DYSPEPSIA

Chronic or recurrent pain or discomfort in the

upper abdomen occurring > 2 weeks.

Gnawing, burning pain

Discomfort defined as: early satiety, upper

abdominal fullness, nausea, bloating, belching
Alarm Symptoms
1. age at onset >45 y.o.
2. weight loss >10%
3. anemia
4. hematemesis
5. melena
6. hematochezia
7. dysphagia
8. odynophagia
9. persistent vomiting
10. abdominal mass
11. jaundice
12. chronic NSAID intake
13. chronic alcohol intake
14. previous history of peptic ulcer
15. family history of GI* ulcer
16. lymphadenopathy*

Metoclopramide 10 mg PO TID

Domperidone 10 mg PO TID

Dimethicone 40 mg PO TID
URINARY TRACT INFECTION
ACUTE UNCOMPLICATED CYSTITIS

Dysuria, frequency, gross hematuria, with or

without backpain

Without symptoms of vaginitis, pyelonephritis,

risk factors for subacute pyelonephritis or
complicated UTI---Upper Tract/STI sx)

5 wbc/hpf (males); 8 wbc/hpf (females)

>100 CFU/mL

Standard urine microscopy is not a prerequisite

for treatment

Pre-treatment urine culture and sensitivity is not

recommended

Dx testing

Empiric trial of acid suppression with proton

pump inhibitor (PPI) for 4-8 weeks (Gr A)

Test-and-treat strategy for H. pylori* (Gr A)

Treatment
Pharmacologic:

2-4 wks PPI, H2 blocker, antacid

Non-Pharmacologic:

avoid alcohol, milk, tea, carbonated

drinks, coffee, acidic beverages

small frequent feedings

avoid skipping meals

WOF : increased abdominal pain, alarm symptoms,
absence of improvement after >7days of tx

ACUTE UNCOMPLICATED PYELONEPHRITIS

fever (>38C), chills, flank pain, CVA tenderness,

nausea, vomiting lower UTI symptoms

>5 wbc/hpf; >10,000 CFU/mL

Urinalysis and gram stain are recommended

Urine culture and sensitivity should be

performed routinely to facilitate cost-effective use of
antibiotics

Non-pregnant patients without sepsis, adherent

to treatment and likely to return for follow-up - treat
as outpatients

Proton pump inhibitors

Esomeprazole 20-40 mg OD

Omeprazole 20 mg OD

Pantoprazole 40 mg OD

Lansoprazole 30 mg OD
H2 blockers

Ranitidine 150 mg BID/ 300 mg HS/ 50 mg IM

Famotidine 20 mg BID/ 40 mg HS

Cimetidine 200 mg BID/ 400 mg HS/ 200 mg IM

Antacids

Mg/Al hydroxide PO QID, pc

Cytoprotectives

Sucralfate 500 mg QID, ac

Prokinetic Agents

INDICATIONS for ADMISSION:

inability to maintain oral hydration or take

medications

concern about compliance;

uncertainty about the diagnosis

severe illness with high fever, severe pain,

marked debility

signs of sepsis
RECURRENT UTI

Episodes of acute uncomplicated UTI

documented by urine culture occurring >2x/yr in a
non-pregnant woman without known urinary tract
abnormality

Treatment of individual episodes: 7-day tx

Prophylaxis (continuous and post-coital)

ASYMPTOMATIC BACTERIURIA

> 100,000 cfu/ml of one or more uropathogens

2 consecutive midstream urine specimen or in

one catheterized urine specimen

absence of symptoms attributable to UTI

Screening:

pxs who will undergo genitourinary manipulation

or instrumentation

post-renal transplant patients up to the first six

months

DM patients with poor glycemic control

ALL pregnant women

Treatment

Any antibiotics for AUC can be used for

treatment of ASB in the above group of patients

7-14 day course is recommended, except for

pregnant women

Routine screening and treatment is not

recommended for healthy adults

URINE CULTURE is the recommended

screening test, but urine microscopy and stain may
be used in the absence of culture
UTI IN PREGNANCY

