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Abdominal Pain
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Hypertension
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Joint Pain
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June 30, 2008
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Abdominal Pain
789.0X
GENERAL CONSIDERATIONS
Scope of This Article
This article discusses atraumatic abdominal pain in adults and older children.
Definition of Abdominal Pain
Complaint of pain in the area between the ribcage and pelvis.
Overview
Abdominal pain is frequent symptom encountered by a large portion of the otherwise healthy
population (in some studies more than 50%). Most commonly it is a benign complaint reflecting
a disease process that can be treated symptomatically. However, it may be the presenting
symptom to an acute life-threatening illness that requires rapid assessment and immediate triage
to an acute care facility.
Red Flags:
Red flags are historical or physical findings that suggest a higher severity of illness, requiring
further investigation.
Red Flag
Possible Etiology
Fever
Diarrhea
Persistent constipation
Hematochezia
Persistent Vomiting
Infection
Infection
Intestinal obstruction
Lower or upper GI bleed
Multiple etiologies
Hematemesis
Severe Pain
Upper GI bleed
Perforation, peritonitis
Pregnancy
Ectopic pregnancy, placental
abruption
Liver failure, biliary
obstruction
Jaundice
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Possible Consequence
Dehydration, sepsis
Dehydration
Dehydration
Hemodynamic instability
Dehydration, metabolic
acidosis
Hemodynamic instability
Sepsis, hemodynamic
instability
Increased fetal and maternal
morbidity, mortality
Hepatic encephalopathy
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History
The history should include:
Duration and frequency of pain
Severity and nature of pain.
Location and radiation of pain.
Aggravating/alleviating factors, such as food, antacids, exertion, defecation.
Associated symptoms, including fever, chills, weight loss or gain, nausea, vomiting,
diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or
stool, change in the diameter of stool.
Family history of bowel disorders.
Alcohol intake.
Medication use, including over the counter medications such as aspirin and NSAIDs.
Menstrual history.
Pain Duration
Acute: Pain of less than a few days duration, that has worsened progressively until the
time of presentation.
Chronic: Pain that has remained unchanged for months or years.
Pain that does not clearly fit either category might be called subacute, and requires
consideration of the differential diagnoses for both acute and chronic pain.
Pain Type
Pain Type
Visceral Pain
Parietal Pain
Character
Dull and aching,
but can be
colicky
Sharp
Localization
Poorly localized
Well localized
University of South Alabama, Department of Family Medicine
Cause
Distention or
spasm of a
hollow organ
Parietal
peritoneal
irritation
Examples
Intestinal
obstruction,
cholecystitis
Acute
appendicitis
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Pain Location
Causes of Abdominal Pain by Location
Location
Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
Epigastric
Periumbilical
Diffuse
Causes
Hepatitis
Cholecystitis
Cholangitis
Pancreatitis
Budd-Chiari Syndrome
Pneumonia
Splenic Abscess
Splenic Infarct
Gastritis
Gastric Ulcer
Pancreatitis
Appendicitis
Salpingitis
Ectopic Pregnancy
Inguinal Hernia
Nephrolithiasis
Inflammatory Bowel Disease
Diverticulitis
Salpingitis
Ectopic Pregnancy
Inguinal Hernia
Nephrolithiasis
Inflammatory Bowel Disease
Peptic Ulcer Disease
GERD
Gastritis
Pancreatitis
MI
Pericarditis
Aortic Aneurysm
Early Appendicitis
Gastroenteritis
Bowel Obstruction
Aortic Aneurysm
Ventral Hernia
Gastroenteritis
Mesenteric Ischemia
Metabolic
Irritable Bowel Syndrome
Bowel Obstruction
Peritonitis
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Pain Severity
The severity of the pain generally is related to the severity of the disorder, especially if acute in
onset. As an example, the pain of biliary obstruction, renal colic, or mesenteric infarction is of
high intensity, while the pain of gastroenteritis is less marked. Age, mental status, and general
health may affect the patient’s clinical presentation. A patient taking corticosteroids may have
significant masking of pain, and the elderly often present with less intense pain.
Associated Symptoms
Symptoms that occur in relation to abdominal pain may give important information. Nausea and
vomiting occur with a number of disorders. Weight loss may occur in association with
malignancy. A change in bowel habits suggests a colonic lesion.
Women should be asked whether they are sexually active, the number of sexual partners,
whether any sexual partners are new, and whether any sexual partners are experiencing
symptoms suggestive of a sexually transmitted infection.
Physical Examination
General Exam
General appearance. Patients with peritonitis try to remain immobile.
Vital signs, including measurement of orthostatic changes in blood pressure and heart
rate. Obstruction or peritonitis can cause large amounts of third spacing of fluid and
intravascular volume depletion or overt shock.
Jaundice.
Abdominal Exam
Auscultation. Hypoactive sounds may be noted in advanced peritonitis or ileus. Highpitched bowel sounds are a feature of early bowel obstruction.
Gentle percussion is useful to identify acute peritonitis. Percussion is also used to
identify ascites, liver span, and bladder and splenic enlargement. Tympany signifies
distended bowel, while dullness may signify a mass.
Palpation must be performed gently and while the patient is distracted. Muscular rigidity
or ―guarding‖ is an important and early sign of peritoneal inflammation. Palpation also
may detect enlarged organs, masses, or hernias.
Rectal and Pelvic Exam
A rectal is generally required in all patients with acute abdominal pain. Fecal impaction
might be the explanation for signs and symptoms of obstruction in the elderly. Stool for
occult blood should also be obtained.
