Family Practice Notebook Updates

Aka: Family Practice Notebook Updates, FPN Updates, Family Practice Notebook Updates 2020, FPN Updates 2020

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II. Updates: June 2020

  1. Troponin Increase in ICU Patients (cv, cad)
    1. Serum Troponin Increase is common (40% of patients) in ICU patients admitted for non-cardiac causes
    2. Avoid ordering Troponin In the absence of signs or symptoms of cardiac event
    3. Echocardiogram may be best non-invasive bedside tool for differentiating cause of Troponin Increase
    4. Distinguish Type I MI (Plaque rupture) from Type II MI (demand ischemia)
  2. Corona Virus 19 (lung, id)
    1. Multiple updates regarding medication management, findings
    2. Added resources related to mental health consequences of social distancing
  3. Hydroxychloroquine (rheum, pharm)
    1. Updated adverse effects for Hydroxychloroquine and Chloroquine (as well as their to date low efficacy in COVID-19)
    2. QTc Prolongation is not rare (esp. when combined with Azithromycin)
  4. SQLT2 Inhibitors (dm, endo)
    1. Preoperative Guidelines for Medications Prior to Surgery
    2. Stop SGLT2 Inhibitors 3 days before surgery
    3. Restart SGLT2 Inhibitors post-operatively when oral intake returns to normal
  5. Telemedicine (manage, communication)
    1. Telemedicine topic started with pointers for establishing
  6. Helicobacter Pylori (gi, id)
    1. Triple Therapy with Amoxicillin and Rifabutin (Talicia) available in capsules of Omeprazole, Amoxil and Rifabutin
    2. Indicated in quadruple therapy refractory cases
    3. Four capsules per dose (total Omeprazole 10 mg, amoxil 250 mg, Rifabutin 12.5 mg) taken three times daily for 14 days
    4. Adverse effects related to Rifabutin (body fluid stained orange, CYP3A4 inducer), and Hormonal Contraception requires backup Contraception for 28 days
  7. High Flow Nasal Cannula (lung, procedure)
    1. Consider High Flow Nasal Cannula prophylactically on Ventilator Weaning
    2. Start at 50-60 L/min for the first day
  8. Ectopic Pregnancy (ob, antepartum)
    1. Reviewed Ectopic Pregnancy evaluation and management protocols including Methotrexate
  9. Atopic Dermatitis (derm, dry)
    1. Not much has changed other than a few new expensive drugs (including a $3000/month Monoclonal Antibody)
    2. Atopic Dermatitis action plan (similar to Asthma Action Plan, which is clever)
  10. Opioid Prescribing Quantity (pharm, Analgesic)
    1. CDC and most states now have guidelines for quantity of Opioids prescribed for acute, post-acute and Chronic Pain
    2. Updated Morphine Milligram Equivalent and derived quantities for commonly prescribed Opioids
    3. Also updated Opioid Overdose and prevention, including keeping Opioid naive patients, naive
  11. Regional Anesthesia (surgery, pharm)
    1. Extensive updates for upper and lower extremities, with landmark and Ultrasound Guided Regional Anesthesia
    2. Thanks to Am Fam Physician series with excellent review
  12. Neonatal Circumcision (uro, procedure, nicu)
    1. Documented the procedure and the various techniques (thought I documented this more than 20 years ago)
  13. Pediatric Dehydration (peds, fen)
    1. For the last few years, Isotonic Saline has been preferred even for fluids after initial bolus
    2. Corrected the replacement examples for NS (Pediatric Isotonic Dehydration, Pediatric Hypotonic Dehydration, Pediatric Hypertonic Dehydration)
