Family Practice Notebook 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: July 2018
   1. Appendicitis (surg, gi)
      1. Cefotetan and Unasyn with Clindamycin are no longer considered adequate pre-surgical antibiotics due to resistance
      2. Skilled bedside Appendix Ultrasound is a first-line test in the evaluation of Appendicitis in children and pregnant women
   2. Recurrent Abdominal Pain Syndrome (surg, peds, gi)
      1. Functional Abdominal Pain is a clinical diagnosis and diagnostic testing is not needed unless red flag findings are present
      2. Consider Cognitive Behavioral Therapy and Probiotic supplementation
   3. Localized Prostate Cancer (urology, hemeonc, Prostate)
      1. Reviewed active surveillance of localized Prostate Cancer
   4. Health Concerns in the Elderly (geri, prevent)
      1. Review Beers Criteria and STOPP Criteria, as well as medication indications before starting a new medication
      2. Preventive evaluations should include fall risk, Major Depression, Hearing Loss, cognitive Impairment and Immunization updating
   5. Allergy Testing (ent, lab, allergy)
      1. Skin Testing for Penicillin Allergy can prevent the overuse of broader spectrum antibiotics
      2. Food Allergy testing has a high False Positive Rate and should only be performed based on a specific history
   6. Medical Decision-Making Capacity (neuro, cognitive)
      1. Ability to communicate, understand the information they are given
      2. Ability to make logical decisions based on given information
      3. Ability to understand their current medical status or condition
      4. Ability to understand options for medical care
   7. Compartment Syndrome (ortho, neuro)
      1. Have a high index of suspicion to check compartment pressures when pain is out of proportion to findings
      2. Pulse loss and weakness are late findings and their absence does not exclude limb threatening pressures
      3. Emergency fasciotomy delayed >4-6 hours may result in permanent injury or even limb loss
   8. Anticoagulant Overdose (hemeonc, pharm, coags, adverse)
      1. Consider Activated Charcoal if ingestion within 1-2 hours (may be effective with DOACs up to 8 hours)
      2. Intentional Overdose: Observe for bleeding for 24 hours (or per poison control) before medically cleared to psychiatry
      3. Unintentional Overdose: If small quantity (e.g. one extra dose) may discharge home with bleeding precautions
      4. Risk of significant bleeding 5% after Anticoagulant Overdose
   9. Emergency Department Observation Unit (ed, cv)
      1. Established protocols exist for Atrial Fibrillation, CHF and PE that are cost effective, safe, shorter duration, with added quality and consistency
      2. Observation protocols have clear inclusion, exclusion and discharge criteria to ensure good patient selection and best outcomes
   10. Emergency Psychiatric Evaluation (psych, exam)
       1. Reviewed strategies for emergency mental health evaluation in children
       2. Consider HEADS-ED as a disposition tool
   11. Gonorrhea (id, std)
       1. Gonorrhea has growing Incidence and resistance, and dual coverage with Ceftriaxone and Zithromax is preferred
       2. Retest all patients in 3 months for new, reinfection
   12. Andexxa (hemeonc, pharm, coags)
       1. Inactivated Factor Xa, reversal agent for Eliquis and Xarelto, to be released in 2018
   13. Oxycontin (pharm, Analgesic, Opioid)
       1. Oxycontin true duration of action approaches 6 hours (instead of 12 hours) in many patients
       2. Oxycontin was released as MS Contin (8 hour duration) patent was expiring
       3. The exaggerated duration may add to misuse and abuse of Opioids
   14. Acute Pain Management (pharm, Analgesic)
       1. Limit Opioids for acute pain to 3 days in most patients (7 days in nearly all patients)
       2. Avoid non-cancer Chronic Opioids
   15. Ketamine (surgery, pharm)
       1. Ketamine is often used as a very effective and safe pre-hospital Chemical Restraint