A pelvic exam is generally required in all women with acute lower abdominal pain, and is
critical for determining whether abdominal pain is due to pelvic inflammatory disease, an
adnexal mass or cyst, uterine pathology, or an ectopic pregnancy.
University of South Alabama, Department of Family Medicine
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ACUTE ABDOMINAL PAIN
Surgical Abdomen (AKA ―Acute Abdomen‖)
The first priority in patients with acute abdominal pain is to determine who has a rapidly
worsening prognosis in the absence of surgical intervention. Only after the clinician is satisfied
that the abdominal presentation is not an acute surgical emergency can consideration of other
diagnostic possibilities begin. Patients should not eat or drink while a diagnosis of a surgical
abdomen remains under consideration.
The two syndromes that cause most surgical abdomens are obstruction and peritonitis. The latter
encompasses most severe abdominal pathology since intraperitoneal hemorrhage or viscus
perforation typically present with common features of peritonitis.
Obstruction
Obstruction generally presents as pain together with anorexia, bloating, nausea, and
vomiting. Physical examination may reveal distension and high-pitched or absent bowel
sounds. Abdominal percussion reveals tympany from proximally dilated loops of bowel.
An abdominal mass, if present, may suggest an etiology for the obstruction.
Peritonitis
Patients with peritonitis of any cause tend to appear ill and lie still to minimize their
discomfort. Rebound tenderness, abdominal wall rigidity, and percussion tenderness are
classically thought to reflect peritonitis. Other subtle signs of peritonitis include
diminished bowel sounds and pain worsened when an examiner lightly bumps the
stretcher.
Initial Diagnostic Testing
Complete blood count with differential
Electrolytes, BUN, creatinine, and glucose
Aminotransferases, alkaline phosphatase, and bilirubin
Lipase
Urinalysis
Pregnancy test in women of childbearing potential
While these laboratory tests are important, they are not sufficient to rule in or rule out a diagnosis
of surgical abdomen, as a surgical abdomen is a clinical diagnosis.
Subsequent Diagnostic Testing
Patients clearly in need of urgent laparotomy may proceed directly to the operating room for
diagnosis and management. In particular, patients with a painful pulsatile abdominal mass, with
or without bruit, should be suspected to have a ruptured aortic aneurysm.
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However, many patients will not have a firm diagnosis after initial assessment, and in these
cases, careful observation of the patient’s course will be the most important factor in their
management. In addition, the following additional investigations can also be considered:
Blood and urine cultures, in the presence of fever or unstable vital signs.
CT Scan. When available, CT scanning is the test of choice for detecting partial or
complete bowel obstruction, hernias, diverticulitis, renal stones, and aortic aneurysms. It
can also be useful in investigating appendicitis, peritonitis, ischemia due to
strangulation/adhesions, and pancreatitis. CT scan may play a decision-making role
when evaluating demented or obtunded patients.
Plain Abdominal Films. Where CT scanning is immediately available, abdominal plain
films are not necessary, as they do not provide additional information. However, in the
absence of CT scanning, flat and upright or lateral decubitus radiographs are a crucial
step in decision making for the suspected surgical abdomen, as proximally dilated loops
of bowel are the hallmark of intestinal obstruction, and free intraperitoneal air can
confirm a suspicion of hollow organ perforation.
Ultrasound. Ultrasound is the preferred test in pregnancy, and evaluating biliary and
pelvic pathology. If more readily available, it may also be useful for many of the
conditions listed above under CT Scan.
Right Upper Quadrant Pain
Usually caused by involvement of the liver or biliary tree.
Initial assessment
The presence of fever and jaundice in a patient with right upper quadrant pain leads to a clinical
diagnosis of ascending cholangitis. Acute cholecystitis can also present as a systemically unwell
patient with low-grade fever. Patients with an acute rise in aminotransferases and right upper
quadrant pain most likely have choledocholithiasis, particularly if there is also an acute rise in
bilirubin.
Initial Diagnostic Testing
Complete blood count with differential.
Electrolytes, BUN, creatinine, and glucose.
Aminotransferases, alkaline phosphatase, and bilirubin.
Lipase.
Abdominal ultrasound. (Plain films of the abdomen are unlikely to yield much
information.)
Subsequent Diagnostic Testing (if available)
Endoscopic ultrasound.
Endoscopic retrograde cholangiopancreatography (ERCP).
Magnetic resonance cholangiopancreatography (MRCP).
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Epigastric Pain
Epigastric pain that is relatively sudden in onset is suggestive of pancreatitis, particularly when it
radiates to the back and is associated with nausea, vomiting, and anorexia.
Epigastric pain that is less acute and is associated with bloating, abdominal fullness, heartburn,
or nausea can be classified as dyspepsia. Most of these patients can safely undergo a therapeutic
trial or watchful waiting. However red flags that suggest a need for further investigation include:
Age over 50.
Weight loss.
Persistent vomiting.
Dysphagia.
Anemia.
Hematemesis, melena, or heme positive stool.
Palpable abdominal mass.
Family history of upper gastrointestinal carcinoma.
Previous gastric surgery.
Refractory/recurrent symptoms.
It is also important to consider nonabdominal etiologies of upper abdominal pain:
Cardiac pain.
Pleural or pulmonary pathology.
Initial Diagnostic Testing
Many patients can be managed with a therapeutic trial of antisecretory therapy without further
investigation. However, those with red flags or suspicion of pancreatitis should have the
following:
Complete blood count with differential.
Electrolytes, BUN, creatinine, and glucose.
Aminotransferases, alkaline phosphatase, and bilirubin.
