Family Medicine Textbook Notes PDF

Family Medicine Textbook Notes 1

RISE
Describe the approach to • Identify the Risks of your patient
applying preventative • Consider recommended Immunizations (and chemoprophylaxis)
care in clinical practice • Review recommended Screening with the patient
• Address appropriate Education or counseling
First time parents
bringing in their baby for It is important to establish trust early on. You can do this by spending a short time interacting with
initial well-‐‑baby exam. the infant at the beginning of the visit, taking time to elicit any concerns or questions from the
What is the approach to parent early in the visit, and remaining aware of non-‐‑verbal cues.
ease anxiety they may
have?
What are the common
causes of lack of Inadequate growth may be the presenting feature of a variety of disorders, such as
development in an infant endocrinopathies, cardiac diseases, and renal dysfunction. More commonly, it is a result of social
seen at a well-‐‑child stressors, poor bonding, and inadequate nutrition.
exam?

What measurements First 2 years: height, weight, and head circumferences à plotted on a standardized growth chart
should be used to
monitor the development After age 2: height and weight à use BMI percentile to compare to other children
of an infant over time?

1) Anaphylactic reaction to vaccine
2) Moderate or severe acute illness following a dose of an injectable vaccine
What are the 3) Known hypersensitivity to component of vaccine
contraindications for 4) Moderate or severe acute illness as it may be difficult to identify subsequent reactions from
vaccines in children? immunization
5) Pregnancy in vaccine recipient (certain live vaccines only)
What are the common
causes of anemia in an
infant seen at a well-‐‑child
exam?

BMI classifications in Overweight: 85th – 95th Percentile
children?
Obese: > 95th Percentile


Colic is a term often used to describe an infant who is difficult to manage or fussy despite being
otherwise healthy.
• May be defined as 3 or more hours of uncontrollable crying or fussing at least 3 times per
Describe colic as seen week for at least 3 weeks
during well-‐‑child • Other symptoms include facial expressions of pain or discomfort, pulling up of the legs,
examinations. passing flatus, fussiness with eating, and difficulty falling or staying asleep
• Symptoms classically worsen during the evening
• Usually dissipates once the child is 3-‐‑4 months old
• Underlying cause is unknown à organic pathology is present in < 5%
• Possible etiologies include an immature digestive system sensitive to certain food proteins,
an immature nervous system sensitive to external stimuli, or a mismatch between the
infant’s temperament and those of the caregivers
• No long term consequences of colic
No definitive treatment can be offered for colic. Little evidence supports the use of simethicone or
acetaminophen drops. May be helpful to reduce the amount of stimulation. Frequent burping,
swaddling, infant massage, or white noise may be helpful.
Diagnoses
1) Primary Diaper Dermatitis: acute skin inflammation in the diaper area with multifactorial
Describe diaper rash as etiology. Main cause is irritation of thin skin as a result of prolonged contact with moisture
seen during well-‐‑child including feces and urine
examinations. 2) Irritant Diaper Dermatitis: combination of intertrigo (wet skin damaged from chafing) and
miliaria (heat rash) when eccrine glands become obstructed from excessive hydration à
typically lasts for < 3 days after a change in diaper practices
3) Candidal Diaper Dermatitis: within 3 days, 45-‐‑75% of diaper rashes are colonized with
Candida albicans of fecal origin
4) Bacterial Diaper Dermatitis: may be a secondaryinfection caused by S aureus or Strep
pyogenes
5) Perianal Streptococcal dermatitis: caused by Group A ß-‐‑hemolytic streptococci

Risk Factors
1) Diarrhea
2) Formula-‐‑fed infants
3) Recent antibiotic use
Describe diaper rash as 4) Urinary Tract Abnormalities
seen during well-‐‑child 5) Poor Skin Care
examinations, continued Treatment
• Parental behavioral change to keep the skin as exposed and dry as possible
• Frequent diaper changes
• Superabsorbant diapers that pull moisture away from the skin are helpful
• Apply barrier preparations, including zinc oxide paste, petroleum jelly, vitamin A and D
ointment, or Burow solution (pastes > ointments > creams/lotions)
• For moderate to severe inflammation, consider a nonfluorinated, low-‐‑potency topical
steroid such as 1% hydrocortisone ointment
• For Candida, use topical nonprescription antifungal creams: clotrimazole, miconazole
• No follow up needed unless it worsens or persists
By 9th grade, 37% of males and 29% of females are sexually active. These youths are
disproportionately affected by chlamydia, Neisseria gonorrhea, and other STIs. Asymptomatic
carrier states are common and associated morbidity is high.

Describe STD testing of All sexually active female adolescents should be screened for chlamydia and gonorrhea. There is
adolescents insufficient evidence to recommend for or against screening asymptomatic males. High-‐‑risk
individuals of both sexes should be screened for syphilis.
• High risk = men who have sex with men, men and women who have unprotected sex with
multiple partners, past or present injection drug users, men/women who exchange sex for
money/drugs or have sex partners who do, individuals whose past or current sexual
partners were HIV-‐‑infected, bisexual, or injection drug users, persons being treated for
STIs, and persons requesting an HIV test

• #1 cause of death in children/adolescents = unintentional injuries
What are the most • Motor vehicle crashes account for the highest number of deaths among children older than
common preventable 1-‐‑year-‐‑old.
causes of death in • Infants who sleep on their stomachs have roughly twice the incidence of SIDS à
children and adolescents? recommended that infants sleep on their backs (“Back to Sleep Campaign”)
• Suicide is the 3rd leading cause of death in 15 to 24 year olds

In the Infant: breastfeeding is associated with a reduced risk of otitis media, gastroenteritis,
What are the benefits of respiratory illness, SIDS, necrotizing enterocolitis, obesity, and hypertension
breastfeeding?
In the Mother: Reduced risk of breast and ovarian cancers, type 2 diabetes, and postpartum
depression

Home
Education
Describe the HEADSSS Activities
mnemonic. Drugs
Sexuality
Suicide
Safety

Describe the risk for
ovarian cancer in women
being seen at well-‐‑adult
appointments.

USPSTF Screening Recommendations for aged ≥ 75
• Tobacco abuse: recommended (Level A)
• Alcohol misuse: recommended (Level A)
• Nutrition screening and counseling: recommended for patients with CV disease risk factors
(Level B)
Describe routine • HTN: recommended (Level A)
preventative care for • Hyperlipidemia: recommended (Level A)
women aged 75: • Aspirin for prevention of CV Disease: recommended for men ≤ 79 (Level A)
• Aspirin for prevention of ischemic stroke: recommended for women ≤ 79 (Level A)
• Diabetes: recommended for BP ≥ 135/80 (Level B)
• Obesity: recommended (Level B)
• Depression: recommended if supportive care is available (Level B)
• Falls (use of exercise, physical therapy, vitamin D supplementation if high risk, community-‐‑
dwelling): recommended (Level B)
USPSTF Screening Recommendation Against for aged ≥ 75
• Prostate Cancer (PSA)
• Cervical Cancer
• Colon Cancer if aged ≥ 85
Middle aged man presenting Screening for CV conditions: blood pressure (screen for HTN) and lipid measurement (screen for
for wellness exam. No dyslipidemia)
complaints on history and has

a normal physical exam. What
screening tests should be Screening for Cancer: Fecal occult blood testing, flexible sigmoidoscopy (w/ or w/o occult blood
considered? Recommended testing), colonoscopy or double-‐‑contrast barium enema to screen for colorectal cancer
immunizations?
Immunizations: Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap)
if he has never had one or if it has been 10+ years since his last Td vaccine; influenza vaccine
annually (in the fall/winter)

What are the components The purposes of the health-‐‑maintenance visit are to identify the individual patient’s health
of an adult health-‐‑ concerns, manage the patient’s current medical conditions, identify the patient’s risks for future
maintenance visit? health problems, perform rational and cost-‐‑effective health screening tests, and promote a healthy
lifestyle.
Screening Tests
1) CV Disease: USPSTF strongly recommends (Level A) screening of adults (aged 18+) for
HTN by measuring blood pressure. USPSTF also strongly recommends (Level A) screening
men aged 35+ and women aged 45+ for lipid disorders. USPSTF recommends (Level B)
screening adults aged 20+ who are at increased risk of CV diseases for lipid disorders. Men
aged 45-‐‑79 are recommended (Level A) to take aspirin daily to reduce risk of MI as long as
the benefit outweighs the risk of GI hemorrhage. Ultrasound to assess for abdominal aortic
aneurysm is recommended (Level B) for men 65-‐‑75 who have ever smoked
2) Cancer: Men and women aged 50+ are strongly advised (Level A) to have screening for
What are the screening colorectal cancer à fecal occult blood testing every year, sigmoidoscopy every 3-‐‑5 years,
tests and immunizations and colonoscopy every 10 years. USPSTF recommends against (Level D) routine screening
that are routinely for prostate cancer using digital examination or PSA. Men and women aged 50-‐‑80 with a
recommended for adult 30+ pack year smoking history who currently smoke or quit < 15 years ago are
men? recommended (Level B) to undergo annual low-‐‑dose CT of chest to screen for lung cancer
3) Other Health Conditions: all adults (Level B) should be screened for obesity (calculate BMI).
Screening for diabetes is recommended (Level B) for adults with HTN or with
hyperlipidemia. Screening and counseling for tobacco use is strongly recommended (Level
A). Screening and counseling for alcohol use is also recommended (Level B)


Immunizations
1) Tdap: all adults aged 19-‐‑65 should receive booster Tdap in place of a scheduled dose of Td
What are the screening 2) Influenza: routine vaccination recommended for everyone aged 6 months and older
tests and immunizations 3) Hepatitis B: for high risk individuals, such as health-‐‑care workers, those exposed to blood
that are routinely or blood products, dialysis patients, IV drug users, persons with multiple sexual partners or
recommended for adult recent STDs
men, continued 4) Hepatitis A: recommended for those with chronic liver disease, those who use clotting
factors, those who have occupation exposure to Hep A virus, those who use IV drugs, men
who have sex with men, or those who travel to countries where Hep A is endemic
5) Varicella: for those who have no reliable history of immunization or disease, those who are
seronegative on testing for varicella immunity, and for those exposed to the virus
6) Meningococcal: recommended for those in high risk groups, such as college dorm residents
or military recruits, those with certain complement deficient, those with function or
anatomical asplenia, and those who travel to countries where it is endemic
The primary diagnostic test of lung function is spirometry.
How do you diagnose
and determine the stage Normal lung function: FEV1/FVC > 0.7
of COPD in adults? COPD: FEV1 and FVC are both decreased; FEV1/FVC < 0.7
Staging: See table 2-‐‑1, page 33 of Case Files FM
• All patients should be encouraged to quit smoking à no significant improvements in lung
function have been shown to occur, but this does prevent the rate of further deterioration
• Vaccination: pneumococcal, annual influenza
How do you manage • Regular efforts + efforts to maintain normal body weight
stable COPD? • Avoid secondhand smoke, aggravating occupational exposures, and indoor/outdoor pollution
• Stage I: Short-‐‑acting bronchodilators (albuterol, ipratropium)
• Stage II: Long-‐‑acting bronchodilators (salmeterol, tiotroprium)
• Stage III: Inhaled steroids (fluticasone, triamcinolone, mometasone)
• Stage IV: Long-‐‑term oxygen therapy and consider surgical interventions

Presents with change in sputum color or amount, cough, wheezing, and increased dyspnea.

How do you manage MCC: respiratory tract infections (viral or bacterial). Also can be causes by air pollutants
acute exacerbations of
COPD? The mainstays of medical therapy are oxygen, short-‐‑acting bronchodilators, and systemic steroids
(which shorten the course of exacerbation and reduce the risk of relapse à 40 mg prednisolone for
10-‐‑14 days). Give antibiotics if appropriate. All dyspneic patients should have an assessment of
their level of oxygenation.
Much in the chest can hurt, and heart disease is actually one of the less common causes of chest
pain in the primary care setting.

1. Acute Coronary Syndrome
• Pain is due to hypoperfusion of the myocardium, usually from occlusion of a coronary
What are the various artery by thrombus formed on the disrupted endothelium of a ruptured atherosclerotic
causes of chest pain? plaque
• Unstable Angina = rest pain for > 20 minutes that is likely associated with an unstable
coronary artery occlusion and hypoperfusion
• Variant Angina is caused by spastic narrowing of otherwise normal coronary arteries
2. Stable Angina
• “Chronic effort-‐‑dependent angina”
• Caused by lack of sufficient oxygen delivery to the myocardium during exertion, most
often because of impaired blood flow past the hallmark atherosclerotic plaques of CAD
• Produced characteristic squeezing or dull “pain” of stable angina as well as characteristic
changes on EKG (b/c ischemic muscle conducts electricity differently) and wall motion
abnormalities on echocardiography (ischemic muscle does not contract normally)
3. Panic Disorder
• Mechanism of chest pain unknown


4. Gastroesophageal Reflux Disease and Esophageal Spasm
• GERD causes irritation of the esophageal mucosa
What are the various • Esophageal spasm mimics angina
causes of chest pain, • Reflux can be exacerbated by triggers that relax the lower esophageal sphincter, most
continued notably caffeine, alcohol, and fatty foods
5. Pericarditis
• Pain is worse when recumbent and relieved by sitting forward
6. Other Causes
• Musculoskeletal chest pain commonly arises from ribs or thoracic soft tissue
• Pulmonary embolism may produce pleuritic pain, but its symptoms are notoriously
variable
• Pleuritic pain can also be produced by inflammation from an infectious process or by
neoplasm
• Spontaneous pneumothorax is uncommon and is associated with vigorous exercise,
primarily in men in their 20s
• Rarely can be due to thoracic aortic dissection (almost exclusively found among
hypertensive patients; Marfan Syndrome and syphilis are very rare) à causes a tearing
pain that may be felt in the back
The most important part of the physical exam is the patient’s overall appearance. If pain is present
What is the most at the time of examination, is the patient simply describing a pain that is annoying, or is he/she
important aspect of the pale and sweaty? The patient presenting with chest pain should have vital signs assessed
physical exam when a promptly and monitored closely for changes during the evaluation.
patient presents with
chest pain? Tachycardia in particular is characteristic of panic and pulmonary embolism (the latter especially
when accompanied by tachypnea). Bradycardia, especially if new or symptomatic, may be
associated with inferior myocardial ischemia.

1) Hypotension, poor tissue perfusion, pulmonary edema, or oliguria à suggestive of decreased
What are the red flags cardiac output, possible large anterior myocardial infarction
suggesting life-‐‑ 2) Tachycardia, tachypnea, hypoxia à suggestive of pulmonary embolism
threatening disease in 3) EKG changes, especially ST Elevation or new left bundle-‐‑branch block à suggestive of MI
patients with chest pain? 4) New systolic mitral murmur à suggestive of ruptured papillary muscle
5) Arrhythmia and/or chest pain in younger patient à suggestive of cocaine abuse
6) Mediastinal widening on chest radiograph à suggestive of aortic dissection with severe tearing
or ripping pain
1) Infection of the joint à this is the first differential that needs to be excluded because
cartilage can be destroyed within the first 24 hours of an infection.
What is the differential 2) Gout à most commonly occurs in men aged 30-‐‑50 and in women aged 50-‐‑70 (increased
diagnosis for non-‐‑ female sex hormones in premenopausal women protects against gout by increasing the
traumatic joint pain? urinary excretion of uric acid)
3) Pseudogout à due to calcium pyrophosphate dehydrate crystals in the joints
4) Osteoarthritis à Most commonly in people > 65 with repetitive use, trauma, and obesity
(knee OA) à presents with dull, deep, ache-‐‑type pain
5) Rheumatoid Arthritis à usually aged 30-‐‑55. Women > men
Physical Exam à Range of motion is important to evaluate.
• A septic joint will have very limited ROM due to pain coupled with joint effusion and
What are the common fever. However, a nearby cellulitis, bursitis, or osteomyelitis (also in the differential) will
diagnostic tests used for usually maintain the ROM of a joint.
the most common causes • In OA, a bony crepitus may be felt on passive ROM
of non-‐‑traumatic joint First step in diagnostics: examination of joint aspirate
pain? 1) Septic Arthritis à aspirate will have an average of 100,000 WBC/microliter, with > 90%
neutrophils. > 90% of aspirates will have a positive culture.
2) Gout à Polarizing microscopy of joint aspirate will show monosodium urate crystals,
which look like needles and have a strong negative birefringence


3) Pseudogout à calcium pyrophosphate dehydrate (CPPD) crystals, which are rod-‐‑shaped,
What are the common rhomboid, and have a weak positive birefringence
diagnostic tests used for Imaging
the most common causes • In OA à X Rays will be normal initially, but there will be gradual development of bone
of non-‐‑traumatic joint sclerosis, subchondral cysts, and osteophytes
pain, continued Labs
• In RA à Rheumatoid Factor (+), Anti-‐‑citrullinated protein antibody (anti-‐‑CCP) (+), elevated
ESR, elevated C-‐‑Reactive Protein, Anemia, Thrombocytosis, and low Albumin
Acute Gout Attack:
• Low-‐‑dose Colchicine
What are the most • NSAIDs (avoid in elderly, heart failure patients, those with peptic ulcer disease, and those
common treatment with liver or renal disease)
options in the acute onset • Intra-‐‑articular glucocorticoids
of gout? • Ice Packs
Chronic Therapy for recurrent attacks:
• Probenecid à increases urinary excretion of uric acid
• Allopurinol à reduced production of uric acid

What are the most
common treatment • IV antimicrobials
options in the acute onset • Surgical drainage of the infected joint
of infectious arthritis?