    3. Expanded on Oral Rehydration Therapy Protocol in Pediatric Dehydration
  14. Mechanical Ventilation (lung, procedure)
    1. Extensive updates on Ventilator settings, perintubation complications, analgesia and sedation
  15. VTE Anticoagulation (hemonc, pharm)
    1. Rivaroxaban (Xarelto) and Apixiban (Eliquis) are being used for DVT in active cancer as of 2020
    2. DVT Prophylaxis is also considered in higher risk cancer patients
  16. Bleeding Esophageal Varices (gi, esophagus)
    1. Reviewed esophageal Hemorrhage Management
  17. Buprenorphine (pharm, Analgesic)
    1. Opioid Dependence and Withdrawal management with Buprenorphine is becoming a more common ED strategy
  18. Expired Medications (pharm, prevent)
    1. Most medications (esp. tabs, capsules) maintain their potency for years past their expiration date
    2. Medications stored in vials or under adverse conditions (e.g. excessive heat) may degrade more quickly
    3. Toxicity from Expired Medications is very rare and limited to case reports
    4. For some critical medications, possible decreased potency after expiration date may be unacceptable
  19. Anaphylaxis (ent, allergy)
    1. All patients with Anaphylaxis history should have an Epinephrine Autoinjector and instruction on use!
  20. Immunizations (id, immunize)
    1. COVID-19 related under-Vaccination is increasing the risk of other outbreaks (e.g. Measles)
  21. Accidental Poisoning Causes (er, pharm)
    1. Hand sanitizer is 60% Alcohol (risk for Alcohol Poisoning in children)
    2. Ammonia and bleach together results in a potentially lethal gas (chloramine)
  22. Pre-Hospital Extraglottic Airway (lung, procedure)
    1. Cardiac Arrest patients often arrive at Emergency Department with extraglottic airways placed in field
    2. Evaluate extraglottic airway placement and ventilation on arrival (e.g. Capnography, lung sounds, Laryngoscope)
    3. Confirmed extraglottic airway proper placement should be left in place initially (allows for complete patient assessment)
    4. Removal of extraglottic airway on arrival and prematurely may result in patient decompensation
  23. Spontaneous Pneumothorax (lung, er)
    1. Small uncomplicated Spontaneous Pneumothorax resolves in 94% of cases without Chest Tube
  24. Norepinephrine (cv, pharm)
    1. Appears to be initially safe peripherally via reliable large bore IV (extravasation is rare)
  25. Crohns Disease (Gi, IBD)
    1. Added Crohns Flare management

III. Updates: May 2020

  1. Emergency Echocardiogram (cv, rad)
    1. PE is among the Reversible Causes of Cardiopulmonary Arrest with nonshockable rhythm (e.g. PEA)
    2. Empiric PE Thrombolysis may be considered if bedside findings suggest PE
    3. Echocardiogram in PE and Focused Lower Extremity Venous Ultrasound may help make the diagnosis
    4. Evaluate for acute dilated right ventricular (RV) chamber (approaching left ventricle diameter) or DVT on 2 point Ultrasound
  2. Emergency Triage Treatment and Transport (ET3)
    1. ET3 is a Medicare Five year pilot program allowing EMS additional reimbursed transport options beyond the Emergency Department
    2. In addition to ED transport, patients may be transported to appropriate medical facility (e.g. urgent care, clinic office, sober center, mental health facility)
    3. EMS may also coordinate care by qualified healthcare practitioner or QHP (medicare enrolled physician, PA or NP) on site or via Telemedicine
    4. Initial trials of the program prior to ET3 release demonstrated safety and cost reduction for medicare population
  3. Chronic Diarrhea (gi, Diarrhea)
    1. First 2 categories have distinct features: Chronic Fatty Diarrhea (malabsorption) and Chronic Inflammatory Diarrhea (Inflammatory Bowel Disease, infection)
    2. The third category, watery Diarrhea, is more broad and includes Secretory Diarrhea (large volume stools at all times of day and night) and Osmotic Diarrhea
    3. Secretory Diarrhea has many causes, among which Functional Diarrhea is common (e.g. Irritable Bowel Syndrome, paradoxical Diarrhea)
  4. Aneuploidy Screening (ob, lab)
    1. Antenatal Screening for trisomy includes Ultrasound, serum testing and in some cases invasive tests (Chorionic Villus Sampling or Amniocentesis)
    2. First Trimester Combined Screening and Second Trimester Quad Maternal Screen Panel have been mainstays of testing for sometime
    3. Placental Cell-Free DNA offers a highly accurate Screening Test for trisomy used in higher risk patients
  5. Endometrial Biopsy (gyn, procedure)
    1. NSAIDs 30-60 minutes before and Lidocaine 2% gel applied to Cervix before procedure decreases pain
    2. Try performing biopsy without the tenaculum (reduces pain)
    3. Insufficient samples are common (30-50%)
    4. Updated Endometrial Biopsy indications
  6. Rib Fracture
    1. Three or more contiguous Rib Fractures may benefit from surgical stabilization of the rib fragments
  7. Central Line Occlusion (er, procedure)
    1. Attempt to flush the line with saline first
    2. Next, inject a few milligrams of Alteplase into the line and wait a few minutes
    3. Repeat saline flush
  8. Pediatric Cervical Spine Injury (ortho, peds, c-spine)
    1. Negative good quality C-Spine XRay in children does not require MRI confirmation
    2. However Fracture on C-Spine XRay should prompt MRI (changes management in 20% of cases)
  9. Ventriculoperitoneal Shunt (neuro, surgery)
    1. VP Shunt series adds little if CT Head is without acute changes
  10. Burn Injury (er, environ)
    1. Updated Burn Injury and Burn Injury management with additional specific approaches
  11. Colloid Solution (er, pharm, FEN)
    1. Reviewed Colloid Solutions and their risks, indications
  12. Tickborne Illness (id, vector)
    1. Reviewed common tickborne illness, their presentations and treatment
  13. Chronic Dyspnea (lung, sx)