Lipase. Elevated lipase in the presence of epigastric pain is very suggestive of
pancreatitis. Amylase is a less specific alternative, if lipase is not available.
Subsequent Diagnostic Testing
Esophagogastroduodenoscopy (EGD), especially for those with red flags and dyspepsia.
Testing for Helicobacter pylori may be considered, especially in refractory/recurrent
cases.
Abdominal ultrasound if pancreatitis is being considered, since biliary disease is a
common etiology for pancreatitis.
CT Scan is more sensitive for the diagnosis of pancreatitis than ultrasound; consider if
doubts remain after an ultrasound has been obtained.
University of South Alabama, Department of Family Medicine
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Lower Abdominal Pain
Pain in the lower abdomen can be associated with pathology in the following:
Distal intestinal tract.
Upper abdominal structures with pain radiating into the lower abdomen.
The pelvis.
The history should include risk factors for infectious and ischemic causes, medication use (e.g.,
NSAIDs, laxatives), and family history of inflammatory bowel disease (IBD). Patients should be
asked about urinary symptoms such as frequency, urgency, and dysuria.
Left and/or right lower quadrant pain, when occurring together with diarrhea, is suggestive of
colitis and/or ileitis. Diverticulitis presents more frequently as left lower quadrant pain, often
with leukocytosis.
In older patients, abdominal pain and a change in bowel habits can be the first sign of colon
cancer.
It is also important to consider nonabdominal etiologies of upper abdominal pain:
Retroperitoneal pathology.
Cystitis can cause suprapubic pain.
Renal colic results in pain that may radiate to the lower abdomen.
Lower abdominal pain (pelvic pain) in women is frequently caused by disorders of the
internal female reproductive organs. (Discussed below.)
Initial Diagnostic Testing
Complete blood count with differential.
Urinalysis (and culture if results dictate).
Subsequent Diagnostic Testing
Stool studies in patients with severe or persistent lower abdominal pain associated with
diarrhea, and immunosuppressed patients, should include culture for enteric pathogens,
microscopy for ova and parasites, and measurement of Clostridium difficile toxin.
However, many patients with less severe presentations will often have self-limited
illness, and can be managed expectantly.
Colonoscopy in patients with illness exceeding two weeks with negative cultures,
systemically unwell patients, immunosuppressed patients, and when ileal pathology is
suspected. (Note that patients over age 50 are also candidates for screening colonoscopy,
and their presenting symptoms provide an opportunity to discuss this.)
CT scan, especially in cases suggestive of diverticulitis.
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Lower Abdominal Pain in Women
Additional history in women should include:
Regularity and timing of menstrual periods.
Possibility of pregnancy.
Presence of vaginal discharge or bleeding.
Recent history of dyspareunia or dysmenorrhea.
In addition to the causes of lower abdominal pain discussed above, other common etiologies of
acute lower abdominal pain in women include:
Pelvic inflammatory disease (PID).
Adnexal cysts or masses with bleeding.
Ovarian torsion.
Ectopic pregnancy.
Uterine pain due to infection (endometritis) or torsion of leiomyomas.
A pelvic examination is part of the physical examination whenever pelvic pathology is in the
differential diagnosis. Purulent cervical discharge, cervical tenderness, uterine enlargement, or
adnexal masses may be detected. PID should be considered when acute left, right, or bilateral
abdominal pain is accompanied by fever and an elevated white blood count with left shift.
Initial Diagnostic Testing
In addition to tests discussed above, women with lower abdominal pain should have the
following:
Pregnancy test in women of childbearing potential, even when pregnancy is felt unlikely.
Wet prep of any abnormal vaginal discharge.
Tests for Chlamydia and gonococcus in women with risk factors for sexually transmitted
infections, mucopurulent cervical discharge, or suspected PID.
Subsequent Diagnostic Testing
Pelvic ultrasound, especially if pregnancy test is positive, or pelvic exam is suggestive of
PID or adnexal masses.
Generalized Abdominal Pain (not meeting the criteria of ―surgical abdomen‖)
Generalized abdominal pain with vomiting and/or diarrhea, alone or in association with systemic
symptoms, often represents an acute self-limited illness, such as viral or bacterial enteritis or
colitis, or toxin-mediated food poisoning. Multisystem symptoms, such as upper respiratory
tract involvement or myalgias, may suggest a viral etiology.
University of South Alabama, Department of Family Medicine
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A condition that may require urgent surgical management, yet present without clear peritoneal
findings, is acute mesenteric ischemia/mesenteric infarction. If clinically reasonable, the
diagnosis of ischemic bowel disease should be entertained, particularly if the patient has the
classic finding of pain out of proportion to physical findings, or risk factors such as congestive
heart failure, recent myocardial infarction, hypotension, hypovolemia, sepsis, or cardiac surgery.
Young patients should have mesenteric ischemia considered if they have a known personal or
family history of hypercoagulable state or venous thrombosis.
Diffuse abdominal pain can also be a nonspecific symptom of underlying metabolic, toxic,
neurogenic, or other extra-abdominal disease. The presence of systemic illness, fatigue,
weakness, nausea, flu-like symptoms, or signs and symptoms of endocrinopathies that are
associated with abdominal pain should signal a search for metabolic abnormalities, such as
diabetic ketoacidosis or Addison’s disease. One should inquire about drug use/withdrawal,
toxin/poison exposures, or possible black widow spider bite. Pain localized to one unilateral
dermatome is highly suggestive of herpes zoster.