> 100,000 cfu/ml of one or more uropathogens

in

- 2 consecutive midstream urine specimen or in

one catheterized urine specimen

absent symptoms attributable to UTI

Must be screened on their first prenatal visit

between 9-17 wks AOG

URINE CULTURE of clean catch midstream

urine is the test of choice
Treatment

Antibiotic treatment must be initiated upon the

diagnosis of ASB in pregnancy

Follow-up cultures one week after completing

the course of treatment

Nitrofurantoin (not for those near term)

Co-amoxiclav, cephalexin

Cotrimoxazole (not in the 1st and 3rd trimester)

7-day course is recommended

COMPLICATED UTI

Presence of INDWELLING catheter or

intermittent
catheterization
INCOMPLETE EMPTYING of the bladder with
>100 ml
retained urine post-voiding
OBSTRUCTIVE UROPATHY due to bladder
outlet obstruction, calculus and other causes
Renal transplant
Diabetes Mellitus
UTI in Males except in young males presenting
exclusively with lower UTI symptoms
Cut off for significant bacteriuria is >100,000
cfu/ml
Urine sample for gram stain, culture and
sensitivity testing must always be obtained before
initiation of any treatment
Treatment:oral fluoroquinolones are
recommended with 7-14 days of therapy
recommended
A repeat urine culture one to two weeks after
completion of therapy

UTI IN MALES

Generally considered complicated

However, the 1st episode of symptomatic LUTI

occurring in young (15-40 years old) otherwise
healthy sexually active men with no clinical or
historical evidence of structural or functional urologic
abnormality is considered uncomplicated UTI

Significant pyuria is >5wbc/hpf in a clean catch

midstream urine specimen

TREATMENT: 7-day antibiotic regimen of TMPSMZ or fluoroquinolones may be used

BRONCHIAL ASTHMA

Chronic inflammatory disorder of the airways

Airway hyperresponsiveness

Airflow obstruction often reversible either

spontaneously or with treatment

Wheezing-high-pitched whistling sounds when

breathing out-especially in children

Reversible and variable airflow limitation- as

measured by using a spirometer (FEV1 and FVC) or
a peak expiratory flow (PEF) meter.

History of any of the ff:

Cough, worse particularly at night

 Recurrent Wheeze
Recurrent Difficult Breathing
Recurrent Chest Tightness
Symptoms occur or worsen in the presence of:

Animal with Fur

Exercise

Aerosol Chemicals

Pollen

Changes in temperature

Respiratory (viral) infxns

Domestic Dust Mites

Smoke

Drugs (aspirin, beta blockers)

Strong emotional expression

When using a peak flow meter, consider asthma if:

PEF increases more than 15 % 15 to 20 mins

after inhalation of a rapid-acting B2 agonist

PEF varies more than 20% from morning

measurement upon arising to measurement 12
hours later in patients taking a bronchodilator

PEF decreases more than 15 % after 5 minutes

of sustained running or exercise.

Lung function is not a reliable test for children 5

years and younger

Goals for successful management

Achieve and maintain control of symptoms

Maintain normal activity levels, including

exercise

Maintain pulmonary function as close to normal

as possible

Prevent asthma exacerbations

Avoid adverse effects from asthma medications

Prevent asthma mortality

Asthma treatment: Controllers

Classification of Asthma Severity (2005)

Leukotriene modifiers

receptor antagonists (montelukast, pranlukast,

and zafirlukast) and a 5-lipoxygenase inhibitor
(zileuton)

Less effective than long acting B2 agonist as

add-on

Less effective than glucocorticoids when used

alone
GINA 2006 CLASSIFICATION OF ASTHMA

Any exacerbation should prompt review of

maintenance treatment to ensure that it is adequate

By definition, an exacerbation in any week

makes that an uncontrolled asthma week

Long acting inhaled B2 agonist

Salmeterol and formoterol

Should not be used as monotherapy

Combined with inhaled glucocorticosteroid,

when medium dose of the latter fails to achieve
control

Formoterol more rapid onset of action

Asthma treatment: Controllers
Theophylline

Significant side effects at higher doses 10

mkday: gastrointestinal symptoms, loose stools,
cardiac arrhythmias, seizures, and even death
Rapid acting inhaled B2 agonists