What are the most
common treatment • Exercises to maintain joint mobility and muscle strength
options in the chronic • Disease-‐‑modifying anti-‐‑rheumatic drugs (DMARDs) à sulfasalazine, methotrexate
management of • Can also use NSAIDs, glucocorticoids, anti-‐‑cytokines, and topical analgesics
rheumatoid arthritis?
What are the most • Mobility exercises
common treatment • Maintenance of adequate ROM
options in the chronic • Weight loss, if appropriate
management of • Intra-‐‑articular corticosteroid injections for short-‐‑term relief à should only be done every 4-‐‑
osteoarthritis? 6 months to avoid cartilage destruction
• Women who intend to become pregnant should be advised to avoid, whenever possible,
potentially harmful agents such as radiation, drugs, alcohol, tobacco, OTC medications,
What are the components herbs, and other environmental agents
of preconception • Radiation exposure greater than 5 rad is associated with fetal harm à most routine X Rays
counseling? (dental, etc) only expose the fetus to a small fraction of that amount
• Recommended that all women of childbearing age should take daily folic acid supplements
and women considering conception should start a folic acid supplement at least 1 month
prior to trying to conceive à low risk women only need 400-‐‑800 micrograms of folic acid
daily to reduce the risk of neural tube defects; women who have had a previous child with
a neural tube defect should take 4 mg of folic acid daily
• Screening for genetic diseases: African and African-‐‑American women may be offered sickle
cell trait screening; French-‐‑Canadian or Ashkenazi Jewish women can be screened for Tay-‐‑
Sachs carrier status; Southeast Asian and Middle Eastern women may be screened for
thalassemia; Ashkenazi Jews and Caucasian women can be screened for cystic fibrosis
• Women aged 35+ at time of delivery should be educated about age-‐‑related risks,
particularly for Down Syndrome

• Women with multiple medical conditions (diabetes, asthma, thyroid disease, HTN, lupus,
thromboembolism, seizures) should be referred to providers with experience managing
high-‐‑risk pregnancies
• Women with psychiatric conditions à co-‐‑manage with a psychiatrist
• Screen for tobacco use and alcohol dependence
• Educate about proper nutrition and exercise during pregnancy
• Discuss social issues, such as financial readiness, social support, and domestic violence
• Ideally, the first visit should be in the first trimester. Most occur at week 8 or later
History
• Assess last menstrual period à accurate gestation dating is one of the most crucial pieces of
information needed
• Pay attention to medical history, prior pregnancies, delivery outcomes, pregnancy
complications, neonatal complications, and birth weights
• Gynecologic history should focus on menstrual history, contraceptive use, and history of
What are the components STDs
of the initial prenatal • Allergies, current medications, and substance use should be investigated
visit? • Social history: Was the pregnancy planned, unplanned? Social support? Genetic history?
Physical Exam
• Height, weight, blood pressure, thyroid, breast, general physical and pelvic examinations
• Estimation of gestational age by uterine size or fundal height measurement.
• Attempt to hear fetal heart tones by Doppler fetoscope
Labs
• Blood type
• Rh status antibody screening
• Rubella status
• HIV
• HBsAg
• RPR

• Urinalysis
• Urine culture
• Pap smear
• Cervical swab for gonorrhea and Chlamydia
What are the components • CBC
of the initial prenatal • Triple Screening (Trisomy 21, Trisomy 18, Neural Tube Defects) at 15-‐‑20 weeks gestation
visit, continued • USPSTF recommends screening for gestational diabetes (Level B) after 24 weeks gestation
à if positive, perform a 3-‐‑hour glucose tolerance test following an overnight fast by giving
the patient a 100-‐‑g glucose load and obtaining fasting, 1-‐‑hour, 2-‐‑hour, and 3-‐‑hour postload
serum glucose à 2/4 positive values = diagnosed with gestational diabetes
• At 28 weeks, perform a repeat RPR and hemoglobin/HCT
• At 28 weeks, give RhoGAM if woman is Rh-‐‑negative
• All women at 35-‐‑37 weeks gestation should be offered Group B Strep screening by
vaginorectal culture
Immunizations
• Inactivated influenza should be offered to all pregnant women during flu season à all
pregnant women should receive the influenza vaccine at their initial prenatal visit
• Tdap should be given between 27 and 36 weeks gestation of each pregnancy, regardless of
prior vaccination status
Logistical Issues
• Follow-‐‑up visits every 4 weeks until 28 weeks gestation, every 2 weeks from 28-‐‑ to 36-‐‑
weeks, and every week from 36-‐‑weeks to delivery

For women who are Rh negative, the next step is to assess the antibody screen or indirect Coombs
Describe in detail the test.
recommended actions for • If the antibody screen is negative, there is no isoimmunization, and RhoGAM is given at 28
RhoGAM treatment in weeks gestation and again at delivery if the baby is confirmed as Rh positive (RhoGAM is
pregnant women? given to prevent isoimmunization)
• If the antibody screen is positive and the identity of the antibody is confirmed as Rh (anti-‐‑
D), then assessment of its titer will assist in knowing the probability of fetal effect
• ACE-‐‑Inhibitors (Level A) à improves survival post-‐‑MI in anterior infarcts with ejection
fraction < 40%
• Emergent Reperfusion (thrombolysis or percutaneous coronary intervention) for STEMI
What is the treatment patients (Level A) à Target time to thrombolysis < 30 minutes; Target time to PCI = < 60
strategy for acute MI? minutes
• All patients with suspected acute coronary syndromes should receive aspirin, 325 mg
swallowed or chewed, immediately and then continued indefinitely
• In addition to immediate anti-‐‑platelet therapy, patients with a suspected ACS should
receive oxygen, nitroglycerine, and morphine, if necessary
• ß-‐‑blockers can improve short-‐‑term and long-‐‑term mortality in patients with ACS, and
should be administered orally within the first 24 hours of onset

What are the cholesterol Patients with CAD:
goals for a patient with • LDL < 100 mg/dL
chronic cardiac disease? • HDL > 40 mg/dL
• Non-‐‑HDL cholesterol (serum triglycerides/5 + LDL) < 130 mg/dL

Percutaneous transcutaneous coronary stenting should be considered instead of coronary artery
bypass in patients with one-‐‑, two-‐‑, or three-‐‑vessel disease who have anatomy suitable for stent
What are the common therapy and who have normal left ventricular function
reasons for heart bypass
or stent? The presence of significant left main coronary disease, multi-‐‑vessel disease not amenable to
stenting, or significant CAD in the presence of left ventricular dysfunction (ejection fraction < 50%)
indicates that coronary artery bypass graft may be beneficial.
New-‐‑Onset AF
• If patient is hemodynamically unstable (ventricular rate > 140 bpm and with acute MI, chest
pain, dyspnea, or HF) à urgent synchronized cardioversion
• If patient is hemodynamically stable (identified w/in < 48 hours of onset) à start heparin,
perform transesophageal echo (TEE) to rule out atrial thrombus, and cardioversion
• If new onset AF identified > 48 hours after onset à TEE can be performed to rule out atrial
How do you treat atrial thrombus and cardioversion; but if thrombus is present, anticoagulation with warfarin is
fibrillation? begun and cardioversion is delayed 3 weeks
• HR should be controlled with IV diltiazem or ß-‐‑blocker to maintain ventricular rate b/w 60-‐‑
80
Paroxysmal AF (self-‐‑limiting)
• Most should NOT be placed on long-‐‑term rhythm maintenance therapy
• If recurrent paroxysmal episodes occur, and if the patient has minimal heart disease, first
line therapy is flecainide propafanone, or sotalol. 2nd line therapy is amiodarone
• For patients with AF and HF à first line therapy is amiodarone
• For patients with AF and CAD à Sotalol is first line therapy
• For patients with AF, HTN, and LVH à amiodarone
• For patients with AF, HTN, and no LVH à flecainide and propafenone are first line;
Amiodarone and sotalol are 2nd line


Persistent AF
How do you treat atrial • If AF doesn’t terminate spontaneously or with initial medications à either have to accept
fibrillation, continued progression to permanent AF or attempt cardioversion to normal sinus rhythm (depends
on risk factors such as age, symptoms, and risk for thromboembolic events)
Permanent AF
• Control HR 60-‐‑80 bpm à use drugs that block the AV node à ß-‐‑blockers (first line),
nondihydropyridine calcium channel blockers, and digoxin
Thiazide Diuretics
• Hypokalemia
• Hyperuricemia
• Hyponatremia
• Erectile dysfunction

ACE Inhibitors

• Hyperkalemia
What are the side effects • Cough
of the major HTN • Angioedema
medications? • Increased serum creatinine
Calcium Channel Blockers
• Peripheral Edema (amlodipine, felodipine, nifedipine)
• Dizziness (Diltiazem, verapamil)
Angiotensin Receptor Blockers
• Hyperkalemia
• Angioedema (less than ACE-‐‑Is)
ß-‐‑Blockers

• Bradycardia

• Bronchoconstriction (with non-‐‑cardioselective ß-‐‑blockers)
• Hypertriglyceridemia
• Hyperglycemia

Loop Diuretics
What are the side effects • Hypokalemia
of the major HTN • Ototoxicity
medications, continued Aldosterone Antagonists
• Hyperkalemia
• Gynecomastia (spironolactone)
ASCVD Risk Assessment

• Blood Pressure à longitudinal studies have shown that systolic BP is a better predictor for
future morbidity and mortality, especially for middle-‐‑aged and older individuals
• Smoking status
What screening tests are • Total cholesterol and HDL cholesterol
best for heart disease in a • Diabetes status
40 year old? Recommendations for initial evaluation of hypertension (based on expert opinion)
• Look for features suggesting secondary disease, such as young age (<25), malignant course, and
lack of response to therapy.
• Ask about symptoms of end-‐‑organ disease, such as chest pain, orthopnea, paroxysmal
nocturnal dyspnea, lower extremity edema, claudication, and left ventricular hypertrophy.
• Identify other CV risk factors, such as diabetes, smoking, family history of early CAD, and
history of elevated cholesterol level
• On physical exam, check pulse (for arrhythmias), BMI (for obesity), cardiac size, rhythm, S3,
JVD, and edema (for LV hypertrophy and heart failure), carotid and peripheral pulses (for
carotid artery disease and peripheral artery disease), renal bruits (for renovascular
hypertension), fundus (for hypertensive retinopathy), and neurologic examination (for prior
cerebrovascular event)
• Labs to order: urinalysis (for hypertensive nephropathy), urine microalbumin (for
microalbuminuria à early hypertensive nephropathy), BUN/Creatinine (for renal dysfunction),
potassium and sodium levels (for aldosteronism), glucose (for diabetes), fasting lipid panel (for
hyperlipidemia), and electrocardiogram (for LV hypertrophy, prior myocardial infarction)

Patient Presentation:
• Acutely painful and swollen leg
Patient history:
• Historical elements with the greatest positive predictive values for DVT are recent surgery,
How do you manage a and immobilization for more than 3 days in the past 4 weeks
DVT? Diagnostic Tests
• Duplex venous ultrasound*
• MRI
• Helical computed tomography
• D-‐‑Dimer*
• Contrast venography (invasive, but considered the reference standard)

How do you manage a
pulmonary embolism?


What is the treatment
protocol for DVT?


What is the treatment
protocol for DVT,
continued


Heparin
• MOA: interacts with antithrombin à enhances its ability to inhibit thrombosis by
inactivating clotting factor proteases, especially thrombin (IIa), IXa, and Xa
Compare heparin, • SE: Hemorrhage, Heparin-‐‑Induced Thrombocytopenia
Coumadin, and low Coumadin (Warfarin)
molecular weight • MOA: prevents action of vitamin K epoxide reductase, which activates vitamin K à blocks
heparins (LMWH) gamma carboxylation of factors II, IV, IX, and X, and proteins C and S
• SE: bleeding, teratogenic (use LMWH when patient is pregnant)
LMWH (Enoxaparin)
• MOA: inhibits clotting factors IIa (thrombin) and Xa
• Advantages include fixed dosing, a subcutaneous route of administration (makes
outpatient treatment possible), and a more predictable anticoagulant response. Also have
better bioavailability, longer half-‐‑life, and dose-‐‑independent clearance.

Mononucleosis
• History/Physical Exam: sore throat follows a 30-‐‑50 day incubation period and a 3-‐‑5 day
prodrome characterized by fever, malaise, myalgias, and headache. Other common physical
signs include pharyngeal inflammation (85%) and transient palatal petechial (50%). Cervical
adenopathy (90% posterior cervical) and fever are present in over 99%. Typically in patients
aged 15-‐‑24 years old.
• Diagnostic Testing: Most develop lymphocytosis (95% have > 60% lymphocytes), which
peaks 2 weeks after onset of symptoms. Atypical lymphocytes are common. Monospot test
(heterophil antibodies that agglutinate sheep erythrocytes) is widely used, but it is negative
in the first week of infection. Another test identifies viral capsid antigen immunoglobulin M
Compare and contrast antibodies, which are produced early in the infection and do not persist once the acute
mononucleosis and strep infection is over.
pharyngitis: • Management: Treat symptomatically with rest, oral fluids, and NSAIDs or acetaminophen
for fever and myalgias. Aspirin should be AVOIDED because of its association with Reye
Syndrome. Corticosteroids are recommended in patients with significant pharyngeal
edema. Participation in contact sports should be limited during the acute phase and
continue to be restricted for at least 4 weeks and as long as the spleen is palpable.
GBS
• History/Physical Exam: Fever, absence of cough, tonsillar or pharyngeal exudate, cervical
adenopathy. The scarlatina rash (sandpapery) is rare, but highly specific for strep.
• Diagnostic Testing: a variety of rapid antigen tests (enzyme immunoassays, liposomal
assays, and immunochromatographic assays) and cultures are available
• Management: If there is a high probability that the patient has GBS, give them
cephalosporin for 7-‐‑10 days, penicillin VK 250 mg PO QID for 10 days, or amoxicillin 1 g
PO BID for 6 days. You can give a Dexamethasone 10 mg IM injection for severe pain and
tonsillar enlargement.


Palliative care is a cornerstone of both end-‐‑of-‐‑life care as well as chronic disease management. The
When do you use goal of palliative treatment is not just to extend life, but to maximize comfort, function, and quality
palliative care? of life. The biggest difference at the end of life is that palliative care principles become paramount,
and the prolongation of length of life becomes less important than the quality of life.
SET up the interview

• Arrange to give potentially bad test results in person
• Arrange for privacy, adequate time, and no interruptions
• Involve significant others
• Sit down, establish rapport, allow for silence/tears
• Mentally rehearse and emotionally prepare for the interview
What is Buckman’s Assess the patient’s PERCEPTION
Protocol for breaking bad • “Ask before you tell” – what does the patient know/understand
news? • Ask open-‐‑ended questions, tailor news to current understand, correct misinformation,
identify denial
Obtain the patient’s INVITATION
• Most patients, but not all, want full disclosure
• Discuss information disclosure at the time of ordering tests and before giving results
Give KNOWLEDGE (information) to the patient
• Warn the patient bad news is coming à “I’m sorry, but I have bad news” or “I’m sorry to
tell you that….”
• Target the patient’s vocabulary/comprehension
• Avoid euphemisms, technical jargon, and excess bluntness
• Ask the patient to repeat back what you’ve said
• Regardless of prognosis, identify goals – e.g., cure, pain and symptom relief, family issues


Address the patient’s EMOTIONS with empathic responses
• Physicians are generally uncomfortable with patients’ emotional reactions to bad news
What is Buckman’s • Four components of an empathic response: 1) observe the patient’s emotions 2) identify the
Protocol for breaking bad emotion to yourself 3) identify the reason for that emotion 4) let the patient know that you
news, continued have connected with that emotion
STRATEGIZE and SUMMARIZE
• A clear plan lessens the patient’s anxiety and fosters patient self-‐‑determination
• Ask if the patient is ready to discuss a plan
• Use the patient’s knowledge, expectations, and goals as a starting point; discuss fears;
gently work past denial
• Arrange follow-‐‑up meetings
Pain may be nociceptive, which presumes normally functioning pain receptors and nerves or
neuropathic, which presumes abnormal function of the peripheral or central nervous system.
In end-‐‑of-‐‑life care, when
do you advance to the Nociceptive pain responds well to opioid analgesics. Neuropathic pain often requires adjuvant
next pain medication for analgesics in addition to opioids.
appropriate pain control?
When rotating from one opiate to another, a relative dose reduction to allow for incomplete cross-‐‑
tolerance is often advisable.


Constipation remains one of the most common distressing symptoms for patients receiving
palliative care. Contributing factors include metabolic derangements from the underlying illness

itself, immobility and decreased fluid intake associated with declining functional status, and
In end-‐‑of-‐‑life care, how medical treatments (especially opioids).
do you control
constipation? When patients are treated with chronic opioids, the standard practice is to initiate regular
administration of a stimulant laxative.


In end-‐‑of-‐‑life care, how
do you control
constipation, continued


Diagnosis of depression in end-‐‑of-‐‑life care is made more difficult by the fact that many of the
How do you handle somatic symptoms of depression in physically healthy adults (sleep disturbance, loss of appetite,
depression care for and fatigue) can be caused by the underlying disease rather than depression. Therefore,
terminal patients? psychological criteria for depression (dysphoria, anhedonia, and feelings of worthlessness or guilt)
become more important in end-‐‑of-‐‑life care.
• Requires that the attending physician certifies a life expectancy of 6 months or less (Since
predicting life expectancy is an inexact science and many physicians are uncomfortable
What are the eligibility predicting a life expectancy of less than 6 months, it is better to ask, “would you be
criteria for hospice? surprised if this patient died in the next 6 months?”)
• If a patient lives beyond the 6 months while on hospice, they may remain on hospice
service as long as there is adequate documentation that they met hospice eligibility criteria
upon initiation of hospice services.
• Occurs when growth is interrupted à may be genetic, medical, nutritional, behavioral,
psychological, or environmental à whatever the underlying causes are, the immediate
cause of FTT is malnutrition
• There is no single definition, measurement, or set of criteria that best diagnoses FTT à most
clinicians will consider the diagnosis for children without weight gain in 2 months or
Failure to Thrive children who have dropped 2 percentile curves in < 6 months. However, the most common
cause of an abnormal growth curve is measurement or plotting error, so this should be
considered before other action is taken.
• History is generally the most important diagnostic tool in finding the underlying cause of
FTT.
• Hospitalization is rarely needed for a child with FTT. Hospitalization should be considered
in cases of severe malnutrition, hypothermia, bradycardia, or hypertension.
• FTT in the first year of life, particularly in the first 6 months, is more likely to affect brain
development.