    1. Expanded on approach to Chronic Dyspnea, including causes, history and diagnostics
  14. Personal Protection Equipment (er, toxin, prevent)
    1. Reviewed Donning and Doffing PPE and Respiratory Personal Protective Equipment, as well as Hazardous Material Labeling
  15. Anticholinergic Toxicity (neuro, pharm, toxin)
    1. Although both may be hyperthermic, tachycardic, and altered, Sympathomimetic Toxicity has diaphoresis, and Anticholingergic toxicity is dry
  16. Newborn Exam (nicu, exam)
    1. Expanded on common presenting complaints within the Newborn Abdominal Exam, Newborn Genitalia Exam, Newborn Cardiopulmonary Exam and the Newborn Neurologic Exam
  17. Elder Abuse
    1. Expanded on findings, red flags and risk factors
  18. Carbon Monoxide Poisoning (er, toxin)
    1. Continuous Positive Airway Pressure (CPAP) with oxygen lowers Carbon Monoxide faster than oxygen alone
  19. Pediatric DKA (endo, peds)
    1. Initial boluses of 10 cc/kg and 20 cc/kg are equally safe with similar outcomes
  20. Hypernatremia (renal, Sodium)
    1. Expanded on Hypernatremia treatment protocols as well as Fluid Management in Critical Care

IV. Updates: April 2020

  1. Resistant Hypertension (cv, htn)
    1. Consider reasons for Resistant Hypertension, review Hypertension Risk Stratification and determine Hypertension Reduction Goal and consider Secondary Hypertension
    2. Advance to next step if BP>15/10 mmHg above goal
    3. Consolidate medications into combination agents and once daily regimens
    4. Consider optimal strategies in specific populations when selecting medications
  2. Genital Ulcer (id, derm, std)
    1. Mnemonic CHISEL: Chancroid, Herpes, Inguinale, Syphilis, drug eruption, Lymphogranuloma venereum (first 2 are painful)
  3. De Winter T Wave (cv, ekg)
    1. Hyperacute precordial T Waves and J Point depression suggests acute LAD Occlusion
    2. Consider other causes of Hyperacute T Waves including Hyperkalemia
  4. Motor Exam (neuro, motor)
    1. A couple of mnemonics to remember critical spinal nerve levels
    2. C3-4-5 keeps the diaphragm alive
    3. S2-3-4 keeps the stool off the floor
  5. Pulmonary Function Test (lung, lab)
    1. Obtain Spirometry in all patients with suspected persistent Asthma or COPD, and point-of-care Spirometry is reasonably accurate
    2. Restrictive Lung Disease evaluation requires additional testing beyond lung function testing
  6. Corona Virus 19 (lung, id)
    1. Expanding on management specific to COVID-19 as well as related topics in Critical Care
    2. Of the up to 20% with significant respiratory illness in Italy, 97% could be supported with oxygen and CPAP
  7. Intensive Care (er, exam)
    1. Expanding Critical Care related topics and approaches for fever, sedation and analgesia, FEN, respiratory, prevention (DVT, GI) and complications
  8. Fever in the Intensive Care Unit (id, fever)
    1. Fever is due to non-infectious causes in 50% of ICU cases
    2. Most common causes include SIRS (Trauma, ARDS), Postoperative Fever, Venous Thromboembolism or transfusion
  9. Drug-Induced Fever (id, pharm, fever)
    1. May be due to Hypersensitivity Reaction (rigors, rash, Eosinophilia), idiosyncratic reaction or hypersensitivity syndrome (e.g. Malignant Hyperthermia)
  10. Postoperative Fever (id, fever, surgery)
    1. Major surgery results in fever in 15-40% on postoperative day 1 (most without infection), and it typically resolves in first 24-48 hours (if not infectious)
    2. Atelectasis is coincidental, but not causative of fever (Atelectasis and fever are both caused by major surgery)
  11. Thromboprophylaxis in Critical Illness and Major Trauma (hemeonc, prevent)
    1. LMWH (Enoxaparin) is indicated in most cases aside from active bleeding and severe Thrombocytopenia
    2. Adjust dosing for weight <50 kg, weight >120 kg or BMI >40-50, and in GFR <30
  12. Gastric Ulcer Prevention in Patients with Critically Illness (gi, pud)
    1. GI Prophylaxis is indicated in Mechanical Ventilation or significant peptic ulcer risk (e.g. recent GI Bleeding, high dose Corticosteroids, Coagulopathy)
    2. Prophylaxis with PPI (e.g. Protonix) or H2 Blocker (e.g. Pepcid)
  13. Anemia in the Intensive Care Unit (hemeonc, Anemia)
    1. Most patients in the ICU will drop Hgb by at least 1.5 g/dl, but supine position alone will result in a similar Hgb drop
    2. Anemia of Chronic Disease, frequent blood draws and Sepsis are the common causes of gradually decreasing Hemoglobin
    3. More rapid drops in Hemoglobin require more urgent evaluation for acute blood loss or Hemolysis
    4. Conservative transfusion strategy for Anemia in hemodynamically stable patients transfuse for Hgb <7 g/dl (or <8 g/dl if active Myocardial Ischemia)
    5. Glucose Control in the Intensive Care Unit
  14. Glucose Control in the Intensive Care Unit (endo, DM)
    1. Hypoglycemia may result in acute catastrophic events (Cardiac Arrest, brain injury)
    2. Avoid tight Glucose control in Critical Illness (esp. intubated and sedated patients)
    3. However, significant Hyperglycemia in the hospitalized patient (esp. post-surgical) is associated with worse outcomes
    4. Follow systematic approaches to keep Glucose within relaxed target ranges (140-200 mg/dl)
  15. Enteral Nutrition for Intubated Patients (gi, procedure)
    1. Early Enteral Nutrition (first 24-48 hours of ICU admission) is preferred and has few contraindications
  16. Sedation and Analgesia in Intensive Care (lung, procedure)
    1. Analgesics should specifically target pain and should not be used for sedation; typically start with Fentanyl and wean to Acetaminophen and longer acting Opioids
    2. Post-intubation sedation typically starts with Propofol, then transitions to Precedex for weaning, but consider Ketamine with or without Clonidine
    3. Monitor with Richmond Agitation and Sedation Scale (RASS) and Critical Care Pain Observation Tool (CPOT)
