosis
- Pneumonia Management in Children (id, lung)
- Updates regarding antibiotic selection and shorter durations (5 days)
- Psychological First Aid (psych, exam)
- Added lay person intervention in Suicidality
- Buprenorphine (pharm, Analgesic)
- Added dental decay related adverse effects
- Melatonin (pharm, alternative)
- Updates regarding safety (not recommended in pregnancy and Lactation), may cause Growth Delay in children
- Updated dosing in children
- Diabetic Neuropathy (endo, neuro)
- Updates on medication management
- Acute Angle-Closure Glaucoma (eye, Glaucoma)
- Updated exam and management
- Buprenorphine (pharm, Analgesic)
- Oral Buprenorphine preparations (e.g. buccal, sublingual) may increase risk of Tooth Decay
- Eczematous Dermatitis (derm, dry)
- Added new agents (monoclonal antibodies, JAK Inhibitors)
- Flecainide Overdose (cv, pharm)
- Reviewed toxicity findings and management
- Body Packer (er, toxin)
- Additional management including Whole Bowel Irrigation added to protocol
- Subcutaneous Hematoma Drainage (surgery, procedure)
- Added
- Postoperative Oral Bleeding (dental, mucosa)
- Added based on author experiences
- Limited evidence for approaches gleamed from expert opinion, including otolaryngology
- Hemophilia B (hemeonc, coags)
- Updates to management
- Wound Closure with Staples (surgery, procedure)
- Added
- Auricular Field Block (surgery, procedure)
- Updated
- Retrograde Urethrogram (urology, procedure)
- Updated
- Central Cord Syndrome (ortho, c-spine)
- Updated
- Spinal Epidural Abscess (ortho, l-spine)
- Spinal Epidural Abscess is frequently misdiagnosed on initial presentation
- Be alert for red flag presentations (esp. with back pain)
- Unexplained fever is present in 86% of cases
- Focal neurologic deficits with progressive or disabling symptoms is present in 82% of cases
- Tramadol (pharm, Analgesic)
- Additional Tramadol updates (many reasons to avoid)
- Read the Tox and the Hound (Tramadont)
- PF Ratio (lung, lab)
- Allows interpretation of ABG PaO2 while on Supplemental Oxygen
- Energy Metabolism (endo, exam)
- Added additional factors affecting Energy Metabolism
- Ear Canal Bleeding after Cerumen Removal (ent, ear)
- Continuous Ear Canal Bleeding after Cerumen Removal by ENT lead to my learning of a quick trick to control bleeding (ear wick)
- Ceftazidime-Avibactam (id, pharm)
- Updates
- Phosphine Toxicity (er, toxin)
- Added
- Updates: March 2022
- Maturity Onset Diabetes of the Young (endo, diabetes)
- MODY accounts for 1 to 5% of Diabetes Mellitus cases and often misdiagnosed as Type 1 or Type 2 Diabetes
- MODY is typically Autosomal Dominant (3 genetic defects account for >95% of cases)
- MODY results from non-autoimmune deficient Insulin secretion, with MODY 1 and MODY 3 typically requiring treatment
- MODY 1 and 3 are highly sensitive to Sulfonylureas (with Hypoglycemia risk), which often maintain efficacy for decades
- Hemoptysis (lung, sx)
- Extensive updates
- Borderline Personality Disorder (psych, behavior)
- Extensive Updates
- Foot Drop (neuro, exam)
- Added a page on Foot Drop (thanks to Dr. Wesam Khalfalla for the suggestion)
- Tracheostomy Obstruction (lung, procedure)
- Updates added to precautions in Hypoxia management
- Intranasal Ketamine (surgery, pharm)
- Updates with sedation dosing which are 2-4 fold higher dosing than the Analgesic dosing
- Left Ventricular Hypertrophy Related EKG Changes (cv, ekg)
- Precautions regarding High Left Ventricular Voltage in healthy young patients, esp. athletes (not LVH)
- Gastrointestinal Metabolism (gi, anatomy)
- Extensive updates to the physiology of Digestion including multiple diagrams
- Diagrams added for Carbohydrate Metabolism, Lipid Metabolism, Protein Metabolism and overall Digestion mechanisms
- Also created diagrams related to Glycolysis, Gluconeogenesis, Kreb Cycle
- Intestinal Atresia (gi, peds)
- Added, and also updated malrotation and Midgut Volvulus
- Respiratory Physiology (lung, anatomy)
- Finally completed a diagram of Lung Physiology