Extra-Abdominal Causes of Acute Abdominal Pain
Cardiac
Thoracic
Neurologic
Metabolic
Hematologic
Toxins
Infection
Miscellaneous
Myocardial ischemia
Myocarditis
Endocarditis
CHF
Pleurodynia
PTE
Pneumothorax
Empyema
Esophagitis
Esophageal spasm
Esophageal rupture
Radiculitis
Herpes zoster
Uremia
Diabetes mellitus
Hyperlipidemia
Hyperparathyroidism
Acute adrenal insufficiency
Sickle cell anemia
Hemolytic anemia
Henoch-Schönlein purpura
Acute leukemia
Hypersensitivity reactions
Lead poisoning
Osteomyelitis
Typhoid fever
Narcotic withdrawal
Heat stroke
Psychiatric disorders
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Initial Diagnostic Testing
In patients with symptoms suggestive of an acute infectious gastroenteritis or toxin-mediated
food poisoning, the most useful diagnostic tool will often be watchful waiting for spontaneous
recovery.
Patients for whom a metabolic etiology of abdominal pain is suspected should have the
following:
Complete blood count with differential.
Electrolytes, with calculation of an anion gap.
BUN, creatinine, blood glucose.
Calcium.
Subsequent Diagnostic Testing
An imaging procedure (angiography, CT/MRI angiography) will generally be required
for patients with suspected ischemic bowel disease.
CHRONIC ABDOMINAL PAIN
Chronic abdominal pain is a common complaint, and the vast majority of patients will have a
functional disorder, often irritable bowel syndrome. The initial workup is therefore focused on
differentiating benign functional illness from organic pathology. Helpful historical clues include
the overall time course of the problem, whether pain is constant or intermittent, abnormalities in
bowel habits, and aggravating/alleviating factors. Since many multisystem illnesses could
contribute to a nonspecific abdominal complaint, a full physical exam should be performed.
Specifically, the physical examination should clarify any focus of abdominal tenderness that may
merit and focus further investigation.
The following features suggest an organic illness:
Unstable vital signs.
Weight loss.
Fever.
Dehydration.
Electrolyte abnormalities.
Symptoms or signs of gastrointestinal blood loss, anemia, or malnutrition.
University of South Alabama, Department of Family Medicine
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Initial diagnostic testing
The following tests should be considered in most patients with chronic abdominal pain:
Complete blood count with differential.
Electrolytes, BUN, creatinine, and glucose.
Calcium.
Aminotransferases, alkaline phosphatase, and bilirubin.
Lipase.
Ferritin.
C-reactive protein and erythrocyte sedimentation rate are sensitive but nonspecific
markers that may suggest the presence of occult organic disease; in selected cases, they
may have some utility in ruling out organic causes of chronic abdominal pain.
Subsequent Diagnostic Testing
At the conclusion of the initial workup, young patients with no evidence of organic disease can
be treated symptomatically. The use of further invasive testing should be directed at ruling in or
out specific diseases and not as a general screen.
A diagnosis of new-onset functional illness should only be made with great caution in patients
over 50 years of age. These patients, by virtue of their increased risk of malignancy, will likely
require investigation with endoscopy, CT, and/or ultrasound.
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FLOW CHARTS
Initial Approach to Abdominal Pain
History
Physical exam
Initial lab tests
Radiographs
Patient
hemodynamically
stable
YES
NO
Rigid (surgical)
abdomen?
Non-rigid abdomen
algorithm
YES
NO
CBC, lytes
CT if available or abd
films & CXR
Surgery consult
Suspect AAA
Nonspecific
Limited
resuscitation/
urgent CT/surgery
Obstruction
Perforation
Resuscitation/
surgery
Consider
unusual causes
of rigid
abdomen
Investigate
Treat
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Non-Rigid Abdomen
See chronic
abdominal pain
discussion
above
Chronic
See pain
location table
above
YES
Signs & Symptoms
Acute
Localized?
NO
NO
Suspect AAA
YES
Early obstruction
Early appendicitis
Mesenteric ischemia
IBD
Enteritis
Pancreatitis
Metabolic diseases
Narcotic withdrawal
Not
Confirmed
CT scan
Consider GI and/or surgery
consult
Confirmed
Limited resuscitation/
surgery
University of South Alabama, Department of Family Medicine
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References:
Penner, Robert M., Sumit R. Majumdar; Diagnostic Approach To Abdominal Pain In Adults;
UpToDate.com; August 2007.
---------------------Tintinalli, Judith E., Gabor D. Kelen, J. Stephan Stapczynski, O. John Ma, David M. Cline;
Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6th Edition; 2004; American
College of Emergency Physicians
---------------------Ables, Adrienne, I. Simon, Emily Melton; Update On Helicobacter Pylori Treatment; American
Family Physician; Volume 75, Number 3; February 1, 2007
---------------------Ramakrishnan, Kalyanakrishnan, Robert Salinas; Peptic Ulcer Disease; American Family
Physician, Volume 76; Number 7, October 1, 2007
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Asthma
493.XX
Definition:
Asthma is defined as a chronic inflammatory pulmonary disorder that is characterized by
reversible obstruction of the airways. Environmental factors, (e.g. allergens, irritants, cold air,
and viruses) play a role in provoking the airway inflammation, which in turn results in wheezing,
breathlessness, chest tightness, and coughing due to airway hyper-responsiveness which
characterizes the asthma patient. These symptoms are often reversible either spontaneously or
with treatment.
General Approach to the patient:
There are four main components in the management of asthma patients:
1.
2.
3.
4.
Assessment and monitoring
Pharmacologic therapy
Control of factors contributing to asthma severity
Patient education
Overview:
More than 22 million people suffer from asthma in the US; 6 million of them are children.