• ASD refers to a continuum of disorders of brain development involving impaired
communication skills; impaired social interactions; and restricted, repetitive, or
stereotypical patterns of behavior
• Concern should be raised when a child exhibits aberrant social skills, abnormal eye contact,
Autism Spectrum aloofness, failure to orient to name, failure to use gestures to point or show, lack of
Disorder interactive play, or lack of interest in peers.
• Several screening tools include the Checklist for Autism in Toddlers (CHAT) for 18-‐‑month
olds, and the Pervasive Developmental Disorder Screening Test.
• There is no widely accepted guidelines for treatment, but there is agreement that early and
sustained intervention greatly improves outcomes.
• CP is a disorder of movement and posture caused by injury to the motor areas of the brain.
Motor abnormalities must be static, not progressive over time. Due to rapid development in
the first year of life, a definitive diagnosis cannot be made until after 1 year of age
Cerebral Palsy • CP has many etiologies, all involving injury to the developing brain.
• Abnormalities are seen in posture, oropharyngeal function (tongue thrusts, swallowing),
strabismus, increased or decreased muscle tone, abnormal evolution of primitive reflexes,
or abnormal deep tendon reflexes
• Other conditions that can occur with CP include seizures, refractive errors, hearing loss,
mental retardation, failure to thrive, and behavioral problems.
• Subtypes of CP: spastic, athetoid, ataxic, and mixed
• The prognosis for children with CP is extremely variable depending on the type and
severity of the neurologic insult.

• MR refers to cognitive ability that is markedly below average for chronological age with a
decreased ability to adapt to the environment. The diagnosis of decreased cognitive ability
must be made via standardized testing.
• Standardized testing is less predictive for young children à the term “developmental
delay” is used for children younger than 3
Mental Retardation • Mild MR: IQ 50-‐‑70.
• Moderate MR: IQ 35-‐‑49
• Severe MR: IQ 20-‐‑34.
• Profound MR: IQ < 20
• Causes: Due to near drowning in children, traumatic brain injury, CNS malignancy, lead
exposure, infection, first trimester maternal fever, intrauterine alcohol or anticonvulsant
exposure, untreated maternal phenylketonuria, metabolic diseases (i.e., hypothyroidism),
single gene mutations (i.e., fragile X syndrome, neurofibromatosis), or chromosomal
abnormalities such as Down syndrome, Klinefelter syndrome, or Prader-‐‑Willi syndrome
• ADHD is characterized by inattention, hyperactivity, academic underachievement,
behavior problems and impulsivity
• Recommended to initiate an evaluation for ADHD in all children between 6 and 12
presenting with symptoms
• Symptoms of ADHD must be present before age 7 and must be present in two or more
Attention Deficit/ settings (e.g., school and home). There must be clear impairment in functioning (social,
Hyperactivity Disorder academic, or occupational)
• Many disorders co-‐‑exist with ADHD, such as oppositional defiant disorder (35%), conduct
disorder (26%), anxiety disorders (26%), and depressive disorders (18%)
• Guidelines recommend initiating treatment with a stimulant medication (methylphenidate)
and/or behavioral therapy
• After stabilizing treatment, children with ADHD should be seen at regular intervals to
monitor continued response to therapy, behavioral goals, academic progress, and side
effects.

• Disruptive behaviors represent a spectrum from normal disobedience and risk taking to
severe conduct disorder
Disruptive Behavior • Oppositional Defiant Disorder: characterized by negativistic, defiant, and hostile behavior
towards authority figures
• Conduct Disorder: the persistent violation of the rights of others and societal, age
appropriate norms
• The most important risk factors for CD are in the domain of the family: poor family
functioning, substance abuse, psychiatric disease in a parent, marital discord, child abuse
and neglect, and poor parenting. Child abuse is the strongest and most consistent risk
factor for CD.
• The family physician should consider both alternative and comorbid disorders including
ADHD, depression, anxiety, personality disorders, learning disabilities, and substance
abuse.
• Treatment of ODD: parent training programs
• Treatment of CD: family and parenting interventions, child skill training
• LLDs very often occur with ADHD and disorders of conduct
• Disorders of expressive or receptive language require delays in these areas not due to
sensory or motor deficit or environmental deprivation. These delays must be in excess of
Language and Learning those expected by nonverbal intelligence scores (IQ)
Disorders • 75% of children with learning disabilities have social skill deficits. In the classroom, they
have less on-‐‑task behavior, more off-‐‑task behavior, more conduct disorder, more
distractibility, and more withdrawn behavior
• More than other disorders, the diagnosis of LLD requires specialized testing beyond the
scope of the family physician

• Anorexia Nervosa: patients refuse to maintain even a minimally normal body weight, have
intense fear of gaining weight or becoming fat despite being underweight, and exhibit
Eating Disorders disturbance in the perception of the shape or size of their bodies. Amenorrhea will be
present in post-‐‑menarchal women.
• Bulimia Nervosa: patients exhibit recurrent episodes of binge eating with recurrent
inappropriate compensatory behaviors to prevent weight gain (vomiting, use of laxatives,
diuretics, enemas, excessive exercise, or diet pills). To meet diagnostic criteria, binge eating
and compensatory behaviors must occur at least twice per week for at least 3 months
• Eating Disorder Not Otherwise Specified: Patient has many eating disorder symptoms but
does not meet criteria for classic AN or BN
• Binge Eating Disorder: a form of EDNOS that involves binge eating without regular
compensatory behaviors

• A patient with disordered eating may present with symptoms related to almost any organ
system. More often, presenting complaints are physical, such as abdominal pain or syncope,
or psychological, such as irritability, depression, or sleep disturbance.
• History and physical exam is the cornerstone to making the diagnosis of an eating disorder.
• Treatment: SSRIs


• Classically, severe hyperglycemia generates symptoms of fatigue, weight loss, polydipsia,
polyphagia, and polyuria.
• More subtle signs and symptoms include obesity, recurrent infections (especially yeast
What is the most common vaginitis, skin infections, and periodontal infections), slow healing wounds, neurological
initial presentation for a syndromes (especially focal limb neuropathies presenting with paresthesia, burning, and
patient with diabetes? tingling in the extremities), visual changes and blurry vision, abdominal pain from
nonalcoholic fatty liver or chronic pancreatitis, heart disease or stroke, and, in women,
menstrual irregularity and obesity, polycystic ovarian syndrome, history of gestational
diabetes, or giving birth to an infant weighing more than 9 pounds.

What are the clinical red
flags suggesting a
hyperglycemic crisis in
Type I and Type II
diabetics?


What are the diagnostic
criteria for diabetes?
What are the criteria for
diagnosing someone with
an increased risk of
diabetes?

What are the components
of the physical exam that
should be performed for
a newly diagnosed
patient with diabetes?


Treatment of Hypertension
• Maintain BP below 130/80 mmHg
• Advise patients to follow DASH diet
• If microalbuminuria is present, treat with ACE inhibitors or ARBs
Smoking Cessation

• Counseling on smoking cessation

Aspirin Therapy to Prevent Stroke
• For women with increased 10-‐‑year risk of stroke; take 81 mg aspirin daily to reduce the risk of
stroke
• For men with increased 10-‐‑year risk of CHD: take 81 mg aspirin daily to reduce risk of heart attack
Management of Dyslipidemia
What are the • Use statins to treat to LDL goal < 100 mg/dL
recommendations for the Management of Hyperglycemia
management of diabetes? • A team approach to care (e.g., provider, nurse, pharmacist, diabetes educator) improves outcomes
and patient satisfaction
• Long-‐‑term A1C below or around 7.0% lowers risk of microvascular and possibly macrovacular
complications
• Metformin is the initial drug of choice for patients who can take it
• When insulin is started, oral agents should be continued, to reduce total insulin needs and weight
gain
• Glucose self-‐‑monitoring improves overall management of hyperglycemia in patients treated with
insulin
• Monitor A1C every 6 months and more frequently if target levels have not been reached
Screening for and Management of Complications
• In patients with retinopathy, control of blood pressure and glucose, laser photocoagulation,
vitrectomy, and other interventions can help preserve sight
• Screen for nephropathy annually using spot microalbumin/creatinine ratio (<30 = normal)
• Screen annually for peripheral neuropathy
• Perform foot exam annually

Rapid-‐‑Acting Insulin à used with meals to decrease postprandial rise in blood glucose
1) Lispro Insulin (“Humalog”)
2) Insulin Aspart (“NovoLog”)
3) Insulin glulisine (“Apidra”)
Short-‐‑Acting Insulin à Regular human insulin used with meals to decrease postprandial rise in
blood glucose. Less expensive than rapid-‐‑acting insulin analogues
1) Regular Insulin (“Humalin R”; “Novolin R”)
Intermediate-‐‑Acting Insulin à used with regular insulin to manage total daily insulin
requirements. Usually administered twice daily. Infrequently used.
1) Isophane insulin suspension (NPH) (“Humulin N; Novolin N”)
2) Insulin Zinc Suspension (lente) (“Humulin L”)
Long-‐‑Acting Insulin à Used as a once daily long-‐‑acting insulin. Infrequently used.
What are the treatments 1) Extended insulin zinc suspension (ultralente) (“Humulin U”)
used in the management 2) Insulin glargine (analog) (“Lantus”)
of diabetes? 3) Insulin determir (“Levemir”)
Biguanides
1) Metformin (“Glucophage”) à watch for signs and symptoms of lactic acidosis. Renal
excretion. Start at a low dose to avoid GI side effects.
Sulfonylureas à Renal excretion
1) Glimepiride (“Amaryl”)
2) Glipizide (“Glucotrol”)
3) Glyburide (“DiaBeta”, “Micronase”, “Glynase”)
Thiazolidinediones à hepatic elimination
1) Pioglitazone (“Actos”)
2) Rosiglitazone (“Avandia”)
Other Newer Agents
1) Sitagliptin (“Januvia”) à expensive; risk of pancreatitis
2) Exenatide (“Byetta”) à very expensive; risk of pancreatitis

Starting a patient on nighttime basal insulin
1) Before initiating insulin à review behavioral management; teach or review self monitoring
blood glucose monitoring; teach adjustment of insulin dose based on SBGM results; Teach
injection technique; Review signs, symptoms, and treatment of hypoglycemia
2) Visit at which insulin is initiated à calculate initial insulin dose (initial dose = Fasting
Plasma Glucose (mg/dL)/18); review patient’s injection technique; review SBGM,
adjustment algorism and hypoglycemia instructions
3) Subsequent visits à consider non-‐‑visit review of SBGM (fax, e-‐‑mail, electronic transmission
What are the therapy from glucose meter)
guidelines for insulin? Initiating and adjusting BID Insulin
• Before starting BID regimen à discontinue sulfonylurea; continue Metformin, TZD agent;
Review SBGM, new insulin adjustment algorithm, diet and exercise plans; if not already
SBGM BID, begin BID monitoring (fasting, before evening meals)
• Starting Dose à AM: 50% of previous nighttime insulin dose; PM: 50% of previous
nighttime insulin dose
• Dose Adjustment à AM dose adjustments based on before-‐‑evening-‐‑meal SBGM readings;
PM dose adjustments based on fasting before-‐‑breakfast SBGM readings
• Dose adjustment frequency à Make dose reductions based on a reading < 70 mg/dL the very
next day; Make dose increases based on the average glucose reading from the previous 3
days every 3 days
• Dose decrease details à if any before supper plasma glucose measurement is < 70 mg/dL,
reduce the before-‐‑breakfast insulin dose by 2 units beginning the next morning; If any
fasting plasma glucose measurements is < 70 mg/dL, reduce the before-‐‑supper insulin dose
by 2 units beginning that afternoon.

What are the
recommendations for
monitoring ongoing
diabetes?

Daytime Hypoglycemia
What is the dosing • Mild hypoglycemia during the day à reduce sulfonylurea dose by 25%
adjustment strategy for • Severe hypoglycemia (requires assistance from someone else) during the dayà reduce
when a diabetic patient sulfonylurea by 50%
has daytime and Nighttime Hypoglycemia
nighttime hypoglycemia? • For any documented hypoglycemia episode at night, reduce insulin dose by 2 units, wait 1
week before any dose increases

A1c < 7%
• Self management medical nutrition therapy
• Exercise
A1c 7-‐‑8%
What is the treatment • Metformin
strategy for a patient with A1c 8-‐‑11%
diabetes? • Metformin plus one other drug:
-‐‑ If insulin deficient à add sulfonylurea (glipizide)
-‐‑ If insulin defect à add DPP-‐‑4 inhibitor (sitagliptin) and GLP-‐‑1 agonist (exenatide)
-‐‑ If insulin resistant à add TZD (pioglitazone)
A1c > 11%
• Metformin + TZD + basal insulin
• Add multi-‐‑daily insulin


Causes
• Congenital hypothyroidism is most commonly caused by endemic iodine deficiency. In
countries with sufficient iodine intake, it is usually caused by thyroid gland dysgenesis or
defective hormone synthesis.
• Acquired hypothyroidism is usually the result of autoimmune (Hashimoto’s) thyroiditis.
Other causes include surgical removal of thyroid tissue or destruction of the thyroid by
How do you diagnose radioactive iodine, other external radiation, or toxin exposure. Also caused by certain
and treat drugs, such as amiodarone and lithium. Transient hypothyroidism can be caused by
hypothyroidism? subacute or lymphocytic thyroiditis.
Signs and Symptoms
• Weakness, lethargy, cold intolerance, decreased sweating, forgetfulness, constipation,
coarse or dry skin, slow speech, eyelid edema, skin cold to touch, thick tongue, facial
edema, coarse hair, skin pallor.
• Physical exam may reveal a diffuse or nodular goiter, sluggish movements, bradycardia,
pretibial edema, facial puffiness, coarse skin, brittle nails, carpel tunnel syndrome, and
prolongation of the ankle reflex.
Diagnostic Testing
• Elevated TSH
• Low free T4
Treatment
• Hormone supplementation with levo-‐‑thyroxine à ~100 mcg/day for women, ~125 mcg/day
for men. Dosages are titrated by 25-‐‑60 mcg every 6 weeks until a euthyroid state (normal
TSH) is achieved
• Because the half-‐‑life of thyroid hormone is nearly a week, it takes 3-‐‑6 weeks after initiating
a dosage change for a steady state to be achieved.

Causes
• Grave’s Disease (60-‐‑80% of cases)
• Toxic Nodular Goiter and solitary hyper-‐‑functioning nodules
• Thyroiditis
• Excess iodine ingestion, either from diet, radiographic contrast, or medication
• Factitious hyperthyroidism (intentional or accidental ingestion of excess thyroid hormone)

Signs and Symptoms
• Tachycardia, fatigue, weight loss, goiter, tremor, apathy, atrial fibrillation, anorexia,
How do you diagnose nervousness, hyperactive reflexes, depression, increased sweating, polydipsia, heat
and treat intolerance, and increased appetite.
hyperthyroidism? • Physical exam may demonstrate weight loss, elevated systolic blood pressure, tachycardia,
pretibial edema, tremor, or proximal muscle weakness.
Diagnostic Testing
• Primarily decreased TSH
• TSH is either normal (Normal free T4 à subclinical hyperthyroidism, resolving
hyperthyroidism, medication, pregnancy, and non-‐‑thyroid illness; High free T4 à
exogenous hormone, thyroiditis, iodide exposure, extraglandular production, Grave’s
Disease, toxic multinodular goiter, toxic adenoma) or TSH is elevated (rarely) à secondary
hyperthyroidism (pituitary tumor)
Treatment
• ß-‐‑blockers resolve the adrenergic symptoms
• Antithyroid drugs (Methimazole, Propothiouracil)
• Persistent hyperthyroidism is treated with antithyroid drugs, radioactive iodine, or surgery

General ways to describe goiter:
1) Endemic vs sporadic: goiter is termed endemic if it occurs in 10% or more of the population
2) Simple vs multinodular: simple means the gland is diffusely enlarged; multinodular goiters
have multiple nodules within the gland
3) Nontoxic vs toxic: nontoxic goiter exhibits normal thyroid function, whereas toxic goiter
refers to an enlarged gland associated with either hypo-‐‑ or hyperthyroidism
History and Physical
Describe the evaluation • Most patients with goiter are asymptomatic. History should be directed towards eliciting
and management of symptoms of hypo-‐‑ or hyperthyroidism and determining the presence of risk factors for
goiter thyroid disease or malignancy (ingestion of goitrogens, pregnancy, smoking, family history
of thyroid pathology, history of neck radiation therapy, previous thyroid surgery, and
cervical adenopathy)
• Physical exam: palpation to determine size, tenderness, and presence of nodules
Labs
• Order TSH
• Thyroid ultrasound should be considered in multinodular goiter to rule out the presence of
a dominant nodule that would need further workup
Treatment
• Surgery is the treatment of choice for patients with large symptomatic goiters or those with
risk factors for thyroid cancer à total thyroidectomy is preferred over subtotal
thyroidectomy b/c it results in no risk of recurrence and has the same risk of surgical
complications

General
• Solitary thyroid nodules are frequently found incidentally. Occur in women > men.
Diagnosis
• Most common type of nodule is a colloid nodule, which has no malignant potential.
• Cysts and thyroiditis are also common.
• Colloid nodules, cysts, and thyroiditis make up 80% of nodules.
• Of the remaining 20%, 15% are benign follicular adenomas, and 5% are cancerous.
History and Physical Exam
• Factors Raising Strong Concern
-‐‑ Family history of medullary thyroid cancer or multiple endocrine neoplasia
-‐‑ Rapid growth of nodule
Describe the evaluation -‐‑ Firm or hard nodule
and management of -‐‑ Nodule fixed to adjacent structures
solitary thyroid nodules: -‐‑ Paralysis of vocal cords
-‐‑ Regional lymphadenopathy
• Factors Raising Moderate Concern
-‐‑ Male sex
-‐‑ Patient age younger than 20 or older than 65
-‐‑ Previous radiation to the head or neck
-‐‑ Nodule greater than 4 cm or partially cystic
-‐‑ Symptoms suggesting compression (dysphagia, hoarseness, dyspnea)
Labs
• TSH
• Free T4, if indicated
• Ultrasound: Doppler criteria that may indicate an increased risk of malignancy include
irregular margins, intranodular vascular spots, and microcalcifications
• Fine needle biopsy of a thyroid nodule is the most accurate and cost-‐‑effective way to
differentiate benign from malignant nodules

Treatment
• All nodules 1 cm or greater, any nodule in a patient with risk factors, or any nodule with
suspicious ultrasound characteristics should be biopsied by an experienced clinician.
• If biopsy shows benign follicular cells à no further treatment
• If malignant cells found à near-‐‑total thyroidectomy, except for medullary carcinoma,
which requires total thyroidectomy and bilateral regional lymph node resection

What are the disease risks
associated with obesity?