Salbutamol, terbutaline, fenoterol, reproterol,

and pirbuterol

Medications of choice for acute attacks and for

pre-treatment of exercise-induced
bronchoconstriction
Systemic glucocorticoids

Treatment of severe acute exacerbations

40-50 mg prednisolone given daily for 5 to 10
days
Anticholinergics

Ipratropium bromide and oxitropium bromide

Alternative bronchodilator for patients who

experience such adverse effects as tachycardia,
arrhythmia, and tremor from rapidacting B2-agonists
Patients at High Risk for Asthma-related death

History of near-fatal death

Hospitalization or ER visit for asthma w/in the
past year
prior intubation for asthma

Current use of, or recent withdrawal from, oral

glucocorticosteroids

Over-dependence on rapid-acting B2-agonists.

Hx of psychosocial problems or denial of asthma

or its severity

Hx of noncompliance w/ asthma medication plan

Patients should immediately seek medical care if

The attack is severe

The response to the initial bronchodilator

treatment is not prompt and sustained for at least 3
hours

There is no improvement within 2 to 6 hours

after oral glucocorticosteroid treatment is started

There is further deterioration

PULMONARY TUBERCULOSIS
Local Symptoms:

cough, hemoptysis, chest pain, dyspnea

Constitutional Symptoms:

fever, weight loss, chills, anorexia

CONCEPTS:
1.TB exposure
2.TB infection: (+) PPD
3.TB disease: (+) target organ damage
SMEAR (+) CASE:

(+) AFB Sputum Smear [two times]

(+) AFB Sputum Smear [once] plus

Radiographic Abnormalities (consistent with active
PTB)

(+) AFB Sputum Smear [once] plus (+) Sputum

Culture
SMEAR (-) CASE:

(-) AFB Sputum Smear [three times] plus

Radiographic Abnormalities (consistent with active
PTB)

No response to a full course of antibiotics

Decision of a clinician to treat with a full course

of anti-TB chemotherapy
INDICATORS OF ACTIVE DISEASE:

(+) AFB sputum smear (at least two times) or

(+) TB culture

(+) symptoms present

increase in apical CXR infiltrates

INDICATORS OF INACTIVE DISEASE:

six months interval with no change in CXR

infiltrates and no constitutional symptoms noted in
the patient

preferably with history of completed TB

treatment regimen
NEW CASE:

never had treatment for TB or has taken anti-TB

drugs for less than one month
RELAPSE:

previously treated for TB, declared cured or

treatment completed, with (+) AFB sputum smear or
culture
RETURN AFTER DEFAULT (RAD):

treatment re-started with (+) AFB sputum smear

or culture, following interruption of treatment for two
or more months
FAILURE:

sputum smear (+) at 5 months during course of

treatment
CURED:

treatment completed and has (-) AFB Sputum

Smear in the last month of treatment and on at least
one other occasion
TREATMENT COMPLETED:

treatment completed but does not meet criteria

to be classified as "cure" or "failure
TREATMENT FAILURE:

AFB Sputum Smear (+) after five months of

treatment OR AFB Sputum Smear (-) before
treatment and becomes (+) during treatment
COMMUNITY ACQUIRED PNEUMONIA

an acute infection of the pulmonary parenchyma

accompanied by symptoms of acute illness
accompanied by abnormal chest findings.

Lower respiratory tract infection acquired in in

the community w/in 24h to < 2wks

Acute cough

Abnormal Vital signs:

tachypnea (RR > 20bpm)
tachycardia (CR > 100/min)
fever (T>37.8C)

At least one 1 abnormal chest finding:

Increased breath sounds
Rhonchi
Crackles
Wheeze

Chest X-ray

Done to confirm diagnosis in most patients

(grade A)

New parenchymal infiltrate in CXR remains the

reference diagnostic standard for pneumonia (Grade
A)

CXR may suggest possible etiology and

differentiate it from other conditions that mimic it
(Grade A)

Atypical CAP
M. pneumoniae- Particle Agglutination Test
C. pneumoniae- Microimmunoflorescence
Legionella- urine antigen test and direct
fluorescent antibody test