Asthma accounts for nearly 500,000 hospitalizations 13.6 million visits to office based
physicians, 1.8 million emergency department visits, and 3780 deaths in the United States each
year. Despite an increased understanding of pathophysiology and treatment options, the disease
remains undertreated. Asthma guidelines have been established to address the disparity between
scientific knowledge and actual management.
The Encounter
Chief Complaint:
Patients often seek medical attention complaining of episodes of wheezing, shortness of breath,
or coughing. In the case of exercise induced asthma patients present with similar symptoms
brought about mainly by physical exercise.
History of Present Illness:
Symptoms of asthma are often worsened by allergens or irritants and in a lot of cases by upper
respiratory tract infections. Symptoms are often worse at night. Some patients will give a history
of multiple doctor visits or emergency room visits for similar symptoms prior to being diagnosed
with asthma. Emotions and stress may also act as a trigger for exacerbation of symptoms.
Asthma patients often have a history of other allergies (e.g. allergic rhinitis or atopic dermatitis).
A family history of asthma may also be elicited.
University of South Alabama, Department of Family Medicine
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Physical:
It is important to keep in mind that asthma patients may have no pertinent findings on
examination due to the episodic nature of the illness. However, symptomatic patients may have
one or more of the following findings:
Wheezing during normal respiration or induced by forced expiration.
In acute exacerbations, evidence of respiratory distress in the form of tachypnea, hypoxia
and use of accessory muscles may be seen.
Hyper-expansion of the lungs.
Manifestations of other allergic illnesses as described above.
Lab Testing:
Pulmonary function testing:
Establish the presence of airflow obstruction:
FEV1 <80%
Establish reversibility:
FEV1 increases 12% or more after using a short-acting inhaled beta2 agonist (e.g.
albuterol)
Special Considerations:
Children younger than 5 years of age suffering from asthma are often mislabeled as
having recurrent upper respiratory tract infections or reactive airway disease. In this population,
the diagnostic criteria discussed above apply as well, however, spirometry is not possible. Hence,
a diagnosis is not needed to begin to treat recurrent episodes of wheezing.
Classification of Asthma severity:
The following classification is used to describe asthma severity in individual patients and aids
the physician in choosing the appropriate medication for every patient.
Days With
Symptoms
Step 4
Continual
Severe
Persistent
Step 3
Daily
Moderate
Persistent
Step 2
3-6/week
Mild
Persistent
Step 1
2/week
Intermittent
Nights With
Symptoms
Frequent
PEF or
FEV1
60%
Interference with
Normal Activity
Extreme Limitation
5/month
>60%<80%
Some Limitation
3-4/month
80%
Minor Limitation
2/month
80%
None
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NOTES:
Patients should be assigned to the most severe step in which any feature occurs.
Clinical features for individual patients may overlap across steps.
An individual’s classification may change over time.
Patients at any level of severity of persistent asthma can have mild, moderate, or severe
exacerbations of asthma. Some patients with intermittent asthma experience severe and
life-threatening exacerbations separated by long periods of normal lung function and no
symptoms.
Management:
Goals of Asthma Therapy:
1. Prevent chronic asthma symptoms and exacerbations.
2. Maintain normal activity levels
3. Have normal or near-normal lung functions
4. Minimizing side effects of therapy
Patient Education:
The following key points should be addressed following the diagnosis of asthma:
Patients can live a normal life if the asthma is managed correctly.
Asthma is better controlled if the patient works together with the physician.
Lack of symptoms does not equal absence of inflammation of the airways, hence, longterm anti-inflammatory medications, if indicated, are important in asthma control.
Many exacerbating factors exist in the home, school, or work environment which may
lead to asthma attacks.
Long-term care and monitoring is essential for the proper management of asthma.
Pharmacotherapy:
Medications used to control asthma consist of:
Long-term control medications: These medications are used daily in the treatment of persistent
asthma and include anti-inflammatory agents, long-acting bronchodilators, and leukotriene
modifiers.
Corticosteroids: Most potent and effective anti-inflammatory medication currently
available. The Inhaled form is used as the first line of therapy in the treatment of
persistent asthma. Systemic corticosteroids are often used during asthma exacerbations
for prompt alleviation of symptoms.
Cromolyn sodium and nedocromil: Mild-to moderate anti-inflammatory medications.
May be used as initial choice for long-term-control therapy for children.
Long-acting beta2-agonists: Long-acting bronchodilator used concomitantly with antiinflammatory medications for long-term control of symptoms.
Methylxanthines: Theophylline is a mild-to-moderate bronchodilator used principally as
an adjuvant to inhaled corticosteroids in severe cases.
Leukotriene modifiers: Leukotriene modifiers may be considered an alternative or used
as an adjunct therapy to low doses of inhaled corticosteroids.
University of South Alabama, Department of Family Medicine
June 30, 2008
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L O N G - T E R M C O N T R O L M E D I C AT I O N S
Name/Products
Indications
Potential Adverse Effects
Inhaled
Corticosteroids:
Beclomethasone
dipropionate
Budesonide
Flunisolide
Fluticasone propionate
Triamcinolone
acetonide
Systemic
Corticosteroids:
Methylprednisolone
Prednisolone
Prednisone
Cromolyn Sodium
and Nedocromil
Long-Acting
Beta2-Agonists
- Long-term prevention of
symptoms; suppression, control,
and reversal of inflammation.
- Reduce need for oral
corticosteroid.
-For short-term (3–10 days)
―burst‖: to gain prompt control of
inadequately controlled asthma.
- For long-term prevention of
symptoms in severe persistent
asthma: suppression, control, and
reversal of inflammation.