When advising patients
about exercise, what
types of everyday
activities can you give as
examples of “moderate
physical activity”?


What drugs can be used
for weight loss?

• Surgical procedures for weight loss should be reserved for patients in whom medical
weight loss treatment has failed, and who are suffering from complications of extreme
What are the indications obesity.
for surgery in order to • Bariatric surgery can be considered an option for patients with a BMI ≥ 40, or ≥ 35 if
help patients lose cardiovascular risk factors are present.
weight? • Gastric bypass has been shown to be more effective than gastric banding for weight loss
and requires fewer surgeries for revision, but has more side effects.
• High-‐‑fat foods do not necessarily help an underweight person gain weight because they
What are some cause the person to feel full for long periods and therefore can act as an appetite
considerations for suppressant
management of • Snacks or small frequent meals may help and should be taken at least two hours before the
underweight patients? next meal
• Adding calories without adding volume to liquids consumed may be effective (e.g., adding
powdered milk to regular milk to increase protein calories)

• Age < 2 years
• Male
What are the risk factors • Genetic predisposition
for the development of • Previous episode(s) of otitis media
acute otitis media? • Cigarette smoking in household
• Attendance at day care
• Recent upper respiratory infection

• Decreased hearing
• Pain that is unaffected by movement of the outer ear (otitis externa causes pain with
What are the clinical external ear movement)
findings in a patient with • Associated systemic signs of infection such as fever or malaise
acute otitis media vs • Otitis media generally causes a dulling of sound, but hearing is still present. Complete
acute otitis externa? hearing loss is more common with auditory canal occlusion (foreign body, cerumen) and
sometimes with otitis externa
• A mobile TM suggests that no fluid is present in the middle ear and that the diagnosis of
otitis media cannot be made.
• With examination of the tympanic membrane for acute otitis media, the most useful
positive findings include a bulging or cloudy TM (due to effusion), bulging of the TM, and
a loss of TM mobility


First Line
• Amoxicillin: 80 mg/kg split at least BID X at least 5 days
• SMX-‐‑TMP: 40 mg/kg SMX and 8 mg/kg TMP divided BID X 10 days à avoid in patients
What is the treatment with Sulfa allergy, G6PD deficiency; light sensitivity possible
strategy for acute otitis Second Line
media? • Ceftriaxone: 50 mg/kg up to 1 g
• Amoxicillin-‐‑clavulanate: 20-‐‑45 mg/day of amoxicillin component in 2 or 3 doses
• Azithromycin: 30 mg/kg as a single dose OR 10 mg/kg QD x 3 days OR 10 mg/kg X 1 day
then 5 mg/kg on days 2-‐‑5
Prophylaxis for recurrent AOM
• Amoxicillin: half daily dosage at bedtime
• SMX-‐‑TMP: 40 mg/kg SMX and 8 mg/kg TMP QHS

What is the treatment 1) Neomycin Solutions: 3-‐‑4 drops QID X 7 days à Adverse effects include rupture of
strategy for acute otitis tympanic membrane, potential ototoxity with ruptured TM
externa? 2) Ofloxacin Solutions: for children 1-‐‑12 years, use 5 drops BID X 10 days; for patients ≥12
years old, use 10 drops BID X 10 days
Swimmers ear is a form of recurrent or chronic otitis externa caused by chronic irritant fluid
accumulation in the acoustic canal, such as can occur in competitive swimmers. Often, this is more
What is the pathogenesis of inflammatory etiology than infective
of “swimmers ear”? What
is the treatment strategy? The use of topical astringent drops, such as acetic acid, sometimes combined with topical steroids
such as hydrocortisone are effective along with efforts to clear water from the canal when drying
off.


Type of Primary Clinical Presentation Key Labs and Prognosis
Dementia Anatomic Radiological
Location Findings
Normal Aging None Occasionally forgetful of names Mild generalized Good
cortical atrophy,
nonspecific white
matter changes
Mild Cognitive Medial Impaired short-‐‑term memory for events Variable medial Increased risk of
Impairment Temporal temporal lobe Alzheimer’s
atrophy
What are the common Delirium Cortical/ Often toxic/ metabolic/ infectious EEG slowing, Depends on
diagnoses among older Subcortical etiology; Impaired attention, may be evidence of drug or etiology and
persons with cognitive fidgety and tremulous, or metabolic toxicity, severity
apathetic/obtunded signs of infection
complaints? What are the Alzheimer Cortical Gradually progressive short-‐‑term Medial temporal Course 4-‐‑20 years
clinical and lab findings? Disease (temporal memory and other cognitive deficits; and parietal lobe (average 8 years)
Prognosis? and parietal) Generally normal neurological exam atrophy
(may be apraxic)
Vascular Cortical Often a history of multiple stroke-‐‑like
Evidence of Course static or
Dementia and/or events and/or vascular risk factors; significant progressive (often
subcortical Variable physical exam cerebrovascular coexists with AD)
disease
Frontotemporal Cortical Typically presents with change in Imaging may show Variable,
Dementia (frontal and behavior/personality/ language; variable severe atrophy in progressive,
temporal) physical exam findings frontal/temporal speech/swallowing
difficulties
Lewy Body Cortical and Fluctuating attention, visual No specific brain Variable, may see
Dementia subcortical hallucinations, parkinsonian motor imaging features rapid functional
signs, sleep disturbance; limb rigidity, decline
bradykinesia, may see intention tremor
and gait disturbance
Parkinson Subcortical Parkinson disease with later-‐‑onset No specific brain Variable, have
Dementia cognitive dysfunction; limb rigidity, imaging features severe motor
bradykinesia, resting tremor, gait disability when

disturbance dementia occurs

• The earliest symptoms in AD are difficulty with higher cognitive functions such as
What is the initial memory, language, problem solving, and reasoning
presentation for a patient • Memory loss is usually prominent early in the disease and typically progresses over time
with Alzheimer’s • Also, patients with early AD are often disproportionately impaired in category fluency
Disease? (e.g., naming as many animals as they can in a minute) compared with letter fluency (e.g.
naming words that begin with F)
• MCI is present when cognitive function is impaired more than one would expect based on
What are the findings in the individual’s age and education level, but is not severe enough to interfere with activities
a patient with mild of daily living
cognitive impairment? • Subtypes
-‐‑ Amnestic MCI: patient has isolated memory loss; high risk of progression to AD
-‐‑ Nonamnestic MCI: patient has impairment in other areas than memory
Mini-‐‑Cog
• 3-‐‑minute instrument to screen for cognitive impairment in older adults
• Uses a 3-‐‑item recall test for memory and a simply scored clock-‐‑drawing test (which serves
as an “informative distractor”)
Which cognitive • Give the patient 3 unrelated words to remember and make sure they repeat them back to
screening tests are you à Ask the patient to draw a clock face placing all of the numbers and hands in the
recommended for use in correct position à Ask the patient to recall the items
primary care? • Scoring: 1 point for each word remembered, 2 points for a normal clock drawing
• Sensitivity = 76% (Mini Mental Status Exam has Sn = 79%)
• Specificity = 89% (MMSE has Sp = 88%)
AD-‐‑8
• 8-‐‑question, rapid screening test for cognitive impairment that is administered to a family
member. Monitors changes in mental status observed by family.
• Sensitivity > 84%; Specificity >80%; PPV > 85%

What is the primary care
approach to the detection
and subsequent
evaluation of dementia?

What are the strategies
for the prevention of
dementia?


Mild Cognitive Impairment
• Cognitive enhancers (donepezil, memantine) (Level B)
Dementia: Cognitive Symptoms
• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine, memantine) (Level A)
What are the key • Cognitive training (Level B)
treatment strategies for • Physical Activity (Level B)
the common symptoms in Caregiver stress, burden, and depression
patients with dementia • Caregiver support group programs and educational programs; sue of respite services (level
and related disorders? A)
Depression in people with dementia
• SSRIs (sertraline, citalopram) (Level A)
• Physical activity/exercise (Level B)
Agitation, aggression, and delusions in people with dementia
• Caregiver training in dementia management skills (Level A)
• Antipsychotic drugs (Level A)
• Anticonvulsants (Carbamazepine, Valproic Acid) (Level B)
• Cognitive Enhancers (donepezil, memantine) (Level A)
• Environmental modification (music reduces agitation, aggression, and mood disturbance)
(Level B)
Physical Activity (Level A)

What is the • Cyclic mastalgia (bilateral pain varying in intensity throughout the menstrual cycle with
pathophysiology of cyclic the premenstrual time often the most painful) is thought to be hormonally mediated.
and non-‐‑cyclic breast However, studies investigating circulating levels of progesterone, estrogen, prolactin, and
pain? quantity/sensitivity of hormone receptors have yielded conflicting results.
• Noncyclic mastalgia (usually unilateral) typically occurs in women over the age of 40.

Cyclic
• Patients usually < 40 YO
• Most severe premenstrually and subsides during menses
Compare the clinical • Usually bilateral, in the upper outer breast quadrants, and a/w nodularity
presentations for cyclic • Described as dull, aching, or heavy
and noncyclic breast Noncyclic
pain: • Patients usually > 40 YO
• No temporal relationship to the menstrual cycle
• Usually unilateral
• Often described as sharp, burning, or drawing
• More commonly located in the subareolar or medial portion of the breast
Cyclic
• Proper-‐‑fitting brassiere
What are the treatment • Evening primrose oil (1 gram every 8 hours) (Level B)
strategies for cyclic and • Topical NSAID (50 mg diclofenac gel every 8 hours) (Level A)
noncyclic breast pain? • Danazol (50-‐‑100 mg every 12 hours) (Level A)
• Bromocriptine (1.25-‐‑2.5 mg orally at bedtime) (level B)
• Tamoxifen (short-‐‑term use only) (10 mg orally per day) (Level A)
• Goserelin (3.6 mg subcutaneous per month) (Level B)
Noncyclic
• Topical NSAID (50 mg diclofenac gel every 8 hours) (Level A)
• Evening primrose oil (1 gram every 8 hours) (Level B)

What is the clinical
algorithm for
management of nipple
discharge?


What are the key
elements of the history
and physical exam for
nipple discharge?

Physiologic breast secretions
• Related to hormonal influences (i.e. prolactin) on breast tissue and are typically bilateral, involve
multiple ducts, and require some form of manipulation to be expressed
What are the
• Galactorrhea (milky discharge) is most common
pathophysiologic causes
• Precipitators include nipple stimulation, sexual orgasm, sleep, exercise, and food ingestion
of nipple discharge? Pathologic breast secretions
• Pathologic reasons for increases in prolactin include hypothalamic lesions, pituitary tumors, chest wall
trauma, hypothyroidism, renal failure (decreased prolactin clearance), and anovulatory syndromes, such
as polycystic ovaries.
• Pathologic discharge can originate either from the nipple and areola region or from a breast duct.
• Eczema, nipple adenoma, and Paget disease can cause erythema and ulceration of the nipple skin, with
an associated bloody discharge
• Ductal diseases associated with nipple discharge are duct ectasia (periductal mastitis), duct papilloma,
and early ductal carcinoma
• Infection and abscess can lead to a purulent discharge

What are the red flags
suggestive of breast
cancer?

What are the key element
of the history and
physical exam when a
woman has a palpable
breast mass?


What is the algorithm for
the management of a
palpable breast mass?


What is the timeframe for • The ovum is only able to be fertilized for 12-‐‑24 hours after ovulation
egg fertilization • Sperm remain viable for 3 days after intercourse
following ovulation? • The most fertile period for women is the several days before ovulation and ends 24 hours
How long can sperm after ovulation
remain viable in a • After the egg is fertilized, it is transported to the uterine cavity in about 2-‐‑3 days
woman’s body? • Implantation occurs approximatly 6-‐‑7 days after fertilization following cell division that
forms a blastocyst
Description
• Contains two hormones: an estrogen and a progestin
-‐‑ In most, the estrogen is ethinyl estradiol 20-‐‑35 mg

-‐‑ Progestins vary by selectivity à there are 9 progestins used
For combined oral
• OCs are described as monophasic (same dose of estrogen and progestin in each pill) or multiphasic
hormonal contraceptives (amounts of hormones in tablets can vary across the cycle/month)
(“The Pill”), describe the MOA
components, mechanism • Primary MOA: suppression of ovulation
of action, efficacy, • Additional contraceptive actions are due to progestins à creation of a thickened cervical mucus that
benefits, and side effects: blocks sperm from the uterus, inhibition of capacitation (ability of the sperm to fertilize an egg),
interference with transport of the egg and sperm, and endometrial changes that interfere with

implantation
Efficacy
• All OCs are equally effective (99% effective when used properly)
Benefits
• Protection against ovarian, endometrial, and colorectal cancer, benign breast tumors, ovarian cysts,
dysmenorrhea, and blood loss
• Reduces acne
• Suppressed endometriosis
• Treats hot flashes
Side Effects
• Amenorrhea, spotting and breakthrough bleeding, nausea, acne, breast pain/tenderness, increased
vaginal discharge, melisma, decreased libido, Venous thromboembolism, risk of MI or stroke (<2
events/100,000 women years), Hyperkalemia, Benign hepatic tumor

What are the
contraindications and
potential risks of using
combined OCPs?

Describe the mechanism, • Ortho Evra is a thin transdermal patch that contains ethinyl estradiol and norelgestromin
use, benefits, and side • Inhibition of ovulation is the primary mechanism of action
effects of the transdermal • It is believed to have similar efficacy, health benefits, health risks, and drug interactions as
patch for contraception the OCP, although patches may be less effective for women who weigh more than 198
(Ortho Evra): pounds
• Use: the patch should be applied once a week for 3 weeks, followed by a patch-‐‑free week.
The patch should be applied to clean dry skin of the upper outer arms, abdomen, buttocks,
or the torso (except the breasts). When a patch is removed, the new patch should be applied
to a different area of the body.

• NuvaRing is a soft, flexible and transparent ring that releases ethinyl estradiol and
Describe the mechanism, etonogestrel (active metabolite of desogestrel)
use, benefits, and side • The efficacy, drug interactions, side effects, and risks/benefits are thought to be similar to
effects of the vaginal ring the OCP
for contraception • Important to remember that the vaginal ring should be kept refrigdrated until use
(NuvaRing) • Use: the vaginal ring should be compressed and inserted high into the vagina (exact
placement not necessary). One ring is left in the vagina for 3 weeks. It is NOT removed for
sexual intercourse. At the end of 3 weeks, it is removed and there is a ring-‐‑free week.
• Use of a backup method of contraception is necessary for the first 7 days the ring is inserted
unless the woman has switched from another hormonal method of contraception.
Description
• There are 3 progestin-‐‑only contraceptives: the progestin-‐‑only pill (POP, also known as the
minipill), DMPA medroxyprogesterone injections, and subdermal implants (Implanon)
For Progestin-‐‑only MOA
Contraceptives, describe • Must take POP at the same time every day in order to produced a thickened cervical mucus
the components, • DMPA is a long-‐‑acting contraceptive administered via injection every 3 months
mechanism of action, • Implanon is a single contraceptive rod that is inserted subdermally in the groove b/w the biceps
efficacy, benefits, and and triceps in the non-‐‑dominant arm. It provides continuous contraception for 3 years.
Efficacy
side effects:
• > 99% effective if used properly

Benefits
• The progestin-‐‑only contraceptives have the advantage of eliminating exposure to estrogen
making these methods useful for women who have contraindications to the use of estrogen.
They are also more suitable for women who want to breastfeed as they do not impair lactation.
• Protection against ovarian and endometrial cancer and PID
• Reduced risk of PID and VTE vs estrogen-‐‑containing OCPs
Side Effects
• Menstrual changes (unpredictable, frequent or prolonged bleeding) and amenorrhea
• Narrow margin for error for contraceptive efficacy (late or missed pills)

What are the
progestin-‐‑only
contraceptives?

Description
For Hormonal Emergency • Available over the counter for women aged 17+; prescription needed for ≤ 16 YO
Contraceptives (Plan B), • Used after intercourse to prevent pregnancy
describe the components, • There are two commonly used ECs: 1) levonorgestrel 2) OCs containing ethinyl estradiol plus
mechanism of action, either levonorgestrel or norgestrel
efficacy, benefits, and MOA
side effects: • Inhibits the mid-‐‑cycle LH surge and thus ovulation
• If given at least 2 days prior to ovulation, prevention or delay of ovulation occurs
• If ovulation occurs, the contraceptive action is prevention of fertilization
• The EC does NOT impair the development of an embryo or disrupt an already established
pregnancy
Efficacy
• Efficacy is highly dependent on timing
• 0.5% pregnancy rate if taken within 12 hours but 4.1% if taken 61-‐‑72 hours after unprotected sex
SEs
• Nausea, vomiting

Compare and contrast the
progestin-‐‑only
contraceptive options:

Description
• There are two types of IUDs: the Copper T-‐‑380A and the levonorgestrel intrauterine system
MOA
• Action is to prevent fertilization of the egg
For Intrauterine Devices • The TCu380A alters tubal and uterine fluids thus impairing sperm function and preventing
(IUDs) describe the fertilization
components, mechanism • The LNG-‐‑IUS has several actions including thickening of cervical mucus, inhibiting sperm
of action, insertion capacitation and survival, and suppression of the endometrium
techniques, efficacy, • IUDs are NOT abortifacients
benefits, and side effects: Efficacy
• Highly effective with very low failure rates


Insertion
For Intrauterine Devices • IUDs should be inserted slowly and gently
(IUDs) describe the • IUDs can be placed at any time during the menstrual cycle, provided the woman is reasonably
components, mechanism certain she is not pregnant, as well as immediately following childbirth (within 10 minutes of
of action, insertion expulsion of the placenta), 4-‐‑6 weeks postpartum in a woman who is breastfeeding and has no
techniques, efficacy, menses, and immediately after or up to 3 weeks after a first trimester abortion
benefits, and side effects, Benefits
continued • Protection against endometrial cancer
• Decreased menstrual blood loss and pain
SEs
• Menstrual cramping and increased or irregular bleeding

What are the
IUDs?