       2. Ketamine at high dose (4-5 mg/kg) results in GCS 3, but typically maintained respiratory drive (GCS-3K)
       3. Many providers prematurely intubate based on ED arrival GCS 3 (despite Ketamine induced)
       4. However, with close monitoring, Ketamine sedated patients may be safely observed without intubation
   16. Supraventricular Tachycardia Management in the Adult (cv, ekg)
       1. Adenosine and Diltiazem have similar efficacy in PSVT
       2. Some patients may prefer the risk of Hypotension with Diltiazem to the pause sensation of Adenosine
   17. Sunscreen (derm, pharm, environ)
       1. Two chemical Sunscreens (Oxybenzone, Octinoxate) will be banned in Hawaii as of 2021 due to adverse effects to ocean wildlife (coral bleaching, reproduction)
       2. Physical Sunscreens (titanium dioxide, zinc oxide) are nanoparticle products despite labeling ("non-nano")
       3. None of the physical Sunscreens are absorbed through the skin regardless of size (nano or "non-nano")
       4. Nanoparticle Sunscreens are typically easier to apply
   18. Genetic Test (lab, gene)
       1. Home Genetic Tests (e.g. 23andMe) are becoming more available in which patients mail in a cheek swab sample for DNA analysis
       2. Tests only a subset of available Genetic Tests at a cost of several hundred dollars and risk of both false positives and false reassurance when testing is incomplete
       3. Genetic Counseling is preferred for test interpretation and test selection based on patient history
   19. Crohns Disease (gi, ibd)
       1. TNF Agents are becoming first-line over Sulfasalazine, Mesalamine, Corticosteroids
3. Updates: June 2018
   1. Discipline (peds, prevent)
      1. Provide anticipatory guidance at visits on positive parenting
      2. Assist with effective behavior changing approaches
   2. Developmental Disorder in Adults (prevent, hme)
      1. Speak directly to patients using the communication methods they are able to use
      2. Focus on adaptive interventions that allow patients to live in their home or community
      3. Specific approaches to common problems include Constipation, Osteoporosis, aspiration, Decubitus Ulcer, behavior changes
   3. Colorectal Cancer Prevention (gi, prevent, hemeonc, bowel)
      1. Screening options include Colonoscopy every 10 years or FOBT (guiaic-based or FIT immunochemical) annually
      2. Although Virtual Colonoscopy and Flexible Sigmoidoscopy are other screening options, they have significant disadvantages
      3. For average risk patients, screening starts at age 50 years and ends at 75-85 years old
      4. The only significantly effective lifestyle changes that have impact on CRC are weight loss, Physical Activity, and avoiding red meat
   4. Oncologic Emergency (hemeonc, sx, er)
      1. Consider Tumor Lysis Syndrome esp. in hematologic malignancies following Chemotherapy or Radiation Therapy
      2. Consider Hypercalcemia of Malignancy esp. in Multiple Myeloma and Breast Cancer in those with confusion, weakness, Vomiting
      3. Consider SIADH esp. in Small Cell Lung Cancer with often asymptomatic Hyponatremia
      4. Exercise caution in Febrile Neutropenia, and start early empiric antibiotic management for best outcomes
   5. Hyperhidrosis (derm, sweat)
      1. Exclude secondary Hyperhidrosis Causes (including Medication Causes of Hyperhidrosis)
      2. Aluminum hydroxide 20% (Drysol) is a first-line therapy for all regions of primary Hyperhidrosis
      3. Iontophoresis is effective for palmar and planter Hyperhidrosis
      4. Onabotulinum Toxin A intradermal injection is effective for Hyperhidrosis on the palms, soles, axilla and face
   6. Atrial Fibrillation Anticoagulation (cv, ekg, atrialfib coags)
      1. Apixaban (Eliquis) may be the preferred DOAC with best Atrial Fib efficacy and lowest adverse effect profile
      2. Andexxa, a factor 10a Inhibitor reversal agent is pending release in 2018
   7. EMS Transport (er, manage, ems)
      1. Air transport (aside from rescue helicopters) offer mobile ICU level care typically staffed by an ICU nurse, advanced paramedic or physician
