Practice Management Book


Family Practice Notebook Updates

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

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