Description
• The diaphragm is a dome-‐‑shaped reusable barrier contraceptive made of latex
MOA
• Physical barrier covering the cervix with or without spermicide
Efficacy
For contraceptive • 94% effective if used correctly
diaphragms describe the Fitting and Insertion
components, mechanism • 3 basic types: arcing, coil, and flat spring à most use the arcing rim style
of action, insertion • Spermicide is applied to the diaphragm so that the cup holding the spermicide faces the
techniques, efficacy, cervix
benefits, and side effects: • Inserted by pinching the sides together and gently inserting it into the vagina with a small
amount of lubricant on the leading edge. Once inserted, it should cover the cervix and fit
snugly but comfortably in place
Benefits
• Protection against some STIs
• Reduced cervical cancer risk
• Reversible and inexpensive
SEs
• Vaginal and UTI risk
• Toxic Shock Syndrome risk
• Latex allergies
• Cervical irritation

What are the
diaphragms?

Description
• The contraceptive sponge is a soft, one-‐‑size polyurethane foam device containing the
For contraceptive spermicide nonoxynol-‐‑9 à single use
sponges, describe the MOA
components, mechanism • Spermicide + sponge absorption of sperm + physical blocking of sperm
of action, efficacy, Efficacy
benefits, and side effects: • More effective for women who have never had a child (16% failure rate for nulliparous
women vs 32% for parous)
Benefits
• Possible protection against some STI
• Low-‐‑cost
• Non-‐‑prescription
SEs
• Difficulty with removal
• Increased vaginal infection and UTI and toxic shock risk (if used while menstruating)

MOA
For spermicide, describe • Contains the agent nonoxynol-‐‑9, which is a surfactant that destroys the sperm cell
the components, membrane
mechanism of action, Efficacy
efficacy, benefits, and • Although not highly effective, efficacy is dependent on use of an adequate amount of
side effects: spermicide
Benefits
• Ease of use
• Non-‐‑prescription
• Low cost
• Lubrication
SEs
• Skin, vaginal, or penile allergy or sensitivity
• Messy
• May cause skin irritation or tiny abrasions (increases risk of STI)
What are the
spermicide and latex
male condoms?


What labs should be • Recommended lab tests are hemoglobin or hematocrit and blood typing
ordered prior to a medical • Anti-‐‑D immune globulin should be administered if indicated
abortion? • Confirmation of pregnancy by ultrasound or pregnancy testing is necessary
• Follow up in 1-‐‑2 weeks

Compare and contrast the
different medical
abortion regimens:


• Most UTIs are caused by bacteria that normally inhabit the colon à 80 to 90% of
community-‐‑acquired UTIs in adults and children are from E. coli
What is the most common • Other gram-‐‑negative organisms (Proteus species, Klebsiella pneumoniae, and Pseudomonas
pathophysiology of a aeruginosa) cause infections but are much less common except among people who are
UTI? hospitalized, live in long-‐‑term care facilities, are immunocompromised, or have undergone
recent genitourinary catheterization or instrumentation
• The usual route of infection involves bacteria invading the bladder by ascending from the
perineum and passing through the urethra

What is the differential
diagnosis for dysuria in
an otherwise healthy
woman of reproductive
age and in older women?


What are the risk factors
for acute pyelonephritis
in healthy women?

What are the red flags for
a complicated urinary
tract infection?


History
• Patients with UTIs typically have urinary frequency, nocturia, pain on urination, and
Describe the history and suprapubic discomfort
physical exam for a • Malodorous urine and cloudy urine color both increase the likelihood of a UTI
patient presenting with • Chills, rigors, fever, nausea, vomiting, and flank pain are all specific for pyelonephritis
dysuria: Physical Exam
• Need to obtain vital signs, palpate the mid and lower abdomen, and percuss the flanks of
the patient
• Tenderness over a flank or in the mid abdomen suggest upper tract disease
• In men, the penis should be gently milked to elicit a urethral discharge, and a rectal exam
performed to feel for a tender or boggy prostate, which suggest urethritis and prostatitis,
respectively
• In women who report vaginal discharge or irritation, perform a vaginal exam
Dry Reagent Test Strip (Dipstick)
• Detects blood, nitrite, and leukocyte esterase
Describe urinalysis for a -‐‑ Blood is detected using the peroxidase-‐‑like activity of hemoglobin in th eurine
patient presenting with -‐‑ The leukocyte esterase test detects the presence of an esterase from WBCs and is
dysuria: positive in 75% of UTIs à sensitivity (0.87) > specificity (0.36)
-‐‑ Nitrite is found in the urine when dietary nitrates are excreted in the urine and
converted to nitrite by bacteria à this test is not very sensitive (0.53), but it is very
specific (0.88)
Sediment Microscopy
• Used to look for white cells, red cells, bacteria, and white cell casts
-‐‑ There is disagreement about how many WBCs need to be identified in order to
diagnose UTI
-‐‑ However, the presence of bacteria is highly suggestive of UTI à Sn = 0.95, Sp = 0.85

Algorithm for the
management of dysuria


What interventions are
recommended for
management of
uncomplicated lower
UTIs, uncomplicated
upper UTIs, and in the
prevention of UTIs?


What is the initial drug
therapy strategy for lower
UTIs?


What is the initial drug
therapy strategy for
upper UTIs?

• A more extensive evaluation is warranted in men with dysuria because they are more likely to have
a complicated infection
What is the treatment • As with women, men should be identified as having either an upper tract or a lower tract infection
strategy when an adult • Other causes of dysuria, including prostatitis and urethritis need to be excluded
• Initial treatment for men with suspected lower UTI = fluoroquinolone
man presents with
• Treatment for men with pyelonephritis = fluoroquinolone for 14-‐‑21 days
dysuria?
• After a 2nd lower UTI or a 1st episode of pyelonephritis, adult male patients should undergo imaging
to identify an anatomic abnormality or nephrolithiasis à ultrasonography and plain abdominal
radiograph appear comparable to IV pyelogram as the initial imaging study.

Epidemiology
• Seen more often in minority populations and in women, especially young women (< 24 YO)
Clinical Evaluation
• Women can prevent with mucoid vaginal discharge without odor, abnormal menstrual bleeding,
and lower abdominal pain.

-‐‑ Physical findings include cervicitis with yellow or cloudy mucoid discharge from the cervical

os.
-‐‑ The cervix is often friable (tends to bleed easily) when touched with a swab or spatula
• Men most commonly present with urethritis with associated dysuria, perimeatal tingling, and a
clear-‐‑to-‐‑white urethral discharge
Chlamydia Diagnostic Testing
• Wet mount and the amine test (significant odor release with addition of potassium hydroxide to
vaginal secretions) on vaginal discharge helps differentiate chlamydia infection from other
infections such as UTI, bacterial vaginosis, and trichomoiasis
-‐‑ In the wet mount, the presence of > 10 WBCs per high-‐‑power field is a predictor of
endocervical infection
• C. trachomatis infections can be detected using culture of epithelial cells (b/c it is obligate

intracellular) and non-‐‑culture techniques.

• Culture is the gold standard. The Nucleic Acid Amplification Tests (NAAT) have replaced the
chlamydia culture recently.
Treatment
• For men and non-‐‑pregnant women:
-‐‑ Azithromycin 1 g orally single dose
-‐‑ Doxycycline 100 mg orally 2x/day for 7 days
-‐‑ Alternatively, could use Erythromycin (500 mg orally 4x/day for 7 days), Erythromycin
Ethylsuccinate (800 mg orally 4x/day for 7 days), Ofloxacin (300 mg orally 2x/day for 7 days),
or Levofloxacin (500 mg orally once/day for 7 days)
• For pregnant women:
-‐‑ Azithromycin 1 g orally single dose


-‐‑ Alternatively, could use Amoxicillin (500 mg 3x/day for 7 days), Erythromycin (500 mg
4x/day for 7 days or 250 mg 4x/day for 14 days), or EES (800 mg 4x/day for 7 days or 400 mg
4x/day for 14 days)
Follow-‐‑Up
• CDC does NOT recommend testing for cure of chlamydia after completion of the antibiotics, except:

-‐‑ In those with persistent or recurring symptoms

-‐‑ In non-‐‑adherent patients
Chlamydia, continued -‐‑ In patients treated with an alternative regiment
-‐‑ In pregnant women
• The majority of post-‐‑treatment infections result from reinfection because the patient’s sex partners
were not treated or the patient resumed sex with a new infected partner.
• Recommended to rescreen patients 3-‐‑4 months after completion of antibiotics
Screening and Prevention
• Behavioral changes recommended: delaying the age of first intercourse, reducing the number of
sexual partners, using barrier contraception
• Annual screening of sexually active women ≤ 25 YO and sexually active older women with risk
factors
• All pregnant women at risk (including those ≤ 25 YO) should be screened at the first prenatal visit
and again during the 3rd trimester
• Routine screening of men is appropriate in settings of high prevalence, such as correctional facilities
and STD clinics
Chlamydia Infections in Children
• Consider chlamydia in all children ≤ 30 days old who have conjunctivitis à present within 5-‐‑12
days of birth with swelling and mucopurulent drainage of one or both eyes
• Treatment for ophthalmia neonatorum: Erythromycin base or ethylsuccinate 50 mg/kg/day orally,
divided into 4 doses per day, for 14 days
• Chlamydia pneuomia can develop: staccato cough usually with no wheezing and no temperature
elevation
Complications
• PID in 20-‐‑40% of untreated women
• Chronic prostatitis & Reiter Syndrome (reactive arthritis, urethritis, conjunctivitis)

Epidemiology
• 2nd most common reportable bacterial STI in the US
• Gram-‐‑negative, intracellular diplococcus
• Highest reported rates are seen among adolescents and young adults (women aged 15-‐‑19
and men aged 20-‐‑24), minorities (20 times greater frequency in blacks than whites), MSM,
and people in southeastern USA
• Acquired both sexually and vertically
Clinical Symptoms
• Incubation period = 2-‐‑6 days
• Often asymptomatic
• Symptomatic infection presents as vaginal pruritus, postcoital bleeding, deep dyspareunia,
Gonorrhea and/or odorless mucopurulent discharge.
• One exam, the cervix may be friable with mucuopurulent d/c from the cervical os
• Men: urethritis with dysuria and yellowish penile d/c
• Penis may be erythematous with a purulent d/c at the meatus
Diagnostic Testing
• As for chlamydia, NAAT testing has replaced culture
• NAAT is not approved for use of testing female urine, because female urine has high levels
of inhibitory substances that can impair test performance
Treatment
• Cephalosporins: single dose 125 mg ceftriaxone, or single dose 400 mg cefixime
• Because dual infection with chlamydia is common (10-‐‑30%), you should treat for both
chlamydia and gonorrhea


Follow-‐‑Up
• Patients treated for uncomplicated gonococcal infection do not require a test of cure
• If symptoms persist or recur shortly after treatment, a test of cure is indicated by culture to
verify susceptibility and direct retreatment
• Pregnant women: test for cure after 3 weeks following treatment
• Rescreening should be performed within 3 months of treatment for all patients
Gonorrhea, continued Screening
• Routine annual screening is recommended for all sexually active women ≤ 25 YO or for
older women at increased risk of infection
• All pregnant women should be routinely screened at the first prenatal visit. If there are risk
factors, rescreening is advised in the 3rd trimester
Gonorrhea in Children
• Presents within 3-‐‑5 days of delivery with ophthalmia neonatorum and sepsis. Other, less
severe, manifestations include rhinitis, vaginitis, urethritis, and infection at the site of fetal
monitoring
Complications
• If untreated in pregnancy, risk of pre-‐‑term rupture of membranes, preterm labor,
chorioamnionitis, and postpartum endomyometritis
• PID in 10-‐‑40%
• Disseminated gonococcal infection is a rare complication à septic emboli à polyarticular
tenosynovitis and dermatitis


Definition
• An acute infection in woman of any or all of her upper genital tract structures (i.e., uterus,
fallopian tubes, and ovaries)
• Initiated by the ascent of a sexually transmitted agent from the endocervix to the upper genital
structures
• MCC: N gonorrhoeae and C trachomatis
• However, up to 70% are nongonococcal and non-‐‑chlamydial à other microorganisms include
Mycoplasma hominis, Streptococcus sp., Staphylococcus sp., Haemophilus sp., Escherichia coli,
Bacteroides sp., Peptostreptococcus sp., Peptococcus sp., Clostridium sp., and Actinomyces sp.

Clinical Evaluation
Pelvic Inflammatory
• No set of signs and symptoms is pathognomonic
Disease
• May present with recent onset of lower abdominal pain that worsens during coitus or with
jarring movement
• Other symptoms include fever, malaise, vaginal discharge, irregular bleeding, nausea, and
vomiting
• Symptoms usually develop during menses or during first 2 weeks of menstrual cycle
Diagnostic Testing
• PID is a clinical diagnosis. Most lab tests are nonspecific
• Begin evaluation for women with suspected PID with a pregnancy test to rule out ectopic
pregnancy or intrauterine pregnancy complications.
• Other recommended tests include:
-‐‑ Gonorrhea and chlamydia
-‐‑ Microscopic exam of vaginal discharge
-‐‑ Complete blood counts (< ½ will have leukocytosis)
-‐‑ Urinalysis
-‐‑ ESR or CRP
Treatment
• If patients with PID meet hospitalization criteria and parenteral antibiotic therapy is indicated
à use cefotetan or cefoxitin plus doxyclycline

Background
• Most common viral STI in the United States
• Types 6 and 11 (low risk) are associated with common venereal warts and recurrent respiratory
papillomatosis
• Types 16, 18, 31, 32, and 35 (high risk) cause low-‐‑ and high-‐‑grade cervical dysplasias and
anogenital cancers
Clinical Evaluation
• Majority are asymptomatic
• Most common clinical manifestation is genital warts, which may appear as single or multiple

papules on the vulva, cervix, vagina, perineum, penis, scrotum, or perianal region

• May also manifest as recurrent respiratory papillomatosis and cancers

Diagnostic Testing

• Definitive diagnosis is based on detection of viral nucleic acid (DNA or RNA) or capsid protein
Human Papillomavirus
• Cervical HPV can be diagnosed by Pap smear, which correlates well with the presence of HPV
DNA by polymerase chain reaction
• DNA probe can be used for viral typing in order to determine if it is a high-‐‑risk or low-‐‑risk
subtype
Treatment for external HPV
• Treatment is not recommended for subclinical genital HPV b/c there is no cure
• Patient applied treatment
-‐‑ Podofilox 0.5% solution or gel applied twice daily for 3 days followed by 4 days of no
therapy. May repeat this cycle 4 total times
-‐‑ Imiquimod 5% cream applied once daily at bedtime, 3 times per week, for up to 16 weeks
• Provider administrated treatment
-‐‑ Cryotherapy with liquid nitrogen or cryotherapy
-‐‑ Podophyllin resin 10%-‐‑25% in a compound tincture of benzoin
-‐‑ Trichloracetic acid or bichloracetic acid 80-‐‑90%
-‐‑ Surgical removal or laser surgery
-‐‑ Intralesional interferon

Background
• Caused by Herpes Simplex Virus (HSV-‐‑1 and HSV-‐‑2_
Clinical Evaluation
• First-‐‑episode primary infection (new infection)
-‐‑ Usually causes significant symptoms including a prodrome of fever, malaise,
headache, myalgia, and genital paresthesias before the breakout of cutaneous lesions
-‐‑ Multiple, painful vesicles develop 1-‐‑3 days after the prodrome which later ulcerate
-‐‑ Often there is painful inguinal lymphadenopathy
-‐‑ Patients are most infectious during this early phase of prodromal symptoms or open
ulcers
• First-‐‑episode non-‐‑primary infection (unrecognized HSV)
Genital Herpes -‐‑ Tends to be less severe with fewer lesions, faster healing, and a shorter period of viral
shedding
• Recurrent Episodes
-‐‑ Usually a prodrome of tingling, pruritis, or dysethesias before the outbreak of genital
lesions
-‐‑ Lesions normally erupt in the same site as the primary episode and crust over in 4-‐‑5
days
Diagnostic Testing
• Isolation of HSV in cell culture is the preferred virologic test for patients who seek medical
treatment for genital ulcers or other mucocutaneous lesions à culture needs to be
performed within the first few days of a breakout
• The presence of serum antibodies to HSV-‐‑2 is usually indicative of genital herpes, whereas
HSV-‐‑1 antibodies do not differentiate b/w genital and oropharyngeal infection


Treatment
• First episode of genital herpes
-‐‑ Acyclovir 400 mg orally 3x/day for 7-‐‑10 days OR
-‐‑ Acyclovir 200 mg orally 5x/day for 7-‐‑10 days OR
-‐‑ Famciclovir 250 mg orally 3x/day for 7-‐‑10 days OR
-‐‑ Valacyclovir 1 g orally 2x/day for 7-‐‑10 days
Genital Herpes, • Suppressive therapy for recurrent genital herpes
continued -‐‑ Acyclovir 400 mg orally 2x/day OR
-‐‑ Famciclovir 250 mg orally 2x/day OR
-‐‑ Valacyclovir 500 mg orally 1x/day OR
-‐‑ Valacyclovir 1 g orally 1x/day
• Episodic therapy for recurrent genital herpes
-‐‑ Acyclovir 400 mg orally 3x/day for 5 days OR
-‐‑ Famciclovir 125 mg orally 2x/day for 5 days OR
-‐‑ Famciclovir 1000 mg orally 2x/day for 1 day OR
-‐‑ Valacyclovir 500 mg orally 2x/day for 3 days OR
-‐‑ Valacyclovir 1 g orally 1x/day for 5 days