      2. Helicopters travel at 100-150 mph, at <3000 feet and are limited by visibility
      3. Fixed wing aircraft are preferred for >100 mile distance and travel at 250 to 600 mph, at high altitude with cabins pressurized to 7000 feet
   8. Pneumaturia (urology, sx)
      1. May be due to Bladder instrumentation (cystoscopy), fistula from bowel or vagina, renal tumor infarction, urinary diversion or Scuba Diving with p-valve
      2. However, it is critical to exclude UTI with gas forming organisms (e.g. Proteus, E. coli, Klebsiella, Candida, Clostridium)
      3. UTI with gas forming organisms may result in Emphysematous Cystitis or Emphysematous Pyelonephritis which are associated with high mortality
      4. Staghorn calculi and low Urine pH may indicate the presence of gas forming organisms
   9. Abdominal Aortic Aneurysm (surgery, gi)
      1. The classic triad of Abdominal Pain or back pain, Hypotension and pulsatile abdominal mass is present <50% of the time
      2. Keep a high index of suspicion for AAA in >50-60 year old patients (esp. men) with back pain or abominal pain
      3. Consider bedside abdominal aortic Ultrasound (turn color doppler on, apply pressure and be patient to allow gas to settle)
   10. CVA Management (neuro, cv)
       1. DAWN study shows benefit for endovascular intervention in selected patients with CVA up to 24 hours after onset
   11. Syncope (cv, sx)
       1. All Syncope patients should have an EKG; additional testing is directed by a thorough history and physical
       2. Emergency department evaluation identifies 80% of syncopal causes
       3. In the absence of high risk criteria, syncopal patients may be discharged from the ED with follow-up
   12. Loperamide Abuse (gi, pharm)
       1. Loperamide crosses the blood brain barrier when taken in very high dose or when in combination with P-Glycoprotein Inhibitor (e.g. Cimetidine)
       2. LoperamideOverdose is associated with QTc Prolongation and risk of fatal arrhythmia
   13. Emergency Psychiatric Evaluation (psych, exam)
       1. As with adults undergoing Emergency Psychiatric Evaluation, lab testing in children should be targeted by history and exam
       2. Use verbal de-escalation techniques in children to prevent the need for escalation to Chemical Restraints and Physical Restraints
   14. Clinical Decision Rule (manage, legal, risk)
       1. Decision rules allow risk stratification, standardization of risky presentations, and limit testing with adverse effects (e.g. radiation exposure)
       2. Use decision rules that have been prospectively validated, refined and used in clinical practice and in combination with clinical gestalt
       3. Avoid applying the decision tool to patients outside the population studied (inclusion and exclusion criteria)
       4. Avoid mashing multiple decision tools together (use each decision tool individually, in the way it was validated)
   15. Postoperative Bleeding after Tonsillectomy (Ent, Surgery, Mouth, Bleed)
       1. Tonsillar bleeding occurs with sloughing of fibrin clot day 5-10 in 2-7% of post-Tonsillectomy patients
       2. Bleeding control can be challenging especially in children
       3. Consider nebulized Tranexamic Acid (TXA)
   16. Ketamine (surgery, pharm)
       1. Ketamine 0.1 to 0.2 mg/kg offers excellent analgesia for acute pain in the emergency department (if expected to improve during ED course)
       2. For adults, 50 to 150 kg, a single dose Ketamine 10 mg IV offers good effect, without risk of emergence reaction
   17. Syphilis (id, std)
       1. Incidence continues to rise in U.S. (now 8 per 100,000)
       2. Review primary, secondary and tertiary presentations, esp. dermatologic findings
   18. Asthma Biologic (lung, Asthma, pharm)
       1. Consider biologic agents for Severe Persistent Asthma
   19. Depression in Children (psych, peds, depression)
       1. Depression is common in teens (1 in 5) - screen each year for depression with PHQ-2 and advance to full PHQ-9 as needed