  17. Fluid Management in Critical Care (re, pharm, fen)
    1. Fluid Overload is much more common in the ICU, then volume depletion
    2. Monitor input and output, IVC Ultrasound closely and pursue diuresis for Positive Fluid Balance >4-5 Liters above dry weight
    3. Diuresis often involves Furosemide with a Thiazide Diuretic
  18. Sepsis (id, fever)
    1. Extensive updates made including fluids, antibiotic selection, stabilization
  19. Headache (neuro, Headache)
    1. Undertreatment of episodic Headaches may predispose to transition to chronic Headaches due to Headache Central Sensitization
    2. Added extensive updates to Headache diagnosis and management
  20. RSV Bronchiolitis (lung, peds, Bronchi)
    1. Warm Respiratory Scoring Tool >4 (or atopic/RAD history) may be an indication for Bronchodilator trial in RSV
  21. Targeted Cancer Therapy
    1. Reviewed CAR T-Cell Therapy and Immune Checkpoint Inhibitors, along with their adverse effects and management
  22. Thrombolytic (hemeonc, pharm)
    1. There is no ideal rescue agent for Thrombolytic-related life threatening bleeding (e.g. Intracranial Hemorrhage)
    2. Consider infusing Fibrinogen concentrate or Cryoprecipitate 10 pack
    3. Consider Fresh Frozen Plasma
    4. Give Tranexamic Acid (TXA)
  23. D-Dimer (hemeonc, lab)
    1. Several studies have now shown cutoff <1000 ng/ml is safe compared with 500 ng/ml in patients at low risk of Pulmonary Embolism
    2. This is well established for adults at age >75 years and for third trimester pregnancy
    3. However, this is growing evidence for D-Dimer >1000 ng/ml for any age
    4. Prior study used YEARS Score with all criteria absent
  24. Subarachnoid Hemorrhage (neuro, cv)
    1. Since 2011, CT Head was considered sufficient within 6 hours of acute onset severe Headache in neurologically intact patient
    2. However, there has been growing evidence that even under 6 hours, Lumbar Puncture should still be performed after negative CT Head in high suspicion cases
  25. Status Epilepticus (neuro, Seizure)
    1. No evidence for one antiepileptic over another (e.g. Keppra, Phenytoin, Valproic Acid), now with a study confirming this in children
    2. Prior 2014 study demonstrated this in adults
  26. Cryosurgery (derm, procedure)
    1. Not much has changed (besides the name Cryosurgery instead of Cryotherapy)
    2. Reviewed, updated and expanded the content
  27. Hallucinogen (psych, cd)
    1. Types include Psychedelic Agents (Classic Hallucinogens) such as LSD and Psilocybin, Dissociative agents (e.g. Ketamine, PCP) and Delirium-inducing agents (e.g. Anticholinergics)
    2. Toxicity includes risk of Serotonin Syndrome and water Intoxication, but most patients will do well with calming and Benzodiazepines
  28. Hyperosmolar Hyperglycemic Syndrome (endo, dm)
    1. Severe Hyperglycemia resulting in increased Serum Osmolality and secondary Altered Mental State
    2. Presents with severe dehydration, Glucose >600, Serum Osmolality >320, Altered Mental Status and minimal to no Ketosis
    3. Management is reviewed including fluid Resuscitation, Glucose and electrolyte management and evaluation of underlying cause
  29. Pediatric Cervical Spine Injury (ortho, peds)
    1. Added additional guidance on Cervical Spine clearance in children
  30. Hyperlipidemia Management (cv, lipids)
    1. Nexletol (ATP-Citrate Lyase Inhibitor) is a new class of AntiHyperlipidemic that lowers LDL Cholesterol as a Statin adjunct or alternative (but does not effect Triglycerides, HDL)
    2. Unknown effect on longterm cardiovascular outcomes and costs $330/month
    3. May consider in Statin intolerant patients and those at very high cardiovascular risk, not at goal
  31. Diclofenac Gel (pharm, Analgesic)
    1. Will be OTC without a prescription in 2020
    2. Limit to 1-2 small joints up to four times daily
  32. Migraine Prophylaxis in Children (neuro, Headache, peds)
    1. Migraine Prophylaxis appears to be ineffective in children as compared with adults
    2. Guidelines recommend lifestyle and behavioral changes (Headache Self-Help Measure)
  33. Naltrexone
    1. Low dose Naltrexone (0.5 mg to 4.5 mg/day) has also been proprosed for various conditions including Chronic Pain
    2. No rigorous evidence of benefit at these low doses and for these varied conditions, but unlikely to cause harm
    3. Postulated to up-regulate Opioid receptors, increas endorphin production and act as Analgesic and antiinflammatory
    4. May cause Opioid Withdrawal if used soon after last use of Opioids
  34. Atypical Antipsychotics (psych, pharm, Psychosis)
    1. Two more expensive atypical antipyschotics: Caplyta (lumateperone) and Secuado (asenapine patch)
  35. Macrolides (id, pharm)
    1. Macrolides in general (including Azithromycin) may increase heart defects with first trimester exposure of 5-7 days
    2. Previously only Clarithromycin was considered a potential Teratogen (Cleft Lip association)

V. Updates: March 2020

  1. Splenic Abscess (GI, ID)
    1. Rare condition with a high mortality rate
    2. Presents with fever and Left Upper Quadrant Abdominal Pain
    3. Causes include Bacteremia including Endocarditis, contiguous spread from intra-abdominal infection or peritonitis and candiasis in immunocompromised patients
    4. Treated with both IV antibiotics and splenectomy
  2. T Wave (cv, exam, ekg)
    1. Expanded on differential diagnosis of T Wave Abnormalities (e.g. Peaked T Wave, T Wave Inversion, T Wave Flattening)
  3. Re-dosing Medications After Vomiting (gi, pharm)
    1. May re-dose medication if medication taken within 15 minutes of Vomiting (or intact drug seen in Emesis)
    2. May re-dose medication IF risk of missed dose outweighs risk of extra dose
    3. Avoid re-dosing of medications at higher risk of toxicity (e.g. antiocoagulation), with rapid absorption (e.g. liquids) or little impact of one missed dose