- Hypothalamus (neuro, anatomy)
- Added Hypothalamus-Pituitary Hormone physiology diagram
- Calcium Metabolism (renal, lab)
- Updated the Calcium Metabolism image to incorporate Vitamin D synthesis and activation
- Thyroid Anatomy (endo, anatomy)
- Added Thyroid function diagram
- Adrenal Gland (endo, anatomy)
- Added adrenal function diagram
- Aldosterone (endo, lab)
- Added a topic on Aldosterone and mineralocortoid
- Glucose Metabolism (endo, exam)
- Added diagrams for Gluconeogenesis (and Ketogenesis), Glycolysis and Carbohydrate Metabolism
- Sleep Problems in Children (psych, peds)
- Extensive updates, including added Parasomnias
- Unknown Ingestion (er, toxin)
- Extensive updates
- Animal Bite (er, derm)
- Extensive Updates
- Cervical Ripening (ob, ld)
- Updates to techniques
- Labor Induction (ob, ld)
- Updated with Labor Induction indications including Gestational age criteria per condition
- Added Amniotomy
- Nerve Agent Exposure (er, toxin)
- Updates
- Sugammadex (neuro, pharm)
- Updates
- Human Trafficking (prevent, abuse)
- Updates
- Intracompartmental Pressure Monitor (ortho, procedure)
- Updates
- Tracheal Suctioning (er, procedure)
- Updates
- Fever of Unknown Origin (id, fever)
- Updates
- Fluvoxamine (psych, pharm)
- Updates (due to increased adjunctive use for Covid, but mixed evidence of benefit)
- Cannabinoid Intoxication (psych, cd)
- Additional updates for accidental THC Intoxication in children
- Inferior Shoulder Dislocation (ortho, Shoulder)
- Updates to management including Shoulder reduction of inferior dislocations
- Closed Thoracic Lavage (lung, procedure)
- Added
- Idiopathic Intracranial Hypertension (neuro, csf)
- Updated MRI findings
- Intravenous Acetaminophen (pharm, Analgesic)
- IV Acetaminophen (Ofirmev) has had minimal use since release in 2010; costs $30/dose compared with $0.01 for oral Acetaminophen
- Use may increase when generic for perioperative patients as well as for NPO patients as adjunctive to NSAIDs and Opioids
- Updates: February 2022
- Pediatric Pneumonia (lung, id)
- Consider occult Pneumonia in fever >5 days, Leukocytosis or Abdominal Pain
- Abdominal Pain is the presenting complaint in 8.5% of patients, age 3 to 14 years old (esp age <5 years)
- Vomiting or Diarrhea is present in 27% of Pediatric Pneumonia cases
- Cardiac Syncope (cv, sx)
- Cardiac cause of Syncope is more likely in known cardiovascular disease (e.g. CAD, CHF, Atrial Fib), first episode after age 35 years
- Associated with no prodrome or prodromal Chest Pain or Shortness of Breath or Cyanosis
- Covid19 (lung, id)
- Nirmatrelvir/Ritonavir (Paxlovid, Pfizer) is FDA emergency authorized, oral Protease Inhibitor
- Indicated in high risk outpatients started within first 5 days
- Transient Global Amnesia (neuro, Amnesia)
- Transient inability to form new memories (Anterograde Amnesia) in episode lasting minutes to up to 24 hours
- One probable trigger is Valsalva Maneuver, which appears to cause transient MRI lesions in the Hippocampus
- Vitamin D Toxicity (pharm, Vitamin)
- Expanded on topic
- Subcutaneous Single Injection Digital Nerve Block (surgery, pharm)
- Another finger Anesthesia block technique
- Essential Tremor (neuro, Tremor)
- Topiramate is now a first-line agent in Essential Tremor
- Drug Induced Tremor causes was also updated
- Abdominal Trauma (er, gi)
- Bowel injury is rare (1-5%) in Blunt Abdominal Trauma, but easily missed when it does occur
- Bowel wall breaks and free air are seen in only a minority of bowel wall injuries
- Free fluid without solid organ injury is a red flag for intraabdominal injury
- Adult Intussusception (surgery, bowel)
- Rare in adults (<0.08% of cases) and associated with malignancy in 15 to 65% of cases
- Bacterial Endocarditis (cv, id)
- General Updates
- Aortic Stenosis (cv, valve)
- General Updates
- Septic Bursitis (ortho, id)
- Updates
- Agitated Delirium (psych, behavior)
- Updated differential of the febrile Agitated Delirium patient
- Staphylococcal Scalded Skin Syndrome (derm, id)
- Updates
- Cluster Headache (neuro, Headache)