Stages and Treatment
Regimens for Syphilis


• T pallidum cannot be detected by culture
• Serological tests are non-‐‑treponemal (Venereal Disease Research Laboratory Test (VDRL)
Diagnostic Testing for and Rapid Plasma Reagin (RPR) tests) or treponemal (fluorescent treponemal antibody
Syphilis absorb (FTA-‐‑ABS))
• A spinal tap for CSF analysis to rule out neurosyphilis is recommended for all children with
syphilis, patients with treatment failure, patients with nervous system or eye involvement,
those with evidence of tertiary syphilis, and those infected with both HIV and late latent
syphilis/syphilis of unknown duration

Background
• HIV is a retrovirus that produces a broad spectrum of disease from asymptomatic to
acquired immunodeficiency syndrome (AIDS)
• After infection, the virus enters, replicates, and then destroys the CD4 Helper T Cells
• The transition from initial HIV infection to AIDS takes a median of 10 years
• Transmission can be sexual, vertical, through the use of shared/contaminated needles,
HIV through exposure to contaminated blood, and via breast milk
Clinical Evaluation
• Most individuals with HIV infection are asymptomatic
• A portion of newly infected individuals will develop an acute syndrome with fever,
pharyngitis, weight loss, adenopathy, and nausea/vomiting
Diagnostic Testing
• It takes 3 weeks to 6 months for a patient to develop detectable HIV antibodies
• Initial testing uses an enzyme immunoassay for antibodies to HIV
• If the initial test is positive, confirmatory testing using the Western blot assay is performed
• Rapid testing using a drop of blood or a buccal swab is also available
• Initial lab testing for patients with newly diagnosed HIV include CD4 count, HIV RNA
viral load, CBC, liver and renal functions, and urinalysis

Cancers, Opportunistic
Infections, and
Syndromes Associated
with HIV


• The ankle joint is a hinge joint, which
can also invert and evert in response to
walking on irregular surfaces
• It includes the distal fibula, talus, and
distal tibia
• The ankle mortise (combined joint
structure) is stabilized on the lateral
side by – from anterior to posterior –
the anterior talofibular ligament, the
Functional Anatomy of calcaneal fibular ligament, the posterior
the Ankle talofibular ligament, and the peroneus
longus and brevis tendons • The Achilles tendon attaches to the
• In the frontal plane, the anterior posterior portion of the calcaneus à
tibiofibular ligament, posterior plantar flexion
tibiofibular ligament and syndesmosis, • Peroneus brevis and longus tendons à
a thickened sheet of interosseous eversion
membrane, stabilize the mortise and • Posterior tibialis tendon runs posterior and
allow minimal motion b/w the distal inferior to the medial malleolus and
tibia and fibular à more importantly, attaches to the navicular bone à inversion
they prevent separation of the tibia and + arch support
fibula as forces from the calcaneous are
transferred up the leg
• On the medial side, the deltoid
ligament has a superficial and deep
layer à provides resistance to eversion
stress

What are red flags in
patients with ankle or
knee pain?


• The physical exam should include evaluation of gait, range of motion, strength testing,
palpation, and finally, ought to include an assessment of stability
Physical exam for a • To help distinguish an ankle sprain from a fracture, you should palpate the posterior edge
patient with ankle pain and the tip of each malleolus and the base of the 5th metatarsal
• You should also have the patient take 4 steps
Anterior Drawer Test

• Small arrow = positive test
• Used to evaluate the intactness of the
anterior talofibular ligament
• A 3-‐‑mm difference between the ankles
suggests disruption of the anterior
Talofibular ligament

What are the physical
Talar Tilt Test
exam maneuvers that can
• Used to evaluate the stability of the
be used to evaluate ankle
anterior talofibular and calcaneofibular
pain?
ligaments
• The ankle is unstable if the anterior
talofibular and calcaneofibular
ligaments are torn


Squeeze Test
• Used for anterior/lateral ankle pain
• Compress the tibia and fibula together
above the midpoint of the calf
• Pain indicates a syndesmosis sprain à
“high-‐‑ankle sprain”

Cotton Test
• “Rocker Test”
• Used for syndesmosis sprains
• Performed like the talar tilt test, except
mediolateral force is applied

Thompson Test
• Used to assess the Achilles Tendon
• Midcalf compression test
• With the patient lying prone on the
exam table and the feet extended over
the edge of the table, the gastrocnemius
and soleus are compressed by squeezing
the calf
• If the foot plantar flexes, the test is
negative or normal
• If the foot does not move à indicates
complete or near complete rupture of
the tendon

Ottawa Ankle Rules


Management of Ankle
Sprains

Grade I
• Partial rupture of the anterior talofibular ligament (ATFL)
How do you grade ankle Grade II
sprains? • Complete rupture of the ATFL and partial rupture of the calcaneofibular ligament (CFL)
Grade III
• Complete rupture of both ATFL and CFL
Grade I Sprain
• Rest, Ice, Compression, Elevation (RICE)
• NSAIDs
Describe the • Do NOT require immobilization. Early mobilization improves function, reduces pain and
management of different swelling, and speeds return to work and sports
types/grades of ankle Grade II Sprain
injuries • RICE
• Immobilization in a lace-‐‑up splint or an air-‐‑stirrup splint for 2-‐‑7 days
• Crutches are helpful

Grade III Sprain
• RICE
Describe the • Air-‐‑stirrup splint or a below-‐‑knee cast for up to 3 months followed by formal physical
management of different therapy
types/grades of ankle Syndesmosis Sprains
injuries, continued • RICE
• NSAIDs
• Removable splints (i.e., posterior splint, pneumatic plent, or a Bledsoe brace) or casting
facilitates progressive weight bearing
• Passive range-‐‑of-‐‑motion exercises (e.g., tracing the alphabet, drawing circles, etc with the
foot), especially dorsiflexion, should begin within a week of injury
• Many fractures can be managed in the office without referral
• Avulsion or chip fractures are the most common and can occur at the distal fibula below the
level of the mortise, the distal portion of the tibial plafond, and the anterior surface of the
talus
Management of Ankle • Regardless of the avulsion fracture size, these usually can be treated based upon the
Fractures severity of the associated ankle sprain
• If the fragments are displaced more than 2 mm, immobilize the patient in a cast or posterior
splint and refer to an orthopedic surgeon
• Avulsion fractures of the peroneus brevis insertion from the 5th metatarsal head will heal
without treatment and should be immobilized
• You should refer patients with fractures of the base of the 5th metatarsal (Jones’ Fracture),
the proximal second, third or fourth metatarsals (known as Lis Franc Fractures) and of the
growth plate (Salter-‐‑Harris Fractures) to an orthopedic surgeon

• Relative rest, rehabilitation of the gastroc and soleus muscles, ice, heel lifts, and analgesics
• Rehabilitation of the calf muscles calf muscles begins with progressive stretching and ROM
Management of Achilles exercises followed by strength training
Tendinosis • NSAIDs for pain and inflammation
• Surgery is recommended only for patients who fail conservative therapy and desire to
continue activities that exacerbate tendinosis , and in those patients with Achilles tendon
ruptures
• The knee joint consists of the patella,
tibia, and femur
• The primary stabilizers of the knee are
the ACL and the PCL, the MCL and
LCL, the menisci, and joint capsule, and
the medial and lateral retinacula that
attach to the patella
Functional Anatomy of • Secondary stabilizers of the knee include
the Knee the iliotibial band (AKA the tensor fascia
lata) and the quadriceps, hamstrings,
and popliteus mm
• The ACL prevents anterior movement of
the tibia on the femur
• The PCL resists posterior movement of
the tibia on the femur
• The medial and lateral menisci primarily
act as shock absorbers but also stabilize
the knee during movements such as
pivoting

• Hearing or feeling a “pop” suggests an ACL
• Locking of the knee (where the knee gets “stuck” at some point in its ROM) is typically
Which findings are associated with meniscus injuries or a loos joint body (usually cartilage)
associated with which • Inability to bear weight and persistent “giving way” of the knee indicate internal
knee injuries? derangement but are NOT specific for any one injury
• Patients with degenerative joint disease typically complain of stiffness with inactivity and
pain with weight bearing activity
Lachman Test
• Very good at ruling in or out ACL tears
• Performed with the knee flexed to 20-‐‑30
degrees and with the top hand
stabilizing the femur while the lower
hand, with the thumb on top, wraps
around the inside of the proximal tibia
What are the physical • Using the lower hand, smoothly and
exam maneuvers that can gently try to slide the tibia forward
be used to evaluate knee • 3-‐‑mm side-‐‑to-‐‑side difference or the
pain? absence of a distinct stop indicates an
ACL tear
Posterior Drawer Test
• Do this test before the Lachman Test
• Flex the knee to 90 degrees and push the
tibia in a posterior direction
• Used to ensure PCL integrity
• If the PCL is torn, the Lachman test is
still accurate but must be done more
carefully

McMurray Test
• Used to detect meniscal damage
• Place the knee in full flexion and place
your fingers along the lateral joint line.
What are the physical Use your other hand to cup the heel
exam maneuvers that can • While applying a combination of
be used to evaluate knee external rotation and medially directed
pain, continued stress, bring the knee slowly into
extension
• A palpable click suggests a lateral
meniscus tear
• It is very likely that, in the presence of a
tear, this will also cause an increase in
pain
• Repeat the maneuvers with your fingers
along the medial joint line and apply
internal rotation and laterally-‐‑directed
stress to the knee to detect medial
meniscus tears

Patellar Apprehension Test
• The examiner applies inferiorly directed
pressure at the superior portion of the
patella
• Test is positive if the patient winces,
What are the physical grabs the knee, or otherwise voices
exam maneuvers that can displeasure
be used to evaluate knee
pain, continued

Patellar Compression Test
• The examiner firmly holds the patella in
place while the patient contracts the
quadriceps muscle
• Test is positive if the patient winces,
grabs the knee, or otherwise voices
displeasure

Ottawa Knee Rules

What are the major • Hemarthrosis or rapid fluid accumulation
reasons to refer a patient • ACL or meniscus tear
with knee pain for an • Third-‐‑degree collateral ligament injuries
additional evaluation or • Severe functional impairment
for surgery? • Uncertainty about the diagnosis (referral for second opinion)
• Poor response to conservative treatment (referral for second opinion)

Management of the most
common causes of knee
pain


Anatomy of the Spine


• Reflects soft tissue inflammation
Lumbar Sprain/Strain • Most common cause of back pain
• Presents with pain in the lower back that can radiate into the buttocks or proximal lower
extremities

• Syndrome of herniated disk or herniated
nucleus pulposus with impingement of
the nerve root (radiculopathy)
Sciatica • The radicular pain typically radiates in a
dermatomal pattern down the leg and
below the knee
• Whether or not the symptoms radiate
past the knee is a key distinguishing
feature of sciatica since non-‐‑radicular
causes of lower back pain

• Diagnosed when acute neurological impairment occurs in those structures supplied by the
Cauda Equina Syndrome sacral nerve roots, notably causing bowel or bladder dysfunction or perineal (“saddle”)
anesthesia
• This is a surgical emergency that requires urgent diagnosis and treatment
• MCC: large paracentral disk herniations and tumors
• Occurs primarily in older individuals and is related to degenerative changes in the spine
Spinal Stenosis with resulting hypertrophy of the facet joints and ligamentum flavum
• Diameter of spinal canal and neural outlets is compromised, often at multiple levels

• Typically occur in older individuals with osteoporosis
Vertebral Compression • Risk factors: female sex, early menopause, Northern European or Asian ethnicity, cigarette
Fractures smoking, sedentary lifestyle, and chronic steroid use

Red flags for patients
with low back pain


• The SLR is performed with the patient supine to see if radicular pain occurs when the leg is
Straight Leg Raising Test elevated between 30 and 60 degrees
(SLR) • The SLR test is fairly sensitive for a herniated disk, but NOT specific
• It is considered positive when the SLR causes or increases lower back pain that radiates
down the leg
• The crossed SLR test (pain radiating down the leg on lifting the opposite leg) is more
specific for a herniated disk, but less sensitive

Algorithm for
management of low back
pain


Findings for disk
herniation at different
levels

Plain Film
• Use for cancer
-‐‑ Sn 0.6, Sp 0.95-‐‑0.995
-‐‑ Costs ~ < $150
Imaging used for CT
different causes of low • Use for herniated nucleus pulposus
back pain -‐‑ Sn 0.62-‐‑0.9, Sp 0.7-‐‑0.87
-‐‑ Costs ~ $400-‐‑1,000
• Use for Spinal Stenosis
-‐‑ Sn 0.9, Sp 0.8-‐‑0.96
MRI
• Use for cancer
-‐‑ Sn 0.83-‐‑0.93, Sp 0.90-‐‑0.97
-‐‑ Costs ~ $750-‐‑1,500
• Use for Infection
-‐‑ Sn 0.96, Sp 0.92
• Use for herniated nucleus pulposus
-‐‑ Sn 0.6-‐‑1.0, Sp 0.43-‐‑0.97

• Unfortunately, the multifactorial nature of back pain makes any single preventative
strategy unlikely to account for much benefit
• The most consistently identified risk factor for LBP is a history of back pain
• Other risk factors include physical determinants such as heavy lifting, frequent bending,
Prevention of lower back twisting and lifting, repetitive work with exposure to vibration, and psychosocial issues
pain such as depressed mood, psychosocial distress, poor coping strategies, fear avoidance,
somatization, workers compensations claims and litigation.
• The most effective prevention strategy seems to by physical exercise
• Education that assists in coping with back pain and encourages activity has a small benefit
in preventing chronic or recurrent back pain
• There is strong evidence that back belts and lumbar supports are NOT effective in
preventing back pain in workers and should not be recommended

Pain receptor sites of the
lower cervical spine


Grade I
• No signs or symptoms of significant structural abnormalities; minimal interference with
normal activities; responds to minimal interventions; requires no diagnostic evaluation
Grading for neck pain Grade II
• No signs or symptoms of significant structural problems; significant interference with daily
activities; requires urgent attention and treatment to minimize prolonged disability
Grade III
• No signs or symptoms of significant structural problems; neurologic signs present; may
require diagnostic evaluation and more aggressive interventions
Grade IV
• Signs of structural problems; requires immediate diagnostic and treatment interventions
• Refers to degenerative change in the intervertebral unit of the cervical spine
Cervical Spondylosis • This term is used synonymously with degenerative disc disease or degenerative
spondylosis
• Degenerative changes include disk space narrowing, osteophytes in the disc margins, and
arthritic changes in the facet joints
Cervical Spondylotic • A condition in which arthritic changes, primarily the development of osteophytes and
Myelopathy thickening of the ligamentum flavum, cause direct compression of the spinal cord, resulting
in myelopathy
• Symptoms develop when the cord has been impinged by > 30%
• Motion can aggravate spinal cord damage by stretching the cord over protruding
osteophytes in flexion or by pressure from a thickened bulging ligamentum flavum in
extension

• Typically defined as an acute injury to the
cervical spine resulting from sudden
acceleration (hyperextension) and
subsequent deceleration (hyperflexion) of
Acceleration/Deceleration the head, often resulting from a rear
Injury (Whiplash-‐‑ impact motor vehicle accident
Associated Disorder) • Injuries can occur to the paracervical
muscles, anterior longitudinal ligament,
nerve roots, disk annulus, and, most
importantly, the facet joints can be forced
to impact posteriorly on each other
• The symptoms often do not occur until 12-‐‑
24 hours after injury, which may be
because it takes time for edema to develop
after microscopic hemorrhage and injury


Spurling Test/Maneuver
• Performed by having the patient side bend
(bring ear close to shoulder) to the side of
the radicular pain and extend his or her
head
• Positive test: pressure exerted downward
by the examiner on the patient’s head will
create or intensify radicular symptoms

• Suggests nerve impingement
Axial Manual Traction Test
Clinical tests that can be • Examiner pulls up on the head to
used to aid the diagnosis momentarily theoretically decrease the
of cervical disk pressure on the cervical root
herniation • Relief of pain is considered a positive
result for cervical root compression

Arm Abduction Test
• Performed by elevating (full abduction of
the shoulder) the affected arm over the
head of the seated patient
• Theoretically decreases the traction on the
cervical root
• Relief of pain is considered a positive
result for cervical root compression


Canadian C-‐‑Spine Rule

Note: a “dangerous
mechanism” is considered
to be a fall from an
elevation of ≥ 3 feet or 5
stairs; an axial load to the
head (e.g. diving); a motor
vehicle collision at high
speed (> 100 km/hr) or
with rollover or ejection; a
collision involving a
motorized recreational
vehicle or a bicycle

collision

Red flags for patients
with neck pain


Spinal Level: C4/C5
Motor Weakness: deltoid, shoulder, biceps
Sensory Loss: lateral upper arm
C5 Nerve Root Injury Paresthesia: None in digits
Referred Pain: Shoulder and upper lateral arm
Reflex Loss: Biceps
Subjective Pain: Shoulder (but relatively pain free)
Spinal Level: C5/C6
Motor Weakness: Biceps, brachioradialis
Sensory Loss: thumb and forearm proximal to thumb
C6 Nerve Root Injury Paresthesia: Thumb
Referred Pain: Radial aspect of forearm
Reflex Loss: Brachioradialis and biceps
Subjective Pain: deltoid, rhomboid muscle areas
Spinal Level: C6/C7
Motor Weakness: Triceps
Sensory Loss: Middle ring finger
C7 Nerve Root Injury Paresthesia: Middle Finger
Referred Pain: Dorsal aspect of forearm
Reflex Loss: Triceps
Subjective Pain: Dorsolateral upper arm, superomedial angle of scapula
Spinal Level: C7/T1
Motor Weakness: Finger intrinsic
Sensory Loss: Inner forearm, little finger
C8 Nerve Root Injury Paresthesia: Ring and little finger
Referred Pain: Ulnar aspect of forearm and little finger
Reflex Loss: triceps or none
Subjective Pain: Scapula, ulnar side of upper arm