    4. Re-dose Progestin-only pill Contraception or Emergency Contraception
  4. Systolic Dysfunction (cv, chf)
    1. Diuretics are for symptom control and not the primary CHF treatment
    2. Start Furosemide (Lasix) 20-40 mg orally daily in AM (increase to 40 to 160 mg per dose, twice daily) and double the dose until Urine Output increases (exceeds threshold)
    3. Consider adding Spironolactone or Eplerenone (Aldosterone Antagonists) if Serum Creatinine must be <2.5 mg/dl (GFR > 30 ml/minute/1.73m2)
    4. Consider adding Thiazides ( Hydrochlorothiazide 25 mg orally daily OR Metolazone 2.5 mg orally daily (preferred for eGFR <30 ml/min)
  5. Elmiron (urology, pharm)
    1. Pentosan polysulfate (Elmiron) is commonly used for Interstitial Cystitis
    2. With prolonged use (years), causes Retinal damage (Pigmentary Maculopathy) with Retinal pigment changes that result in Blurred Vision and difficulty in adjusting to dim lighting
    3. Dilated Eye Exam is recommended for patients on Elmiron
  6. Nutrition in Toddlers (pharm, peds)
    1. Whole cows milk is preferred for age 1-2 years, and unsweetend Fortified Soy Milk may be used as an equivalent to cow's milk
    2. Other non-cow's milk (almond milk, rice milk, coconut milk, hemp milk) are not recommended since they are associated with decreased adult height and decreased Vitamin D
  7. Cystic Fibrosis (lung, peds, congenital)
    1. CF Transmembrane Conductance Regulator (CFTR) Modulatorsa are CF disease modifying agents that partially return function of chloride channels, resulting in less mucus accumulation
    2. Trikafta (elexacaftor/tezacaftor/ivacaftor) is a new agent released in 2020, that targets gene mutation found in 90% of CF patients (contrast with 50% for other agents)
    3. To maximize absorption, take with fat containing food such as peanut butter or avocado, and with pancreatic enzymes
    4. Very expensive ($300,000 per year)
  8. Prion Disease (id, prion)
    1. Extensive updates on Prion Disease in general as well as Creutzfeldt-Jakob Disease (sporadic, genetic, iatrogenic and acquired variant)
  9. Lower Gastrointestinal Bleeding (gi, sx, bleed)
    1. General approach to Lower Gastrointestinal Hemorrhage is reviewed including in unstable patients
  10. Upper Gastrointestinal Bleeding (gi, sx, bleed)
    1. General approach to upper gastrointestinal Hemorrhage is reviewed including in unstable patients
  11. Gastrointestinal Angiodysplasia (gi, cv, bleed)
    1. Relatively uncommon cause of Gastrointestinal Bleeding (esp. at the cecum and ascending colon) in over age 60 years
    2. Includes Dieulafoy Vascular Malformation which is a tortuous arteriole in the submucosa of the Stomach which may result in upper gastrointestinal Hemorrhage
  12. Cerebral Palsy (peds, neuro)
    1. Extensive updates to diagnosis and management
  13. Coccidioidomycosis (lung, fungus)
    1. Increasingly more common in U.S. endemic regions (southwest) whose territory has expanded in the last 2 decades
    2. More than half will have an uncomplicated course and resolve spontaneously without Antifungal management
    3. However, those at risk, including Diabetes Mellitus and pregnancy, may have severe courses with disseminated disease as well as Meningitis
  14. Foreign Bodies of the Skin (surgery, derm)
    1. Among the more complicated retained skin foreign bodies are broken needles, which may occur in IVDA, Subcutaneous Injections (e.g. Insulin) or acupunture
    2. Along with the typical complications of retained foreign bodies (e.g. infection, granuloma), needle fragments may also embolize
    3. Foreign Body Removal techniques, including those with Ultrasound are reviewed
  15. Pulmonary Embolism
    1. Reviewed Pulmonary Embolism including new risk stratification tools (Bova Score and sPESI)
  16. Point of Care Ultrasound (rad, Ultrasound)
    1. Am Fam Physician has a nice review of current indications for primary care Ultrasound and its efficacy in primary care provider's hands
    2. Expanded on Bedside Ultrasound indications
  17. Sexual History (psych, exam)
    1. Added Sexual History
  18. Cold Weather Injury (er, environ)
    1. No absolute core Temperature cut-off for survival (57 F core Temperature patient has survived)
    2. Continue rewarming during resucitation and retry medications and Defibrillation at >30 C
  19. Heat Illness (er, environ)
    1. Severe hyperthermia requires rapid cooling (esp. cold immersion bath), but avoid over-shooting to Hypothermia
  20. Frostbite (er, environ)
    1. Avoid thawing a limb if there is risk for immediate re-freezing
    2. Avoid aspirating hemorrhagic bullae
  21. High Altitude Sickness (er, environ, altitude)
    1. Updated altitude sickness in general
    2. Added Lake Louise Acute Mountain Sickness Score
  22. Electrical Synchronized Cardioversion of Atrial Fibrillation (cv, ekg)
    1. Atrial Fibrillation electrical cardioversion now has many conditions for those not on Anticoagulation for at least 4 weeks
    2. Onset <48 hours before presentation if normal CHADS2-VASc Score, without TIA or CVA in last 6 months, and no Valvular Atrial Fibrillation
    3. Atrial Fibrillation <12 hours in high risk patients (CHADS2-VASc Score >=2 in men or >=3 in women)
  23. Calcium Channel Blocker Overdose (cv, pharm, toxin)
    1. Calcium Channel Blocker Overdose presents in one of three patterns
    2. Vasoplegic Shock from from vasodilation due to DihydropyridineOverdose (e.g. Amlodipine) with hyperdynamic cardiac activity and warm skin
    3. Cardiogenic Shock presents with decreased contractility and Bradycardia due to Verapamil or DiltiazemOverdose, but with cool, Vasoconstricted skin
    4. Mixed Presentation may also occur with Poor contractility on Bedside Ultrasound and warm, vasodilated skin
  24. Newborn Resuscitation (nicu, exam)
    1. Even pulseless newborns with Apgar 0 at 10 minutes, survive to discharge in >50% of cases for Gestational age >32 weeks