       2. Cognitive therapy is the most effective first line treatment for Childhood Depression
       3. Most effective Antidepressants include Fluoxetine, Escitalopram, Sertraline
   20. More expensive drugs (pharm)
       1. Vitamin K costs $50 per 5 mg tablet
       2. Naloxone autoinjectors are still $125, and $4900 if your device is to speak to you
       3. Epinephrine Autoinjectors are still $600 and up to $4900
       4. Another HIV Treatment me-too drug (Biktarvy)
       5. Lonhala Magnair is a new LAMA for COPD at $1100 per month
   21. Synthetic Cannabinoid (psych, cd)
       1. Anticoagulant-laced Synthetic Cannabinoids have resulted in life threatening bleeding
4. Updates: May 2018
   1. Running Injury (sports, Running)
      1. Most common Running injuries include Patellar Tendinopathy, Patellofemoral Syndrome, Achilles Tendonitis, Iliotibial Band Syndrome
      2. Keep Tibial Stress Fractures in the differential diagnosis (esp. with Shin Splints)
   2. Osteoarthritis (rheum, Osteoarthritis)
      1. Diagnosis is typically clinical with onset after age 50 years, pain with activity (esp. late in the day), and pain in fingers, Shoulders, hips, knees
      2. Analgesics, avoiding provocative activity and in some cases joint replacement are effective treatments
      3. Unfortunately Glucosamine and joint steroid and viscoreplacement injections offer minimal to no benefit
   3. Group A Streptococcus (id, Bacteria)
      1. Numerous complications (which are now much less common in the U.S.) including Rheumatic Fever, PSGN, PANDAS, Poststreptococcal Reactive Arthritis
      2. Keep Rheumatic Fever in the differential when seeing children with Reactive Arthritis or neuropsychiatric symptoms (Sydenham Chorea)
   4. Croup (lung, airway)
      1. Humidified oxygen offers no benefit over standard oxygen
      2. Administer Corticosteroids to croup of any severity
      3. Nebulized Epinephrine for moderate to severe croup and observe for 2-3 hours
   5. Charcot Foot (rheum, neuro)
      1. Consider Charcot Foot in the >40 year old with Peripheral Neuropathy, Obesity, and minimally painful swollen, red, warm foot without fever
      2. Charcot Foot is misdiagnosed on average for 7 months, delaying diagnosis, and risking deformity and amputation
   6. Pediatric Limp (rheum, sx, peds)
      1. Consider Nonaccidental Trauma in nonambulatory or developmentally delayed children with Fractures
      2. Limp is not always a lower extremity problem (consider back, hip and Pelvis causes)
      3. AP Pelvis may miss hip pathology (nearly always obtain frog-leg Pelvis)
      4. Back pain is rare in children (consider serious causes such as Discitis, referred abdominal source, Nonaccidental Trauma)
   7. Medication Use in the Elderly (geri, pharm)
      1. Consider noncompliance, OTC medications and Herbals when evaluating adverse drug events
      2. Consider taking a medication away, instead of starting a new medication, in older patients
      3. Anticoagulants (esp. Warfarin), diabetic medications (esp. Insulin) and Digoxin account for the most common adverse drug events in elderly
   8. Pediatric Congestive Heart Failure (cv, peds, chf)
      1. Viral Myocarditis (e.g. Parvovirus B19, HH6, Kawasaki's, enterovirus) can be life threatening in infants
      2. Acute presentations for "URI" may reveal a sicker infant with Tachycardia out of proportion progressing to Acute Respiratory Failure
   9. Necrotizing Fasciitis (derm, id)
      1. Necrotizing Fasciitis is a life threatening infection with an insidious, occult presentation
      2. Do not ignore pain out of proportion, Sinus Tachycardia or unexplained fever
      3. Do not delay surgical exploration when Necrotizing Fasciitis is suspected
   10. ST Elevation (cv, exam, ekg)
       1. Consider alternative causes of ST Elevation, including neurologic catastrophe (e.g. Subarachnoid Hemorrhage)
   11. Marijuana Toxicity (psych, cd)
       1. Children (esp. <6 years old) are at high risk of toxicity from accidental Marijuana ingestion