HYPERTENSION
Co-morbities for Low Risk

Grade A
DM
Neoplastic dse in remission
Neurologic,
CHF I
CAD
Immunosuppresion

Grade B
Renal insufficiency

Grade C
COPD
CLD
chronic alcohol abuse
Co-morbities for Medium-High Risk

Uncontrolled DM

Active malignancies

Progressing neurologic disease

CHF II-IV

Unstable CAD

High doses of immunosuppressive tx

Renal failure on dialysis

COPD, IAE

Decompensated liver disease

Uncontrolled alcohol abuse

Microbiologic Studies

Low Risk CAP optional

Mod and High Risk CAP

Blood Culture (at least 2)--gold standard
Gram stain/culture of respiratory specimens

Diagnostic workup:

FBS

U/A

serum Crea

serum K

Lipid profile (HDL,LDL, Cholesterol, Trigly)

12 L-ECG
Principles of Treatment

Target BP: < 140/90

Patients with diabetes or CKD:

Target BP< 130/80 mmHg

HYPERTENSIVE URGENCY

no end organ damage

oral medications given initially

lower BP within 2-3 days

HYPERTENSIVE EMERGENCY

(+) changes in sensorium, papilledema, or CHF

IV meds given STAT

lower BP within 24 hours

MEDICATIONS:

Calcibloc (Nifedipine)

5-10 mg SL or PO, Q30 mins

Captopril (Capoten)
25 mg SL or PO, Q30 mins
Clonidine
75 mcg SL or PO, Q1

Without Compelling Indications

Stage 1 Hypertension
SBP 140-159 or DBP 90-99mmHg
Thiazide-type diuretics
May give ACEI, BB, CCB or combination

Stage 2 Hypertension
SBP >/= 160 or DBP >/= 100mmHg)
2-drug combination for most ( usually thiazidetype diuretic and ACEI, or ARB, or BB, or CCB)

Chronic Complications of DM
Microvascular

Eye disease
Retinopathy (nonproliferative/proliferative)
Macular edema

Neuropathy
Sensory and motor (mono- and polyneuropathy)
Autonomic

Nephropathy
Macrovascular

Coronary artery disease

Peripheral vascular disease

Cerebrovascular disease
Others

Gastrointestinal (gastroparesis, diarrhea)

Genitourinary (uropathy/sexual dysfunction)

Dermatologic

Infectious

Cataracts

Glaucoma

DIABETES MELLITUS
Criteria for the diagnosis of Diabetes

Symptoms of DM and a casual plasma glucose

of more than or equal to 200mg/dl (11.1mmol/L).

Casual is defined as any time of the day w/out

regard to time since last meal.

Symptoms of diabetes:
polyuria
polydipsia
unexplained weight loss

FPG >/= 126 mg/dL (7.0 mmol/L).

Fasting is defined as no caloric intake for at
least 8 hours.

2-h plasma glucose >/= 200mg/dl (11.1mmol/L)

during a 75-g anhydrous OGTT.
Summary of recommendations for adults with diabetes
(ADA, 2007)
Glycemic control

A1C 7.0%*

Preprandial capillary plasma glucose 90130

mg/dl (5.07.2 mmol/l)

Peak postprandial capillary plasma glucose

180 mg/dl (10.0 mmol/l)

Blood pressure 130/80 mmHg

Lipids

LDL 100 mg/dl (2.6 mmol/l)

Triglycerides 150 mg/dl (1.7 mmol/l)

HDL 40 mg/dl (1.0 mmol/l)

OBESE

BIGUANIDES
Metformin 500mg OD, BID, TID
optimal dose 1,500mg/day
starting dose: 500mg BID after meals
ELDERLY (>60 YEARS)

SULFONYLUREAS
Glibenclamide 1.25-20 mg OD or in divided
doses
starting dose: 5mg OD 30min before meals
Glipizide 2.5-30 mg OD or in divided doses
Gliclazide 80-240 mg OD or in divided doses

may give

ACE INHIBITORS
may slow down the development of microalbuminuria
Fosinopril 10mg/tab OD
Enalapril 10mg/tab OD

ASA 80mg/tab, OD,p.c.