  25. Status Epilepticus (neuro, Seizure)
    1. Keppra is as effective as Phenytoin after initial Benzodiazepine dosing
  26. Tuberculosis (lung, tb)
    1. M72/ASO1E Vaccine reduced progression to pulmonary Tuberculosis by 50% in HIV negative after Tb exposure and positive PPD
  27. Migraine Abortive Treatment (neuro, Headache)
    1. Two new third-line agents for abortive Migraine Management that are half the efficacy of Triptans at 100x the cost
    2. Ubrogepant (Ubrelvy) is a Gepant (CGRP receptor blocker)
    3. Lasmiditan (Reyvow) is a Ditan (Selective Serotonin5-HT1F agonist)
    4. Ditans are FDA schedule V due to euphoria and Hallucinations
  28. Corona Virus 19 (lung, id)
    1. Added Corona Virus 19 to section including SARS and MERS with available background information
  29. Sickle Cell Anemia (hemeonc, sickle cell)
    1. Two new adjuncts to Hydroxyurea to reduce Sickle Cell Crisis at $10,000 per month: Adakveo and Oxbryta
  30. Anti-Mullerian Hormone (lab, endo)
    1. Considered a stable marker of ovarian reserve and a predictor of menopausal age
    2. Anti-Mullerian Hormone (AMH) is secreted by granulosa cells in follicles (small antral and preantral)
    3. AMH increases from birth to age 25 years, and then AMH gradually decreases until Menopause
    4. Created a simplified calculation to estimate menopausal age based on AMH and current age

VI. Updates: February 2020

  1. COPD Management (lung, COPD)
    1. Corticosteroids are not uniformly effective in COPD
    2. Eosinophil Count >300 cells/ul (>4% of total WBC) predicts steroid responsiveness
    3. Eosinophil Count only has predictive value if off inhaled and Systemic Corticosteroids
    4. COPD may still respond to steroids despite low Eosinophil Count
  2. Electronic Prescriptions (manage, computer)
    1. Controlled substances must be E-Prescribed per Medicare Part D by 2021
  3. Apadaz (pharm, Analgesic)
    1. Benhydrocodone 4.08 mg, 6.12 mg and 8.16 mg is roughly equivalent to Hydrocodone 5, 7.5 and 10 mg
    2. Benhydrocodone is a prodrug enzymatically converted to Hydrocodone in gastrointestinal tract
    3. Submitted and declined by FDA to label as an Opioid Abuse Deterrent Agent
    4. Offers no benefit over other Opioids including Hydrocodone and not recommended
  4. Daytime Somnolence (psych, sleep)
    1. Pitolisant (Wakix) is released in 2020 for Daytime Somnolence for Narcolepsy
    2. A novel agent that is not a controlled substance, is active at CNS histamine receptors and appears to be as effective as Modafinil
    3. However, very expensive ($11,400 per month) andf many Drug Interactions as well as QT Prolongation
  5. CVA Prevention (neuro, prevent)
    1. Lowering LDL Cholesterol <70 mg/dl (compared with 95 mg/dl) decreases recurrent CV event in 3.5 years (NNT 42)
  6. Mucocele (ent, lip)
    1. Differential Diagnosis includes Lip Neoplasm, lip aneurysm and dermoid cyst
    2. Local removal techniques for typical Mucoceles including lesion unroofing, suturing, Cryotherapy and electrocautery
  7. Rickets (rheum, peds)
    1. Consider especially in exclusively Breast fed infants of darker skin and reduced sunlight exposure (esp. winter)
    2. Classic XRay Findings consistent with Rickets at metaphysis include Forearm/tibia cupping (scalloping) of metaphysis, fraying (tattered rope appearance) at metaphysis, widened metaphysis (splayed)
  8. Tonsillitis (ent, mouth)
    1. In addition to Group A Streptococcal Pharyngitis and Mononucleosis, consider Lemierre Syndrome or Fusobacterium Necrophorum
    2. Consider STD Causes (Gonorrhea, Acute HIV Infection, HSV)
    3. Consider airway emergencies (Peritonsillar Abscess, Retropharyngeal Abscess, Ludwig Angina, Epiglottitis, Bacterial Tracheitis
    4. Point-Of-Care GAS Nucleic Acid Amplification Test is a 15 minute test, with nearly perfect Test Sensitivity and requires no Throat Culture
  9. Lemierre Syndrome (ent, Pharyngitis)
    1. Infection by Fusobacterium necrophorium (Lemierre Syndrome), responsible for 10% of acute Pharyngitis cases in young adults and adolescents
    2. Occurs with contiguous infection from Pharyngitis (typically) or Dental Infection to lateral pharyngeal space, resulting in Septic Thrombophlebitis of Internal Jugular Vein
    3. Septic Thrombophlebitis of Internal Jugular Vein complicated by high morbidity and mortality, Septic pulmonary emboli, Carotid Artery erosion (with life-threatening bleeding)
  10. Functional Dyspepsia (gi, sx)
    1. Persistent chronic or recurrent Epigastric Pain, burning, early satiety or post-prandial fullness without structural cause
    2. Upper Endoscopy for Dyspepsia >1 month in over age 60 years (or significant Dyspepsia Red Flags) and then Antacid therapy (PPI, H2 Blocker)
    3. For those <60 years old, start with avoidance of Gastric Irritants and FODMAPS, and consider H. pylori testing before starting Antacids
  11. Systemic Glucocorticoids (endo, pharm)
    1. Even short course Corticosteroids are associated with increased serious adverse effects (e.g. Fracture, VTE, Sepsis, AVN)
    2. Systemic Corticosteroids are not recommended in Acute Bronchitis (aside from Asthma, COPD) and mild-moderate acute Pharyngitis (aside from Peritonsillar Abscess)
    3. Systemic Corticosteroids are also not recommended in Acute Sinusitis and Allergic Rhinitis
  12. Muscle Weakness (neuro, sx, motor)
    1. Differentiate weakness from pain-related disuse, Asthenia, Fatigue, Dyspnea, as well as Frailty and Sarcopenia of advanced age
    2. Categorize the findings as unilateral or bilateral, proximal or distal, upper or Lower Motor Neuron, and pure motor or combined sensory and motor
    3. Consider Medication Causes of Myositis, Neuropathy, Myopathy, and toxic-metabolic causes
  13. Apical Four Chamber Echocardiogram View (cv, rad)
    1. Added echo measurements including RVSP, VTI
  14. Monteggia Fracture (ortho, elbow)