       2. CNS depression (somnolent to obtunded) and Cerebellar dysfunction (e.g. Ataxia) are most common findings
       3. Effects do not peak until 2-4 hours after ingestion and may persist for 6-12 hours
   12. Hypertension in Diabetes Mellitus (dv, endo, htn)
       1. Diabetes Mellitus targets move once again to <130/80 for everyone per ACC/AHA, but <140/90 per ADA in non-high risk patients
   13. Cocaine-Induced Coronary Vasospasm (cv, cad)
       1. MI Relative Risk increases to 24 fold over baseline (risk increases within first hour of use and persists for 4-7 hours)
       2. Acute Cocaine Intoxication causes tachyarrhythmias, Hypertension, prothrombotic state, QT Prolongation, QRS Widening
       3. Chronic Cocaine use increases coronary atherosclerosis, Cardiomyopathy, Pulmonary Hypertension and stroke risk
   14. Drugs of Abuse (psych, cd)
       1. Substances of abuse are difficult to distinguish by sight
       2. White powder could be Cocaine, Methamphetamine, synthetic Opioids, NBOMe or bath salts
       3. Crystals could be Crystal Meth, U-47700
       4. Many substances of abuse are reformulated into tablets (e.g. Fentanyl may be formed in tablets similar to Oxycodone or Hydrocodone)
   15. Gastric Lavage (er, pharm, toxin)
       1. Rarely indicated in modern Emergency Medicine
       2. Consider in Overdoses that approach 100% mortality (consult poison control) such as ColchicineOverdose, Paraquat Poisoning (herbacide used outside the U.S.)
       3. May also consider in Hydrofluoric acid ingestion due to risk of lethal Hyperkalemia and Hypocalcemia
   16. Rhus Dermatitis (ent, allergy, derm)
       1. Corticosteroid course of 14-18 days is preferred due to risk of rebound with shorter courses
   17. Emergency Department Triage System (er, exam)
       1. ESI 3 is the achilles heal of the Emergency Severity Index (50% are triaged to ESI 3)
       2. Techniques to optimize ESI 3 flow include provider in triage, split flow, vertical triage and most recently, electronic triage
   18. Limited Ultrasound for Acute Renal Colic (uro, renal)
       1. More evidence that Ultrasound is a safe, effective approach to Renal Colic
   19. Nocturia (uro, Bladder, sx)
       1. Noctiva (low dose Desmopressin) - another expensive drug with marginal efficacy, real risk (Hyponatremia)
       2. Treat Nocturia instead by identifying, treating and optimizing the underlying causes of Nocturia
   20. Ottawa Aggressive Atrial Fibrillation Protocol (cv, ekg)
       1. In stable patients with Atrial Fibrillation <48 hours, consider Procainamide 1 g over 1 hour, then electrical cardioversion if fails
5. Updates: April 2018
   1. Stable Coronary Artery Disease (cv, cad)
      1. High intensity Statin for age <75 years
      2. Blood Pressure control with Beta Blocker, ACE Inhibitor, Thiazide Diuretic, optimally <130/80 and keep <140/90
      3. Low dose Aspirin 81 mg is sufficient for most patients
      4. Encourage aerobic Exercise, Tobacco Cessation, Influenza Vaccine
   2. Chronic Pancreatitis (gi, Pancreas)
      1. CT Abdomen is first line imaging followed by MR/MRCP, then EUS, and finally ERCP if other testing non-diagnostic
      2. Malabsorbtion and steatorrhea occur when <10% pancreatic exocrine function remains, at which point enzyme replacement is indicated
   3. Dementia (neuro, cognitive)
      1. Dementia screening with Mini-Cog, GPCOG, or Ascertain Questionnaire, and diagnosis with SLUMS, Addenbrooke or MMSE
      2. Evaluation includes CBC, TSH, Vitamin B12, Serum Glucose and MRI Brain
      3. Exclude Major Depression, medications, infections and other causes of Delirium
   4. Cervical Cancer (gyn, hemeonc)
      1. Cervical Cancer Screening has eased with no screening before age 21 years, and cytology and/or HPV screening at 3-5 year intervals
      2. Except for Stage IA1, Cervical Cancer management typically involves radical Hysterectomy, pelvic lymphadenectomy and chemoradiation
   5. Rheumatoid Arthritis (rheum, ra)
      1. Methotrexate is the preferred first line DMARD in most cases