- Long-term prevention of
symptoms; may modify
inflammation.
- Preventive treatment prior to
exposure to exercise or known
allergen.
- Long-term prevention of
symptoms, especially nocturnal
symptoms, added to antiinflammatory therapy
- Prevention of exercise-induced
bronchospasm.
- Not to be used to treat acute
symptoms or exacerbations.
Methylxanthines
Theophylline
- Long-term control and prevention
of symptoms, especially nocturnal
symptoms.
Leukotriene
Modifiers
Zafirlukast tablets
Zileuton tablets
- Long-term control and prevention
of symptoms in mild persistent
asthma for patients
>12 years of age.
University of South Alabama, Department of Family Medicine
- Cough, dysphonia, oral thrush.
- In high doses, systemic effects may occur,
although studies are not conclusive, and clinical
significance of these effects has not been
established.
-Short-term use: reversible, abnormalities in glucose
metabolism, increased appetite, fluid retention,
weight gain, mood alteration, hypertension, peptic
ulcer, and rarely aseptic necrosis of femur.
- Long-term use: adrenal axis suppression, growth
suppression, dermal thinning, hypertension,
diabetes,
Cushing’s syndrome, cataracts, muscle weakness,
and—in rare instances—impaired immune function.
- Consideration should be given to coexisting
conditions that could be worsened by systemic
corticosteroids, such as herpes virus infections,
Varicella and tuberculosis.
-15 to 20 percent of patients complain of an
unpleasant taste from nedocromil.
-Tachycardia, skeletal muscle tremor, hypokalemia,
prolongation of QTc interval in overdose.
- Dose-related acute toxicities include tachycardia,
nausea and vomiting, tachyarrhythmias
(SVT), CNS stimulation, headache, seizures,
hematemesis, hyperglycemia, and hypokalemia.
- Adverse effects at usual therapeutic doses include
insomnia, aggravation of peptic ulcer or reflux,
increase in hyperactivity in some children, difficulty
in urination in elderly males with prostatism.
-Elevation of liver enzymes has been reported.
June 30, 2008
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Quick relief medications:
These medications are used to provide prompt treatment of acute airflow obstruction and may be
the sole medication used in intermittent asthma.
Short-acting beta2-agonists: It is the treatment of choice for the relief of acute
symptoms and prevention of Exercise Induced Asthma.
Anticholinergics: Ipratropium bromide may provide some additive benefit to inhaled
beta2-agonists in severe exacerbations.
Systemic corticosteroids: Used in moderate-to-severe exacerbations to speed recovery
and prevent recurrence of exacerbations.
Q U I C K - R E L I E F M E D I C AT I O N S
Name/Products
Indications
Short-Acting
Inhaled Beta2-Agonists
Albuterol
Bitolterol
Pirbuterol
Terbutaline
-Relief of acute symptoms;
quick-relief medication.
-Preventive treatment prior to
exercise for exercise-induced
bronchospasm.
Anticholinergics
Ipratropium bromide
-Relief of acute
bronchospasm.
Systemic Corticosteroids:
Methylprednisolone
Prednisolone
Prednisone
-For moderate-to-severe
exacerbations to prevent
progression of exacerbation,
reverse inflammation, speed
recovery, and reduce rate of
relapse.
University of South Alabama, Department of Family Medicine
Potential Adverse Effects
-Tachycardia, skeletal muscle
tremor, hypokalemia,
increased lactic acid,
headache, hyperglycemia. Inhaled route, in general,
causes few systemic adverse
effects.
-Drying of mouth and
respiratory secretions, and
increased wheezing in some
individuals.
-Short-term use: reversible
abnormalities in glucose
metabolism, increased
appetite, fluid retention,
weight gain, mood alteration,
HTN, peptic ulcer, and rarely
aseptic necrosis of femur.
June 30, 2008
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Stepwise Approach for Management of Asthma:
University of South Alabama, Department of Family Medicine
June 30, 2008
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University of South Alabama, Department of Family Medicine
June 30, 2008
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University of South Alabama, Department of Family Medicine
June 30, 2008
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Step Down Therapy:
This involves gradual reduction of long-term control medications after a long period of control of
persistent asthma. Inhaled steroids may be reduced by about 25% every 3 months until the lowest
dose required to treat is reached.
If the patient is on chronic systemic steroid therapy, continuous attempts should be made to
reduce the dosage.
Step Up Therapy:
This involves increasing therapy in response to indicators of poor asthma control. A short course
of systemic steroids may be necessary to rapidly alleviate the symptoms and regain control of the
asthma. It is necessary to explore possible causes of the deterioration of the patient’s condition
(e.g. non-compliance with medications, infections, or exposure to triggering factors).
University of South Alabama, Department of Family Medicine
June 30, 2008
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Strength of Recommendation
Label Key clinical recommendations
B
Inhaled corticosteroids are more effective than cromolyn, nedocromil, theophylline, and
leukotriene modifiers for the long-term control of asthma.
A
Inhaled corticosteroids are recommended as first-line treatment in children with acute
asthma.
A
The combination of a beta agonist and an inhaled corticosteroid is superior to the
addition of a leukotriene modifier.
C
Adding an antibiotic to usual care is not recommended in patients with asthma.
2
Managing Exercise Induced Asthma:
With this entity, patients will present with a history of wheezing, shortness of breath, chest
tightness, or cough spells in response to activity. Generally it begins at the start of exercise,
peaks 5 to 10 minutes later and usually resolves in another 20 to 30 minutes. Diagnosis may be
confirmed by measuring a 15% decrease in peak flow readings or FEV1 after vigorous exercise.