    1. Proximal ulna Fracture AND Radial Head Dislocation typically from Fall on Outstretched Hand WITH extended elbow AND Hyperpronated Forearm
    2. Risk of Radial Nerve injury (including posterior interosseous nerve which branches from Radial Nerve); perform a careful Hand Neurovascular Exam (esp. extension of thumb, wrist and MCP joint)
    3. Closed reduction AND Long Arm Splint immobilization for stable, non-displaced Fractures
    4. Emergent orthopedic consult for displaced Monteggia Fracture Dislocations (unstable)
  15. Intubation Associated Sinusitis (ent, sinus)
    1. Most common with Nasotracheal Intubation and Nasogastric Tube, but also occurs with orotracheal intubation
    2. Common cause of unexplained fever in ICU patients
    3. Obtain CT Sinus, Gram Stain and Culture of sinus aspirate (by ENT) and MRSA Nasal PCR
    4. Consider Invasive Fungal Sinusitis (immunocompromised patients), which rapidly progresses over hours and requires emergent surgical management
  16. Lamictal (neuro, pharm)
    1. Anticonvulsant used commonly in Bipolar Disorder
    2. In Overdose, risk for life threatening arrhythmia with QRS Widening, Serotonin Syndrome, as well as the more common sedation
    3. Seziures may also occur in Overdose, esp. in children
  17. Ophthalmic Anti-inflammatory Agent (eye, pharm)
    1. Updated Ocular NSAIDs
    2. Added topics Ophthalmic Corticosteroid and Ophthalmic Cyclosporine (Ophthalmic Calcineurin Inhibitor, Restasis)
  18. Nocardia (derm, id)
    1. Weakly Gram Positive rod that forms fungus-like filaments and is found in soil
    2. Causes Pneumonia, CNS Abscess and disseminated Nocardiosis, and in 20% of case causes Skin Infection including Nodular Lymphangitis
  19. Beers List (geri, pharm)
    1. A few assorted updates to the list
  20. Health Maintenance in Adolescents (prevent, peds, teen)
    1. Updated Health Maintenance in Adolescents, Adolescent History (HEADSS Screening) and added Social Media Use in Adolescents
  21. Clostridium difficile (gi, id)
    1. Continues to increase in Incidence, and in mortality
    2. Vancomycin has been the first-line drug recommendation for C. difficile since 2018
    3. Stool odor is not sensitive nor specific for c. diff
  22. Chronic Wound (surgery, derm, Trauma)
    1. Chronic Wounds are divided into Arterial Ulcer, Venous Ulcer, diabetic ulcer and Pressure Ulcer
    2. Check ABI (which may be inaccurate in Diabetic Foot Ulcer) before applying compression
    3. Broad-based review with added topics including Arterial Ulcer and Chronic Wound Infection
  23. Suicidality (psych, depression)
    1. Added the Columbia Suicide Severity Rating Scale (C-SSRS) and Modified MSPS Suicide Risk Assessment, as well as safety plan information
    2. Expanded on the approach to the disposition of the suicidal patient
  24. Enterostomy Tube (gi, procedure)
    1. Added more pearls on G-Tube, J-Tube complication management
  25. Pediatric Intubation (lung, procedure)
    1. Added pearls on pediatric airway management
  26. Scalp Laceration (surgery, derm, wound)
    1. Control Hemorrhage, repair the galea if torn and keep hair out of the wound closure
  27. Amnotic Fluid Embolism (ob, cv)
    1. Experimental protocol (A-OK Amniotic Fluid Embolism Protocol) includes Atropine, Ondansetron, Ketorolac
  28. Digoxin Toxicity (cv, pharm)
    1. Although Digoxin Toxicity is much less common now, several Herbals contain toxic levels of cardiac glycosides (e.g. pong-pong) and may be lethal
  29. Hypertensive Encephalopathy (cv, htn, neuro)
    1. Ill appearing patients with Altered Level of Consciousness and Severe Hypertension
    2. Contrast with severe, but asymptomatic Hypertension (other than mild Headache) which is not Hypertensive Encephalopathy

VII. Updates: January 2020

  1. Cirrhosis (gi, liver)
    1. Viral Hepatitis has surpassed Alcohol as most common Cirrhosis cause, and NAFLD is steadily increasing
    2. Biopsy has largely been replaced in fibrosis staging due to noninvasive techniques (biomarkers, calculators, transient elastography)
    3. Ultrasound screening every 6-12 months for Hepatocellular Carcinoma
  2. Amblyopia (eye, peds)
    1. Effects up to 6% of children and is the most common cause of monocular Vision Loss in children and causes irreversible blindness in nearly 3% of adults
    2. Early recognition and treatment is key (ideally before 3-5 years old) and photoscreening with an iphone is an effective strategy
    3. Ophthalmology referral indications have been expanded
    4. After correction of primary eye disorders (e.g. Congenital Cataracts), patching, glasses and Atropine drops obscuring the good eye, are the main treatment strategies
  3. Nasotracheal Intubation (lung, procedure)
    1. Nasotracheal Intubation is rarely done outside of Angioedema and other tenuous airway management in which an awake intubation is preferred
    2. Complications include Nasopharyngeal Hemorrhage, Retropharyngeal Perforation (may occur with Blind Nasotracheal Intubation), Post-Intubation Otitis Media
  4. Otitis Media Prevention (ent, ear, id)
    1. Antibiotic prophylaxis for Otitis Media has not been recommended for 1-2 decades due to Antibiotic Resistance (esp. pneumococcus)
    2. Recommended prevention includes PrevnarVaccine, Influenza Vaccine yearly, avoiding passive smoke, propped bottles and Pacifiers, and Allergic Rhinitis management
    3. Consider Tympanostomy Tubes for three Otitis Media episodes in 6 months OR 4 episodes in 1 year AND Last episode within prior 6 months
  5. Cutaneous Larva Migrans (derm, Parasite)
    1. Serpiginous formation of Papules, typically on the legs after barefoot walking on soil, sand in Southeastern United States
  6. Acute Parotitis (ent, Salivary)
    1. Distinguish the hot, swollen, tender Parotid Gland (Acute Parotitis) from the cold, swollen, minimally tender Parotid Gland (chronic Parotitis)