Therapeutic options for
management of neck pain

• A “stinger” or “burner” (transient neurapraxia) is a form of injury unique to collision sports
• The “stinger” is where the athlete complains of burning or tingling in an upper extremity
“Stingers” in contact after a collision à distributed in the upper arm or in the entire arm; peri-‐‑scapular pain also
sports possible
• Nerve roots most common affected are C5-‐‑C6
• Injury is likely due to a traction injury to the brachial plexus or compression injury to the
dorsal nerve root ganglion as it exits the neural foramen à symptoms last minutes to hours
• Can return to play when they have full, pain free ROM and symmetric strength with
uninjured side

Shoulder Anatomy

• The bony anatomy of the shoulder is composed of: the humerus, the clavicle and the
scapula, which is further divided into the acromion, the coronoid, and the glenoid.
• Shoulder joint complex has 4 different articulations: Sternoclavicular, Acromioclavicular,
Glenohumeral, and Scapulothoracic joints
• The soft-‐‑tissue support can be divided into static and dynamic stabilizers
-‐‑ Static stabilizers: bony support, joint capsule, glenohumeral ligaments, and glenoid
labrum
-‐‑ Dynamic Stabilizers: rotator cuff muscles, long head of biceps tendon à function is to
maintain the humeral head centered within the glenoid of the scapula during
movement

• The majority of OA in the shoulder occurs at the AC Joint, particularly with repetitive
overhead activities or a history of heavy weight lifting
Shoulder osteoarthritis • OA of the glenohumeral joint is much more rare and generally occurs with a history of
distant trauma/dislocation or a history of auto-‐‑immune arthritis involving the shoulder
joint
• Both conditions involve the degeneration of articular cartilage at the joint with associated
synovitis, effusion, and osteophyte formation

Key elements in the
history for common
shoulder disorders


Differential Diagnosis of
the patient with shoulder
pain


Red Flags for patients
with shoulder pain
indicating more serious
disease

Abduction
• Tests the supraspinatus
Muscle Strength Testing Internal Rotation
for Shoulders • Tests the subscapularis
External Rotation
• Tests the infraspinatus and teres minor

Hawkins’ Impingement Test
• Used to diagnose impingement of the
rotator cuff muscles
• A positive result is when pain results
reflecting rotator cuff injury
• The test is performed by the examiner
passively forward flexing the patient’s arm
to 90 degrees followed by passively
Physical Exam internally rotating the arm to its end point
Maneuvers for the (approximately 90 degrees)
Shoulder


Empty Can Test
• Isolates the supraspinatus more effectively
than abduction
• A painful result is often associated with
rotator cuff disease
• Performed by having the patient abduct
their arm to 90 degrees, followed by
forward flexing the arm 30 degrees to lie in
the plane of the scapula. The patient is
then instructed to “empty the imaginary
can.” The examiner then places a
downward force at the wrist, which the
patient should resist
Physical Exam • Pain and/or weakness may signify a
Maneuvers for the rotator cuff injury, particularly the
Shoulder, continued supraspinatus
Subscapularis Lift Off Test
• Designed to best isolate the subscapularis
• Performed by having the patient place the
dorsum of their hand against their low
back while sitting on the exam table. The
patient then manually lifts the hand away
(mainly by forcible extension of the
shoulder) from the low back while the
examiner resists
• Pain and/or weakness suggests injury to
subscapularis

Drop Arm Test
• Performed by passively abducting the
patient’s arm to 160 degrees and then
asking the patient to slowly lower the arm
to their side
• A positive test is when the arm cannot be
lowered in a controlled fashion and
“drops” to their side
• When positive, it is highly specific for a
large or massive rotator cuff tear, often
necessitating a surgical consultation
Physical Exam
Maneuvers for the
Shoulder, continued


Cross-‐‑Body Adduction Test
• Stresses the AC joint à assists in the
diagnosis of AC joint osteoarthritis
• Performed by passively bringing the
patient’s arm across the body towards the
contralateral shoulder
Physical Exam • Considered positive if the patient has pain
Maneuvers for the localized to the AC joint
Shoulder, continued

Apprehension Test

• Used to diagnose chronic anterior

shoulder instability

• Performed by having the patient lie supine

and in a relaxed state. The patient’s arm is

brought into 90 degrees of abduction with

the elbow flexed to 90 degrees. The

examiner then applied gentle external

rotation with the arm still abducted at 90

degrees.

• If the patient becomes apprehensive, this is

a positive sign of anterior instability

Sulcus Sign
Physical Exam • Diagnostic of multidirectional instability
Maneuvers for the • Performed with the patient’s arm dangling
Shoulder, continued at their side. The examiner then exerts an
inferiorly directed force on the arm by
pulling down on the patient’s wrist
• The test is positive if a sulcus or
indentation is created between the
acromion and proximal humeral head
• The majority of shoulder disorders can be diagnosed with history, physical exam, and plain
radiographs
Diagnostic Imaging for • Generally, the role of MRI is when a patient has failed 6-‐‑8 weeks of conservative
Shoulder Injuries management and the diagnosis remains uncertain
• Plain radiographs can assess whether there is a hook or spur of the acromion, significant
AC joint osteoarthritis, as well as a potential accessory os acromiale that might predispose
patients to rotator cuff injury and tendonitis
• Diagnostic Accuracy of MRI
-‐‑ Any rotator cuff tear: Sn 0.83 Sp 0.86
-‐‑ Partial-‐‑thickness rotator cuff tear: Sn 0.44 Sp 0.90
-‐‑ Full-‐‑thickness rotator cuff tear: Sn 0.89 Sp 0.93
• Diagnostic Accuracy of Ultrasound
-‐‑ Any rotator cuff tear: Sn 0.80 Sp 0.85
-‐‑ Partial-‐‑thickness rotator cuff tear: Sn 0.67 Sp 0.94
-‐‑ Full-‐‑thickness rotator cuff tear: Sn 0.97 Sp 0.96

Algorithm for patient
presenting with acute
shoulder pain


Algorithm for patient
presenting with chronic
shoulder pain


• Span the spectrum from tendinopathy to partial or complete tears
• The majority of rotator cuff pathology can be managed with nonsurgical treatment options
• The least invasive treatment options include:
Rotator Cuff Disorders: -‐‑ Relative rest with avoidance of overhead activity
Management -‐‑ Anti-‐‑inflammatory medication (NSAIDs)
-‐‑ Physical Therapy
-‐‑ Subacromial injections with corticosteroids are often used in the short-‐‑term reduction
of pain and improvement of function. Also shown to be beneficial for rotator cuff
tendonitis
• Adhesive capsulitis (“frozen shoulder”) is challenging to treat
• Majority of cases will resolve spontaneously over the course of 12-‐‑18 months
• Treatment is directed at decreasing the duration of symptoms and improving function
-‐‑ Activity modification to decrease pain
Adhesive Capsulitis: -‐‑ Anti-‐‑inflammatory or analgesic medication
Management -‐‑ Physical Therapy
-‐‑ Systemic oral steroids have been found to provide significant short-‐‑term relief as well
as improved range of motion
-‐‑ Intra-‐‑articular steroid injection has been shown to provide short-‐‑term benefit
-‐‑ Arthrographic distention of the joint with saline and stoid has shown short-‐‑term
benefit


• Most often due to acute dislocation or subluxation
• Initial treatment (after ruling out acute fracture or significant rotator cuff tear):
Glenohumeral Joint -‐‑ Activity modification
Instability: Management -‐‑ Pain medication
-‐‑ Short-‐‑term use of a sling for pain control
• After initial symptoms have subsided:
-‐‑ Strengthening of the rotator cuff and scapular stabilizers
• If no improvement with conservative treatment over 6-‐‑12 weeks, or if there is recurrent
episodes of instability, or if the patient is a young athlete (< 20 YO) who with acute anterior
dislocation:
-‐‑ Surgery
• AC arthritis is associated with hypertrophy of the AC joint
• Hypertrophied AC joint can be associated with impingement and wear of the rotator cuff
AC Joint Arthritis: between the hypertrophied AC joint and the proximal humerus during abduction
Management • Treatment:
-‐‑ Pain control with NSAIDs
-‐‑ Activity modification
-‐‑ Corticosteroid injections into the AC joint may be effective short-‐‑term in severe cases
-‐‑ Resection of distal clavicle is often ultimately effective in resistant AC arthritis
• Uncommon, but causes significant pain and disability when present
• Treatment:
Glenohumeral Joint -‐‑ Focus is to maintain overall function with adequate pain control (NSAIDs)
Arthritis: Management -‐‑ If pain in inadequately controlled, intra-‐‑articular steroid injection may be considered
-‐‑ Physical therapy can be helpful, but must be undertaken with caution
-‐‑ Need to control comorbid conditions (such as rheumatoid arthritis)
-‐‑ Surgical referral if conservative treatment fails: capsular release and arthroscopic
debridement, hemiarthroplasty, and total shoulder arthroplasty are options

• Fair skinned people older than 65 YO
• Patients with many atypical moles
Risk Factors for • Patients with ≥ 50 moles
Melanoma • Family history
• Substantial history of sun exposure and sunburns
• When a person has had basal cell carcinoma à risk of 2nd BCC is ≥ 40% in the next 3 years

Primary Skin Lesions


Secondary Skin Lesions


Microscopy
• Used for suspected fungal infection
• Scrape some of the scale from the skin lesion onto a microscopic slide à add potassium
Diagnostic Testing for hydroxide (KOH) à look for hyphae of dermatophytes or pseudohyphae of Candida or
assessing skin disorders Pityrosporum
Wood’s Light Exam
• Used for tinea capitis and erythrasma
• Tinea capitis caused by the Microsporum species produce green fluorescence
• Erythrasma has a coral red fluorescence
Surgical Biopsy
• Shave, punch, or elliptical biopsy can be useful
Skin Disorders
• As severity or chronicity of disorder increases à use higher potency steroids
What factors must be • Thicker lesions (e.g., psoriatic plaques) à use higher potency steroids
considered when you are Site
choosing a topical steroid • Face, genitals, skin folds (thin, moist areas) à use weakest potency steroids
in order to maximize • Palms à use higher potency steroids
benefit and minimize Age
adverse effects? • Infants, Children (high surface area per body mass) à use weak potency steroids


Choosing Topical
Corticosteroids


Strength of
recommendation for
treatment of bacterial
skin infections of the
skin

*Oral antibiotics must cover Group A Beta-‐‑hemolytic streptococci and S aureus (1 line: dicloxacillin,
st
cephalexin; 2nd line: clindamycin)

• Superficial skin infection often characterized by “honey” crusts
• It can also be vesicular or bullous
• Variations:
Impetigo -‐‑ Ecthyma: has an ulcerated punched-‐‑out base
-‐‑ Bullous
• Staphylococcal-‐‑scalded skin syndrome (SSSS) is a life-‐‑threatening, more severe variation of
bullous impetigo à bullae are caused by exfoliating toxin; patient is systematically ill
-‐‑ Patients need IV antibiotics, fluids, and supportive care

• Cellulitis is an acute infection of the skin that involves the dermis and subcutaneous tissues
à often caused by ß-‐‑hemolytic streptococci and S aureus
Cellulitis and Erysipelas • Erysipelas is a specific type of superficial cellulitis with prominent lymphatic involvement
causing lesions that are raised above the level of the surrounding skin with a clear line of
demarcation between involved and uninvolved tissue
• Infection or inflammation of the superficial portion of the hair follicle
• Usually caused by S aureus, or it can be caused by other bacteria, yeast, or occlusion
• Presentation can include perifollicular erythema, papules, or pustules
Folliculitis • Lesions are associated with hair follicles
• Hot tub folliculitis is due to Pseudomonas
• Also can be caused by Pityrosporum yeast or occlusion of hair follicles with tight-‐‑fitting
clothing
• Localized collection of pus that occurs in or directly below the skin à includes furuncles,
carbuncles, and abscesses around fingernails
Abscess • A furuncle/boil is an abscess that starts in a hair follicle or sweat gland
• Carbuncle occurs when the furuncle extends into the subcutaneous tissue
• Most are caused by S aureus
• Treatment: Incision and Drainage
• Deep infection of the subcutaneous tissues and fascia
• Often presents with diffuse swelling of the arm or leg, followed by the appearance of bullae
with clear fluid that may become violaceous in color
Necrotizing Fasciitis • Patient has marked systemic symptoms such as pain out of proportion to the apparent skin
lesion with gas in the soft tissues, edema that extends beyond the margin of erythema,
cutaneous anesthesia, and systemic toxicity marked by fever, tachycardia, delirium, and
renal failure
• Almost always due to S pyogenes
• Can lead to cutaneous gangrene, myonecrosis, shock, and death

• Caused by > 100 subtypes of HPV
• Commonly occur on the hands, feet, and genitals
• Warts on the hands (verruca vulgaris) are usually raised and hyperkeratotic
-‐‑ Tx: salicylic acid or cryosurgery
• Warts on the soles of the feet (plantar warts) are flat, disrupt skin lines, have dark dots
Warts visible in them, and may be quite painful
-‐‑ Tx: salicylic acid or cryosurgery
• Flat warts (verruca plana) are usually seen in groups on the face or legs
-‐‑ Tx: salicylic acid, topical tretinoin (Retin-‐‑A), cryosurgery, or imiquimod (Aldara)
• Genital warts (condylomata acuminate) often have a cauliflower appearance and are
transmitted sexually (90% are caused by HPV 6)
-‐‑ Tx: Podophyllin resin, podofilox (Condylox), trichloroacetic acid, cryosurgery, or
imiquimod (Aldara)
• A major characteristic of herpes infection is that the virus lies dormant in dorsal root ganglia,
leading to recurrences
• All herpetic skin infections are characterized by vesicular eruptions with surrounding erythema,
which progress to ulcers and/or crusts and then reepithelialize over the course of days or weeks
• Herpes Gingivostomatitis/Labialis (cold sore)

-‐‑ MCC: HSV-‐‑1

-‐‑ Initial infections are often the most severe
Herpes Virus • Genital Herpes
-‐‑ MCC: HSV-‐‑2
• Chickenpox
-‐‑ MCC: VZV
-‐‑ Consists of a few days of fever and respiratory symptoms with the characteristic vesicles on a
red base that begin on the trunk and spreads to the extremities
• Herpes Zoster (shingles)
-‐‑ Reactivation of VZV along a skin dermatome

• Tinea of the head
• Annular appearance with central clearing, redness, and scale on the perimeter
Tinea Capitis • Causes patchy alopecia (hair loss) with broken hairs and scaling
• Because the hair shaft and follicle are involved, topical antifungals are not effective
• Oral antifungals: Griseofulvin, Itraconazole, Terbinafine
• Tinea of the body à can occur anywhere
• Annular appearance with central clearing, redness, and scale on the perimeter
Tinea Corporis • Tx: topical OTC antifungals à miconazole, clotrimazole
• Large areas require oral antifungals à griseofulvin, terbinafine, itraconazole
• Tinea of the groin

• May be red and scaling without the central clearing seen in tinea corporis
Tinea cruris • Topical or systemic antifungals may be used
• Topical antifungals that cover all superficial fungal skin infections include the azoles and
terbinafine (Lamisil)
• Tinea of the feet
• May be seen as macerated white areas between the toes or as dry red scaling on the soles or
Tinea pedis sides of the feet (moccasin distribution)
• Treat with same topical or oral antifungals used for tinea corporis or cruris

• Tinea unguium à fungal infection of the nails
• It is important to establish a definitive diagnosis of onychomycosis before starting
Onychomycosis treatment with oral antifungals, because there are other causes for dystrophic nails such as
psoriasis, lichen planus, and trauma
• Terbinafine is most effective treatment

• Type of eczematous eruption that is itchy, recurrent, and symmetric and often found on
flexural surfaces
Atopic Dermatitis • Often have personal or family history of asthma and allergic rhinitis
• Most cases are not caused by specific allergies, but develops from a number of trigger
factors in patients who have a strong genetic predisposition to develop eczematous
eruptions
• Tx: avoid skin irritants (e.g. drying soaps), use emollients or moisturizers to add needed
moisture to the skin, treat the inflammation with a topic steroid or another anti-‐‑
inflammatory agents such as topical immunomodulators (tacrolimus and pimecrolimus)
• Allergic response to an allegen such as the chemical found in the poison ivy or poison oak
plant (rhus dermatitis)
Allergic Contact • These lesions are often linear and vesicular
Dermatitis • Other contact allergens: nickel in jewelry and belt buckles and chemicals in deodorants and
cosmetics)
• Seen on the hands and/or feet
• Tapioca-‐‑like vesicles occur between the fingers or toes along with scaling
Dyshidrotic Eczema • The scaling inflamed skin can proceed to develop painful cracks and fissures

• Coin-‐‑shaped with erythema and scale
• Most often found on the lower legs
Nummular Eczema • Tx: avoid skin irritants (e.g. drying soaps), use emollients or moisturizers to add needed
• Dfn: a superficial inflammatory dermatitis that is characterized by erythema and scaling on
the scalp and face
• Typical distribution includes the scalp (dandruff); eyebrows and eyelids; cheeks; nasolabial
creases; behind the ears; forehead; cheeks; around the nose; udner the beard or mustache;
over the sternum; and in the axillae, submammary folds, umbilicus, groin, and the gluteal
Seborrhea creases à these regions have the greatest number of pilosebaceous units producing sebums
• Characterized by remissions and exacerbations à MC precipitating factors are stress and
cold weather
• People with seborrhea have a profusion of Pityrosporum (Malassezia) on the skin
• Treatment should be directed at the inflammation and the Pityrosporum
-‐‑ Low-‐‑dose steroids (1% hydrocortisone cream)
-‐‑ Antifungals: ketoconazole cream for skin, antifungal shampoo (selenium sulfide, zinc
pyrithione, ketoconazole, or coal tar derivatives)