Pharmacotherapy:
Two to four puffs of short-acting beta2-agonist 5 to 60 minutes before exercise (effects
last 2-3 hours).
Use of long-acting beta2-agonist (effects last 10-12 hours)
Cromolyn or nedocromil can also be used before exercise (effects last 1-2 hours)
Montelukast may be used for this purpose if taken daily.
A 6-10 minute warm-up period before exercise may be beneficial to the patient.
Increase in long-term control medication, if appropriate.
Follow-up:
Follow up for proper management and monitoring of asthma is as follows:
Every 2-6 weeks while gaining control of symptoms.
Every 1-6 months to monitor maintenance of sufficient control.
Every 3 months to assess for step down in therapy.
University of South Alabama, Department of Family Medicine
June 30, 2008
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During the follow up visit a history of their asthma symptoms should be obtained to ascertain
proper asthma control. The following is an example of such a questionnaire:
1) In the past 4 weeks, how much of the time did your asthma keep you from getting as
much done at work, school or at home?
2) During the past 4 weeks, how often have you had shortness of breath?
3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing,
shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in
the morning?
4) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer
medication (such as albuterol)?
5) How would you rate your asthma control during the past 4 weeks?
A thorough physical exam should be performed with a special attention to the lung examination.
A verification of the asthma severity should be made and medications altered accordingly.
Steps for Correct use of an Inhaler:
1. Remove the cap and hold inhaler upright.
2. Shake the inhaler.
3. Tilt your head back slightly and breathe out slowly.
4. Position the inhaler into mouth as directed.
5. Press down on the inhaler to release medication as you start to breathe in slowly.
6. Breathe in slowly (3 to 5 seconds).
7. Hold your breath for 10 seconds to allow the medicine to reach deeply into your lungs.
8. Repeat puff as directed. Waiting 1 minute between puffs may permit second puff to penetrate
your lungs better.
9. Spacers/holding chambers are useful for all patients. They are particularly recommended for
young children and older adults and for use with inhaled corticosteroids.
Avoid common inhaler mistakes. Follow these inhaler tips:
Breathe out before pressing your inhaler.
Inhale slowly.
Breathe in through your mouth, not your nose.
Press down on your inhaler at the start of inhalation (or within the first second of
inhalation).
Keep inhaling as you press down on inhaler.
Press your inhaler only once while you are inhaling (one breath for each puff).
Make sure you breathe in evenly and deeply.
University of South Alabama, Department of Family Medicine
June 30, 2008
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Management of Asthma Exacerbation at Home:
Assess Severity
Measure PEF: Value <40% personal best or predicted
suggests severe exacerbation.
Note signs and symptoms: Degrees of cough,
breathlessness, wheeze, and chest tightness correlate
imperfectly with severity of exacerbation. Accessory
muscle use and suprasternal retractions suggest severe
exacerbation.
Initial Treatment
Inhaled short-acting beta2-agonist: up to three
treatments of 2-4 puffs by MDI at 20-minute
intervals or single nebulizer treatment.
Good Response
Mild Exacerbation
-PEF >70% predicted of
personal best
-No wheezing or shortness
of breath
-Response to beta2-agonist
sustained for 4 hours
May continue beta2agonist every 3-4 hr for 2448 hours.
For patients on inhaled
corticosteroids, double
dose for 7-10 days.
Contact clinician for
follow-up instructions.
Incomplete Response
Moderate Exacerbation
-PEF 40-70% predicted
of personal best
-Persistent wheezing and
shortness of breath
Poor Response
Severe Exacerbation
PEF <40% predicted of
personal best
Marked wheezing and
shortness of breath
Add oral corticosteroid.
Continue beta2-agonist.
Add oral corticosteroid.
Repeat beta2-agonist
immediately.
If distress is severe and
nonresponsive, call your
doctor and proceed to
emergency department;
consider calling 911.
Contact clinician
urgently (this day) for
instructions.
Proceed to emergency
department.
University of South Alabama, Department of Family Medicine
June 30, 2008
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Supplemental Material:
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
http://www.aafp.org/fpm/20041000/asthmaencounterform.pdf
Resources for Patients:
http://www.aaaai.org/patients/publicedmat/tips/asthmatriggersandmgmt.stm
http://www.aaaai.org/patients/publicedmat/tips/childhoodasthma.stm
http://www.aaaai.org/patients/publicedmat/tips/exerciseinducedasthma.stm
References:
National Institutes of Health (NIH) guidelines
University of South Alabama, Department of Family Medicine
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Chest Pain
780.5x
Definition:
A complaint based diagnosis which refers to any of a number of conditions associated with
discomfort between the clavicles and the xyphoid process that cause a patient to seek evaluation.