    2. Acute Parotitis may be Bacterial (esp. Staphylococcus aureus) or viral (mumps, EBV, parainfluenza, Influenza)
    3. Chronic Parotitis may be due to Sarcoidosis, Sjogren's Syndrome, Diabetes Mellitus, Cirrhosis
  7. Chronic Hypertension in Pregnancy (cv, ob, htn)
    1. PIH risk with chronic Hypertension is 20-50%
    2. Aspirin 81 mg daily starting in second trimester and continuing until delivery is recommended
    3. Antihypertensives and their indications are reviewed
  8. Diphtheria (ent, mouth, id)
    1. Diphtheria is Vaccine preventable, yet it continues with worldwide cases including rare cases in the U.S.
    2. Mortality from Diphtheria is as high as 50% in untreated cases (5-10% with treatment)
  9. Foodborne Illness (gi, Diarrhea)
    1. Suspect preformed toxin (Staphylococcus aureus, b cereus, Scombroid Fish Poisoning) when onset <6 hours after ingestion
    2. Although most Foodborne Illness is self limited, life threatening illness may occur with Listeria, Vibrio and Botulism
    3. Consider parasitic causes when onset >1 week
    4. Food handlers and healthcare workers should not return to work until symptoms have resolved for 48 hours
  10. Parental Consent to Treat Minor Children (neuro, cognitive)
    1. In adults, substituted judgment is based on knowing a patient's opinions and values and the surrogate acts on what they believe the adult patient would want
    2. However, younger children do not typically have the ability to understand their medical options and make decisions
    3. Instead, parents and surrogates practice what they interpret as best interests of the child, although "Best interest" is often difficult to determine, and may reasonably vary from one surrogate to another
    4. Nonmaleficence ("do no harm") may be a more manageable way to judge surrogate decision making, in which the clinician should consider whether surrogate decision making risks significant child harm
  11. Scoliosis (ortho, t-spine)
    1. Scoliosis screening is not recommended by USPTF and AAFP, but is recommended by AAP and AAOS
    2. Scoliosis XRay for Cobb Angle is indicated based on Scoliosis Examination (Forward Bending Test, Scoliometer)
    3. BMI <85%: Scoliometer measurement 7 degrees or more of trunk rotation (~20 degree Cobb Angle)
    4. BMI >85%: Scoliometer measurement 5 degrees or more of trunk rotation (~10 degree Cobb Angle)
  12. Atrial Fibrillation Acute Management (cv, ekg)
    1. In complex presentations of Atrial Fibrillation with rapid ventricular rate, consider compensatory Tachycardia for secondary cause (Alcohol Withdrawal, decompensated COPD, Sepsis, CHF exacerbation)
    2. Although immediate cardioversion is indicated in unstable primary Atrial Fib RVR, it may be harmful in secondary cause
    3. If Hypotension is due to Atrial Fibrillation with rapid rate, expect the patient to be cool; contrast with Sepsis with vasodilation, in which the patient's skin will be warm
    4. Expect typical rates for Atrial Fibrillation rapid ventricular response (130-140 if younger, 110 if older); Heart Rate of 160 suggests compensatory Tachycardia for secondary cause (e.g. Sepsis)
  13. Myxedema Coma (endo, Thyroid)
    1. Consider in the elderly, hypothermic patient with Altered Level of Consciousness
    2. Consider triggers (e.g. Sepsis, cold exposure, Amiodarone or Lithium)
    3. ABC Management, IV Thyroxine (and consider T3 IV) and supportive care (e.g. IV crystalloid)
    4. Mortality is very high (approaches 30-60%)
  14. Lymphoma (hemeonc, lymph)
    1. Extensive updates on Hodgkin's Lymphoma and Non-Hodgkin's Lymphoma
  15. Anorectal Conditions (gi, exam)
    1. Multiple topics updated including Perianal Pruritus, Anal Fissure, Functional Rectal Pain, Fecal Incontinence
  16. Bariatric Surgery (endo, surgery)
    1. Sleeve Gastrectomy is responsible for 60%, and Roux-En-Y 18% of the nearly 230,000 bariatric surgeries per year
    2. Complications include anastomotic leak, Internal Hernia, Pulmonary Embolism, Vitamin Deficiencies (including Acute Thiamine Deficiency)
  17. Coronary CT Angiography (cv, rad)
    1. CCTA is an option evaluation of Low Risk Chest Pain patients in the prediction of short-term significant coronary event (risk 0.2-0.3% or 2-3 per 1000)
    2. However, in Low Risk Chest Pain, there is high risk of False Positive tests and unnecessary cardiac catheterization
    3. CCTA has a Test Specificity at best of 90%, or 100 patients in 1000 tested with a False Positive result
    4. CCTA could subject 100 Low Risk Chest Pain patients to invasive catheterization to find 2-3 true positives
  18. Salicylate Toxicity (pharm, Analgesic, adverse, toxin)
    1. Salicylate Overdose, especially chronic toxicity in the elderly, is under-recognized
    2. Consider Salicylate Toxicity in the patient with Altered Level of Consciousness and Tachypnea
    3. Respiratory Alkalosis precedes Metabolic Acidosis with Anion Gap
    4. Chronic Salicylate Toxicity presents with greater symptoms at lower Salicylate levels and noncardiogenic pulmonary edema
  19. Hyperkalemia Management (renal, Potassium)
    1. When using Glucose and Insulin Infusion, risks of Hypoglycemia include pretreatment Glucose <150, no diabetes, weight <60 kg, female gender, Renal Failure
    2. Consider decreased Regular Insulin dose (0.1 unit/kg up to 5-10 units IV) instead of a full 10 units IV for everyone
    3. Administer dextrose with Insulin if Serum Glucose <250 mg/dl and esp. if risks and consider second dextrose bolus or infusion
    4. Monito Glucose for 4-6 hours
  20. Echocardiogram (cv, rad)
    1. Extensive updates to the Echocardiogram content with more to come after attending a 1 week course at GCUS
    2. Eight new diagrams covering measurements, color-doppler and pulse-wave doppler added with more to come

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