      2. Do not start biologic agent (e.g. tnf agent) before a trial on Methotrexate or similar DMARD
      3. Screen for Tuberculosis, Hepatitis B, Hepatitis C and skin cancer before starting a biologic agent
      4. Consider tapering DMARD if in remission for at least 6 months (esp. if anti-citrullinated protein negative)
   6. Rheumatoid Arthritis in the Emergency Department (rheum, ra)
      1. CV presentations - MI, CHF, Atrial Fibrillation, Pulmonary Hypertension, PE, Pleural Effusion, Pericardial Effusion
      2. ID presentations due to RA, TNF agents, steroids, such as Pneumonia, opportunistic infections
      3. In Joint Pain presentation, exclude Septic Arthritis, even if underwhelming signs
      4. Treat Rheumatoid Arthritis flare after excluding Septic Joint with Prednisone taper, 60-10 mg over 2 weeks
   7. Clarithromycin (id, pharm)
      1. Observational studies find possible increase in cardiovascular deaths while on Clarithromycin
   8. Clostridium difficile (gi, Diarrhea)
      1. Vancomycin is becoming first-line for C. Diff over Flagyl even in first episode except in mild cases
   9. Fentanyl Patch (pharm, Analgesic)
      1. Fentanyl Patches should only be used for Chronic Pain with patients using at least 60 mg Morphine per day
   10. Prescription Cannabinoids (gi, pharm)
       1. Consider in wasting, Anorexia, intractable Nausea for patients with AIDS, cancer, Chemotherapy
   11. Lactic Acid (renal, lab)
       1. Lactic Acid is primarily used as a Sepsis marker and tissue ischemia marker, e.g. ischemic bowel, but differential diagnosis of Lactic Acidosis is broad
       2. Avoid ordering Lactic Acid in low risk patients, non-toxic, previously healthy
       3. Lactic Acid clearance outside Sepsis does not uniformly improve with Intravenous Fluids
       4. Cardiogenic Shock can also increase Lactic Acid and will worsen with excess fluids
   12. Abdominal Trauma in Pregnancy (er, ob)
       1. Abdominal tenderness and maternal Vital Sign changes are often absent despite significant hemoperitoneum
       2. Maternal stabilization and needed imaging, even if requiring ionizing radiation, takes precedence
       3. Give RhoGAM even in minor Trauma in Rh negative women
   13. Transesophageal Echocardiogram (cv, rad)
       1. Consider in Cardiac Arrest, as may be monitored without interruption and not interfere with Resuscitation efforts
       2. Heart function, compression quality and Great Vessels are seen without chest wall or epigastric bowel gas obstruction
       3. Distinguishes cardiac standstill, true PEA or Asystole, from ineffective contraction and may identify Cardiac Tamponade, PE with RV strain, vascular rupture
   14. Sickle Cell Anemia (hemeonc, Hemoglobin)
       1. Treat sickle cell vaso-occlusive crisis aggressively with early IV Opioids
       2. Have a high index of suspicion for serious Bacterial Infection in febrile children <5 years old
       3. Always consider Acute Chest Syndrome in "Pneumonia" in Sickle Cell Anemia
       4. Splenic Sequestration is a life threatening complication
   15. Chance Fracture (Ortho, L-spine, Fracture, Trauma)
       1. High velocity Traumatic Injury, e.g. MVA with lap belt only, causes flexion and distraction of the thoracolumbar spine
       2. Results in unstable, transverse Fracture through the anterior, middle and posterior Vertebral body, that typically requires surgical repair
       3. Associated with cord injury, aorta injury, liver Laceration, Splenic Rupture and mesentary and Small Bowel injury Pediatric Cervical Spine Injury (ortho, peds, c-spine)
       4. New radiculopathy or myelopathy (hyperreflexia, Clonus, babinski, weakness), esp. if bilateral, requires MRI prior to discharge (even if negative CT)
       5. MRI for ligamentous instability with subluxation, Central Cord Syndrome, Vertebral Fracture
6. 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
7. 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)
8. 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. BiliTool.com) 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