• Dfn: chronic condition characterized by alterations in the immune system that lead to
epidermal proliferation and inflammation
• Lesions are well-‐‑circumscribed, red, scaling plaques, with white thickened scales
• Areas affected include the scalp, nails, and extensor surfaces of the limbs
• Treatment:
-‐‑ Emollients
Psoriasis -‐‑ Topical steroids
-‐‑ Vitamin D (calcipotriene or calcipotriol)
-‐‑ Topical tar and tar shampoo
-‐‑ Intralesional steroids
-‐‑ UV light
-‐‑ Topical retinoids
-‐‑ Systemic treatment with methotrexate, acitretin, cyclosporine, and injectable biologics
-‐‑ Tarazotene (topical) is effective for plaque psoriasis


• Dfn: inflammatory disease of the pilosebacous unit which involves blockage of the unit
with sebum and desquamated cells, accompanied by the overgrowth of P acnes in the
follicle
• Treatment:

Acne


• Most potent medication for acne
• Has many potential side effects, including birth defects
Isotretinoin (Accutane) • Should NOT be prescribed or dispenses to any woman without two negative pregnancy
tests and two forms of birth control

ABCDE Guidelines for
Melanoma


• Most common skin cancer
• 85% are on the head and neck
Basal Cell Carcinoma • 3 major morphologic types:
(Skin) -‐‑ Nodular: pearly and raised with telangiectasias à expands à ulcerates, bleeds, and
becomes crusted
-‐‑ Superficial: red or pink, flat, scaling plaques that may have erosions or crusts
-‐‑ Sclerosing: flat and scarlike; very rare
Squamous Cell • Can look like superficial BCC or can be more elevated and nodular
Carcinoma (Skin) • SCCs are frequently hyperkeratotic and bleed easily
• Premalignant lesions
Actinic Keratoses • Treated with cryotherapy for a small number of lesions or topical field treatment for areas
with many lesions (5-‐‑fluorouracil, imiquimod, and diclofenac)
Sebaceous hyperplasia • May look like BCC
• Benign lesions that are raised and can have pearly borders and telangiectasias

• Can mimic melanoma
Seborrheic Keratosis • These develop with age and are often large and pigmented with irregular borders
• Have a stuck-‐‑on appearance, but they can be flat and irregular

• A chronic, genetically linked primary headache that usually begin in late childhood or early
adulthood
• Neurologic symptoms may either precede (“aura”) or accompany the headache. Patients
often report pain in the face or around (or behind) one eye
Migraine Headaches • Typical features: intense facial pain, photophobia
• The frequency, severity, and associated symptoms can vary between patients and even
within a given person’s lifetime
• Known triggers include estrogen changes (menstrual cycle), caffeine, sleep deprivation,
psychosocial stressors, or changes in weather or barometric pressure

Diagnostic criteria for
migraines with and
without typical aura


Treatment for acute
migraines and for
prevention of migraines

1) Headaches > 2 days/week, on average
2) Recurring migraines that, in the patient’s opinion, significantly interfere with his or her
Clinical criteria for daily routine
initiating migraine 3) Failure of, or contraindications to, acute therapies
prophylaxis: 4) Patient preference
5) Significant cost of acute therapies
6) Presence of uncommon headache conditions including hemiplegic migraine, basilar
migraine, migraine with prolonged aura, or migrainous infarction

Common Headache
Triggers

• Most common type of headache overall
• Has are usually mild or moderate in severity and are often self-‐‑treated
• Pain is bilateral in a “headband-‐‑like” pattern
Tension-‐‑Type Headaches • They are commonly episodic but can develop into daily or near-‐‑daily headaches
Treatment


• More prevalent in males; very rare (0.3-‐‑0.4%)
• Classic presentation is described as a series of headaches occurring close together over 6-‐‑12
weeks à severe, intense, unilateral pain lasting from several seconds to many minutes
• Concurrent symptoms include ipsilateral lacrimation, rhinorrhea, and ptosis
Cluster Headaches • The headache is always on the same side, no matter how many months lapse between
episodes
Treatment

• Have symptoms suggestive of nasal or sinus etiology (rhinosinusitis) including purulence
Sinus Headache in the nasal cavity, nasal obstruction, altered smell (hyposmia or anosmia), and/or fever
• Often have incomplete resolution of pain after taking decongestants
• Patients may actually have migraines rather than sinusitis
• Headaches that occur daily or nearly daily

• Paradoxically, the very medications commonly used to treat episodic headaches (including
OTC analgesics, especially acetaminophen, and migraine-‐‑specific medications such as
Chronic Daily Headache triptans) are implicated in the transformation of episodic to chronic headaches, especially if
consumed more often than 2 days per week over several months
Treatment


Signs and symptoms that
suggest neuroimaging
may be indicated in
patients with headaches

Red flags suggesting that
a headache may indicate
a progressive or life-‐‑
threatening disease

• Commonly presents with severe headache reaching maximal intensity within minutes and
Subarachnoid lasting an hour or more
Hemorrhage • SAH may be accompanied by focal neurologic signs or other symptoms such as nausea,
vomiting, photophobia, neck stiffness, seizures, or altered level of consciousness


Presentation
• Child maltreatment often presents with symptoms of inattention, school failure, disruptive
symptoms, anxiety, depression, failure to thrive, and a broad range of somatic symptoms
Physical Abuse
• Suspect in cases of childhood injury that are (i) unexplained, (ii) not plausible by the
explanation offered, (iii) in a pattern suspicious for inflicted injury, (iv) developmentally
inconsistent, or (v) from punishment with excessive force
• Physical markings that last ≥ 24 hours are regarded as significant injuries
Sexual Abuse
• Usually presents with child disclosure. However, may present with acute sexual trauma,
Child Maltreatment STDs, pregnancy, extremes of sexualized behavior, and somatic symptoms such as dysuria
and enuresis
Neglect
• Neglect can be thought of as failure to meet the basic needs of a child, such as adequate
supervision, food, clothing, shelter, medical care, education, and love.
• Often manifests as a pattern of chronic unmet needs
• The cause of neglect may or may not be malevolent, but the child is still at risk à for
example, a poor single father may leave his 2-‐‑year-‐‑old child alone at night so that he can
work a 2nd job
Psychological Abuse
• Common, but very difficult to substantiate because of social norms
• Some examples include (i) threatening to leave or abandon a child, (ii) threatening to kick a
child out of the home, (iii) locking a child out of the house, or (iv) calling a name like
stupid, ugly, or useless
• Often only made through long-‐‑term observation of parent-‐‑child interaction
• Symptoms include aggressiveness, impulsivity, depression, hyperactivity, school failure,
inattention, disturbances of conduct, anxiety, eating disorders, and somatic symptoms
• Consider a referral to family therapy

Management
• Physicians are mandated by law to report suspected child abuse and neglect à laws
include immunity from lawsuits for reports made in good faith
• It is not required by law that the parent be informed of the report

Suspicious injuries
indicative of child abuse


Situations that should
raise suspicion for
intimate partner violence

Physical Violence
• Intentional use of physical force with the potential for causing death, disability, injury, or
harm
Sexual Violence
• (i) use of physical force to compel a person to engage in a sexual act against his or her will,
Intimate Partner Violence whether or not that act is completed
• (ii) Attempted or completed sex act involving a person who is unable to understand the
nature or condition of the act, to decline participation, or to communicate unwillingness to
engage in the sexual act (e.g. illness, disability, influence of alcohol/drugs, or because of
intimidation)
• (iii) abusive sexual contact
Psychological/Emotional Violence
• Trauma to the victim caused by acts, threats of acts, or coercive tactics


Common Presentations
• Injuries
-‐‑ Partner violence causing physical injury is the most direct health effect of IPV
-‐‑ Certain patterns of injury, such as injuries to the head, neck, breast, or abdomen
should raise suspicion
• Other Physical Health Effects
-‐‑ Concerns related to sexual health, such as STIs, cervical dysplasia, and unplanned
pregnancy are common
Intimate Partner -‐‑ Victims are at increased risk for CV disease and for stroke
Violence, continued -‐‑ Could present with GI disorders such as irritable bowel syndrome
-‐‑ Could present with a variety of chronic pain complaints, such as arthritis, migraine,
fibromyalgia, chronic fatigue syndrome, and temporomandibular joint syndrome
-‐‑ May present with somatic complaints, such as stomach pain, back pain, menstrual
problems, headaches, chest pain, dizziness, fainting spells, palpitations, shortness of
breath, constipation, generalized fatigue, and insomnia
• IPV and Pregnancy
-‐‑ IPV often continues throughout pregnancy
-‐‑ Victims are often delayed in seeking prenatal care
-‐‑ Infants are at risk for low birth weight, prematurity, and perinatal death
• Mental Health
-‐‑ Victims commonly experience depression, suicidal thoughts and attempts, and PTSD
-‐‑ Tobacco, alcohol, and illicit drug abuse are common
-‐‑ Abused women are more likely to have disordered eating patterns


Assessment
• All clinicians examining children and adults should be alert to physical and behavioral
signs and symptoms associated with abuse or neglect. Patients in whom abuse is suspected
should receive proper documentation of the incident and physical findings, treatment for
physical injuries, arrangement for skilled counseling by a mental health professional, and
the telephone number of local crisis centers, shelters, and protective service agencies
• Physicians should ensure a private setting, without friends or family present. They should
assure patients of confidentiality, but notify them if any reporting requirements apply.
Intimate Partner Language should be direct and nonjudgmental
Violence, continued Management
• Key components of an initial interaction should include validation of the patient’s concerns,
education regarding the dynamics and consequences of IPV, safety assessment, and referral
to local resources
• An initial response to a disclosure of IPV should include listening to the patient
empathically and nonjudgmentally, expressing a concern for her health and safety, and
affirming a commitment to help her address the problem
• Abused women often have very low self esteem, so it is important to physicians to help
counter this belief, reassuring that although partner violence is common, it is unacceptable
and not the fault of the victim

WAST-‐‑Short screening
for domestic violence


Intimate partner violence
red flags indicating
increased risk for serious
injury or homicide

Background
• Elder mistreatment is defined as intentional actions that cause harm or create a serious risk of harm
(whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in
a trust relationship to the elder, or failure by a caregiver to satisfy the elder’s basic needs or to
protect the elder from harm

• Includes physical abuse, psychological abuse, sexual abuse, financial exploitation, and neglect

• Elders who live with their caregivers are more likely to be victims of mistreatment. Social isolation
Elder Abuse of both elders and their caregivers also appears to increase risk for mistreatment. Patients with
dementia, in particular patients who have disruptive behavior or aggression, are at increased risk
Assessment
• Insufficient evidence to recommend for or against routine screening
• There is no clear constellation of symptoms that is suggestive of elder mistreatment à remain alert
to bruises or burns in unusual locations or injuries that are not consistent with the explanation
offered. Genital or breast injuries should raise suspicion of sexual abuse. Findings that should raise
suspicion for neglect include dehydration or malnutrition, pressure ulcers, poor hygiene, or medical
nonadherence
Management
• In most states, reporting of elder abuse and neglect is legally mandated

Criteria for an episode of
Major Depression


Criteria for a single
episode of MDD

Criteria for recurrent
MDD

• Complaints that involve multiple organ systems or are physiologically unrelated
• Emotional flatness, or worry that is not consistent with the severity of the presenting
What are some clues that problem
may indicate a patient • Sleep disturbance that is persistent or unrelated to obvious stressors
has depression? • Frequent office visits for unclear or seemingly minor complaints
• Frequent emergency room visits for unexplained physical symptoms
• Patients who are “difficult” for unclear reasons
• Patients who express thoughts or emotions that are inappropriate to the context
• Patients with a previous history of emotional disturbances or “nervous breakdowns”

dysthymic disorder


mood disorders
secondary to a medical
condition


Criteria for a hypomanic
episode

Criteria for Bipolar II
Disorder


Criteria for seasonal
pattern specifiers for
depressive disorders


Medications that often
cause or worsen
depression


Red flags suggesting
more serious or complex
disease in patients
presenting with
depression


Factors that increase the
risk of suicide in
depressed patients

• Patients who have considered a specific plan for suicide or have made a suicidal gesture
How do you manage should be referred to a mental health specialist for rapid evaluation
depressed patients who • Patients with suicidal thoughts may require escorting to an emergency room with mental
are at risk of attempting health specialists on staff.
suicide? • Telephone contact between the family physician and receiving specialist is essential to
convey the specific statements of the patient that are eliciting concern.

Medication should be initiated when:
When do you initiate • Symptoms have been present for more than 1 month
medications in patients • Symptoms result in significant interference with ability to function at work or home, or
with MDD? • Score on the PHQ-‐‑9 is ≥ 15

Recommended
Treatments for MDD


• History of good response to previous use
• Successful use of an agent in a close relative (use by a parent or sibling may enhance
What considerations compliance)
should be made when • Presence of chronic pain or severe sleep disturbance (if so, consider using a TCA)
you are choosing an anti-‐‑ • Coexisting medical conditions (e.g., avoid TCAs in patients with known cardiac conduction
depressant medication to disturbances)
prescribe? • Hypersomnia (if so, consider an SSRI)
• Cost
• Allow 12-‐‑14 weeks of treatment at maximum effective dose before abandoning the drug
For how long should you being used. If there is no response by 14 weeks, augment or switch medication and/or
keep a patient on an consider referral
antidepressant drug that • It is important to emphasize to the patient that failure of one medication does not mean that
has not begun to work? the condition is untreatable.
• Asthma is defined as a chronic inflammatory disease involving mast cells, neutrophils,
eosinophils, T lymphocytes, macrophages, and epithelial cells à this inflammatory process
Asthma definition may lead to diffuse, variable airflow obstruction, manifested as recurrent episodes of
coughing, wheezing, breathlessness, and chest tightness
• Airway obstruction in asthma worsens in response to a number of stimuli (such as
infection, allergies, and irritants), and improves either spontaneously, after withdrawal of
the offending stimulus, or with treatment.
• BMI
• Smoking or exposure to secondhand smoke
Modifiable risk factors • Maternal use of tobacco during pregnancy
for asthma? • Exposure to allergens from pollen types, dust mites, cockroaches, cats, dogs, rodents, and
some fungi
• Exposure to outdoor air pollution, such as ozone, nitrogen oxides, sulfur dioxide, and diesel
exhaust particles

• Allergic rhinitis
• Postnasal drip
What is the differential • Sinusitis
diagnosis for chronic • GERD
cough similar to asthma? • CHF
• COPD
• Airway obstruction

Key elements in the
history and physical
examination for asthma


• A chronic cough lasting several months primarily lasting several months primarily
occurring at night may be the only symptom
• More typical symptoms of asthma include difficulty breathing, wheezing and cough, either
in combination or alone
• Adults with asthma may describe difficulty in getting enough air, tightness in the neck or
chest, or having to work harder or concentrate more in order to breathe
• Exercise may precipitate asthma symptoms by increased ventilation, resulting in the
irritation of airways secondary to loss of heat and moisture à exercise-‐‑induced asthma
Typical symptoms of (compared to poor physical conditioning) usually starts 5-‐‑15 minutes after starting exercise
asthma and continues more than 10 minutes after stopping
• During an acute episode, the patient may look anxious, have rapid or labored breathing,
and be sitting upright or standing to maximize efficiency of thoracic muscles
• Vital signs:
-‐‑ Elevated respiratory rate and heart rate
-‐‑ Fever present if infection is the trigger
-‐‑ Pulsus paradoxus (when the difference between systolic blood pressure in inspiration
and expiration is increased > 10 mm Hg) may be present with significant airway
obstruction
• Auscultation
-‐‑ Most useful technique
-‐‑ Decreased intensity of breath sounds is most common finding
-‐‑ Wheezes during expiration are characteristic of obstructive airway disease
-‐‑ Rhonchi (low-‐‑pitched breath sounds similar to snoring) are often present during
exacerbations

Physical examination
findings in status
asthmaticus


• Spirometry is recommended to confirm diagnosis and define the severity of asthma
• Basic tests are forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1),
and the ratio of the two (FEV1/FVC)
Pulmonary Function • Obstructive disease =
Tests for Patients with -‐‑ FEV1/FVC ratio < 70% in adults (or < 80% in children)
Asthma -‐‑ In asthma, both the FEV1 and FEV1/FVC ratios are decreased
-‐‑ In asthma, FEV1 improves at least 12 % (and at least 200 mL) with bronchodilators
such as inhaled albuterol à if it doesn’t improve by 12%, diagnosis is more likely to
be COPD
• Methacholine Challenge Test
-‐‑ Methacholine is given in progressively higher concentrations to determine the dose
causing a 20% reduction in FEV1
-‐‑ Reaction to a concentration < 10 mg/mL is diagnostic of asthma
• Control factors that contribute to asthma severity (such as allergens and irritants) to
improve baseline respiratory status and decrease the frequency of exacerbations
• Monitor respiratory status with objective measures of lung function for diagnosis, for
Asthma Management classification of severity, and to assess response to treatment
• Use pharmacologic therapy to address the inflammatory nature of asthma
• Provide education for a partnership in asthma care, so that the patient and family
understand the disease well enough to be motivated to make changes, use medications
wisely, and work collaboratively with the physician.

Classification of asthma
in adults


Long-‐‑term control
medications for
managing asthma in
adults

• Pregnant women with asthma can be treated accordingly to the same protocols as other
patients
Treating pregnant • All of the inhaled asthma medications may be used in pregnancy. Montelukast and
women with asthma zafirlukast both have Category B safety indications for pregnancy. Because very little
prednisone crosses the placenta, it is also considered safe in pregnancy

Red flags for increased
risk of death from asthma


Make sure you go
through the USPSTF A https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-‐‑a-‐‑and-‐‑b-‐‑recommendations/
and B Recommendations

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Family Medicine Textbook Notes 1

ASCVD Risk Assessment

SET up the interview

Anterior Drawer Test

cephalexin; 2nd line: clindamycin)

• Tinea of the groin

• Headaches that occur daily or nearly daily

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