- Extensive updates
- Adenomyosis (gyn, Uterus)
- Extensive updates
- Orthostatic Hypotension (cv, exam)
- Extensive updates
- Pruritus (derm, sx)
- Extensive updates
- Arterial Atherosclerosis (surgery, cv)
- Updated interventions for AAA, Carotid Stenosis, Renal Artery Stenosis and Peripheral Arterial Disease
- Positive Predictive Value (prevent, epi)
- Updated examples and links to calculator
- Inhalation Injury (er, environ, burn)
- General updates
- Venous Thromboembolism in Pregnancy (ob, hemeonc)
- Updates
- Provider Burnout (manage, psych)
- Organizational prevention strategies added
- PCSK9 Small Interfering RNA (cv, pharm)
- New Subcutaneous Injection for severe Hyperlipidemia
- Covid19 (lung, id)
- Updates related to Paxlovid
- Gastroesophageal Reflux (gi, esophagus)
- Updates on PPI discontinuation
- HIV PrEP (hiv, prevent)
- Updated options for management
- Fertility Tracking (gyn, Contraception)
- Updates regarding Urine LH kits
- Dual Antiplatelet Therapy (hemeonc, pharm)
- Status post coronary DES, use dual agents for 6 months, then Aspirin
- If high risk of bleeding (e.g. Gastrointestinal Bleeding), than use 3 months dual, 9 months Clopidogrel, then Aspirin daily
- Updates: January 2022
- Acute Aortic Occlusion (surgery, cv)
- Added
- Arrhythmia Following Myocardial Infarction (cv, ekg)
- Added
- Septic Arthritis (rheum, id)
- Extensive updates, including added Prosthetic Joint Infection
- Pediatric Vomiting (gi, peds)
- Extensive updates to Pediatric Vomiting and Vomiting Causes in Children
- Superior Mesenteric Artery Syndrome (surgery, gi)
- Added
- Hepatitis C (gi, id)
- Extensive Updates
- Cannabinoid (psych, cd)
- Extensive updates
- Pneumonia in Children (lung, peds)
- Updates
- Unprovoked Seizure in Children (neuro, Seizure)
- Added
- High Sensitivity Troponin (cv, lab)
- Added protocol for High Sensitivity Troponin I
- Thyroiditis (endo, Thyroid)
- Updates
- Color Blindness (eye, Vision)
- Added
- Covid19 Vaccine (id, immunize)
- Pfizer Covid19 Vaccine approved for ages 5-12 years. Updated dosing
- Covid19 (lung, id)
- Updated Venous Thromboembolism Prophylaxis in Covid19
- Prevnar (id, immunize)
- Prevnar 20 is available for adults, pending approval in children
- Dry Eyes (eye, sx)
- Intranasal Varenicline (Tyrvaya) is a approved intranasally at $600/month for modest effect on Dry Eyes
- Subcutaneous Injection (er, procedure)
- Updates
- Intramuscular Injection (er, procedure)
- Updates
- Seasonal Effective Disorder (psych, depression)
- Updates
- Eczematous Dermatitis (derm, dry)
- Opzelura (Ruxolitinib) is a a topical JAK Inhibitor approved for refractory mild to moderate Eczema
- Isotretinoin (derm, pharm)
- Updated
- Citalopram Overdose (psych, pharm)
- Updated Citalopram and SSRI ovderose
- Presbyopia (eye, Vision)
- Added topic as well as Vuity (Pilocarpine)
- Septic Joint (rheum, id)
- Updates
- Patella Dislocation (ortho, knee)
- Relocation updates
- Ulnar Nerve Block (surgery, pharm)
- Updates
- Aortoenteric Fistula (surgery, cv)
- Added
- Fallopian Tube Torsion (gyn, ovary)
- Rare, isolated tube torsion added
- Subarachnoid Hemorrhage (neuro, cv)
- Updates to diagnostic rules
- Tube Thoracostomy (lung, procedure)
- Updates
- Nutritional Support (pharm, nutrition)
- Reviewed Enteral Nutrition, parenteral nutrition
- Isoniazid Overdose (lung, pharm)
- Added
- Intravenous Angiotensin (cv, pharm)
- New agent for refractory Hypotension
- Patient Education (manage, general)
- Updated, including misinformation
- Benign Prostatic Hyperplasia (urology, Prostate)
- Updated management
- Lybalvi (psych, pharm)
- Olanzapine/Samidorphan (Lybalvi) is released in 2021 at $1400/month
- Samidorphan is a Naltrexone derivative added to reduce weight gain that typically occurs with Olanzapine
- Marginal efficacy for cost (other strategies to reduce weight gain are preferred)
- Prostate Cancer Management (urology, hemeonc)
- Reviewed Prostate Cancer hormonal management
- Vaping (psych, cd)
- Updates
- Turmeric (pharm, alternative)
- Updates