General Approach to the patient:
Goals:
1. Identify specific or life-threatening causes of chest pain
2. Obtain adequate information to develop a working diagnosis in an efficient manner
3. Arrange for definitive care of identified specific causes of chest pain at time of
presentation or with appropriate follow-up
4. Allay fears of patient and family regarding symptom if cause is benign
5. Provide symptomatic relief of patient complaints
6. Avoid ordering unnecessary tests on low risk patients
University of South Alabama, Department of Family Medicine
June 30, 2008
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Rules of Thumb:
1-10
11- 25
25-40
40-65
>65
Complaint
frequency
Common
Common
Common
Common
Common
Commonly
diagnosed
diseases (in
descending
order of
prevalence)
Chest wall
pain
Asthma
Functional
GE reflux
Chest wall
pain
Functional
Asthma
GE reflux
Age
Acute chest
(sickle cell)
Cardiac
conditions
Pulmonary
embolism
Cocaine and
other
substances
Life
threatening
diseases to
consider
Asthma
Acute chest
(sickle cell)
Cardiac
conditions
Key
worrisome
features
(history)
History of
heart disease,
History of
recent cancer
treatment
History of
heart disease,
History of
recent cancer
treatment
Key elements
of exam
Respiratory
rate,
Palpation of
chest wall
Cardiopulmonary
exam
Respiratory
rate, Pulse,
Palpation of
chest wall
Cardiopulmonary
exam
Key
diagnostic
study
Common
Treatment
Functional
limitations
None,
consider
CXR
NSAIDS,
asthma meds
Usually none,
especially if
asthma
controlled
None,
consider CXR
Chest wall pain
GE reflux
Panic disorder
Peptic ulcer
disease
Atypical chest
pain
Unstable
angina
Pulmonary
embolism
Pneumonia
Acute chest
(sickle cell)
Cocaine and
other
substances
Male sex,
History of
CAD,
diaphoresis,
radiation of
pain
Respiratory
rate, Pulse,
Palpation of
chest wall
Cardiopulmonary
exam
Based on
clinical
suspicion,
consider ECG
and if severe
cardiac markers
Chest wall pain
GE reflux
Atypical chest
pain
Typical angina
Unstable angina
Pulmonary
embolism
Aortic aneurysm
Male sex, History
of CAD,
diaphoresis,
severity and
radiation of pain
Respiratory rate,
Pulse,
Palpation of
chest wall
Cardiopulmonary exam
Atypical chest
pain
Typical angina
GE reflux
Chest wall pain
Unstable angina
Pulmonary
embolism
Valvular
disease
Aortic
aneurysm
History of
CAD,
diaphoresis,
severity and
radiation of
pain
Respiratory
rate, Pulse,
Palpation of
chest wall
Cardiopulmonary
exam
ECG, consider
cardiac markers,
others based on
clinical suspicion
ECG, consider
cardiac
markers, others
based on
clinical
suspicion
Disease
dependent
Disease
dependent
Disease
dependent
Disease
dependent
Based on
diagnosis
Based on
diagnosis
Based on
diagnosis
Based on
diagnosis
University of South Alabama, Department of Family Medicine
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Overview:
Chest pain is a common reason for patients and parents of patients to seek care. In a large part
because of public attention regarding ischemic heart disease, 50% of adolescents presenting with
chest pain were worried about heart disease, despite the fact that heart disease rarely causes chest
pain in this age group (less than 5%)1. Even in adults, the most common etiology is chest wall
pain although a cardiac etiology is much more likely than in children and adolescents (ranging
from 16% in an office setting to 50% in an emergency department setting). 2,3 The role of the
physician is to evaluate and quickly assess the likelihood of the complaint being one of several
life threatening conditions. The reality is that often these conditions can be eliminated on the
basis of history in the office setting, and then the clinician’s main task is one of reassurance.
Because of patient and family concern, it is important to quickly reach a decision about whether
the symptom warrants intensive evaluation or can be evaluated in a more leisurely fashion (or
even be treated symptomatically until it resolves with no further evaluation). Complaints related
to an acute onset of symptoms (under 48 hours) are associated with more severe illness but this is
not always the case. These complaints always tend to be of more concern to the patient than do
more persistent symptoms (some people will have had symptoms for as long as 6 months or
more before seeking evaluation).
There is no single reassuring finding that can eliminate life-threatening diagnoses from
consideration. The most common of these in adults, though, have had evidence based decision
rules developed which allow clinicians to comfortably triage patients into appropriate settings for
diagnostic tests and definitive treatment. The clinician can take advantage of these decision
support tools either by accessing them electronically or using traditional resources and
completing calculations by hand or approximating risk and using the support tools to develop
―rules-of-thumb‖.
Chief Complaint: Typically the complaint is ―Chest Pain‖
Vitals:
Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse,
respiratory rate, basal metabolic index (BMI) and pulse oximeter if applicable should be noted.
In addition, in patients over 20, cardiovascular risk factors (tobacco use, diabetes, hypertension,
hyperlipidemia, obesity, known CAD, strong family history) should be identified through chart
review prior to entering the room as well.
General approach to history:
The history for chest pain is primarily to establish risk of the symptom being caused by a life
threatening condition. This is done by characterizing and documenting the nature of the pain
experienced by the patient, the time course of the pain, aggravating and alleviating symptoms,
and noting pertinent past medical history. Because pain histories tend to be subjective and
patients tend to ruminate over time, it is useful to re-evaluate or even seek out other people to
retake the history if it is confusing or does not easily fit into an identifiable pattern.
University of South Alabama, Department of Family Medicine
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Location – Where does your chest hurt? (Can ask patient to indicate with hand the place of most
severe pain)
Timing – When did the pain begin? What were you doing when you first noticed it? What
activities are you engaged in when you notice the pain? Are there activities that reliably bring on
the pain?
Quality – What kind of pain is it? (Sharp, dull, aching, stabbing, burning, pressure, etc)
Severity – How bad is the pain on a scale of 1-10?
Aggravating/Relieving factors – Does anything make it better? (Stopping, sitting, lying down,
shallow breathing, certain positions, certain medications) Does anything make it worse?
(Exertion, cough, movement, etc)
Associated symptoms – Are any other symptoms associated with the chest pain? (Diaphoresis,
nausea, vomiting, radiation to arm, radiation to jaw, radiation to other sites, acid brash)
Age Specific Concerns in the history:
Infants, School Aged Children, Adolescents:
Key Question Content
Acute onset, decreased breath sounds
Genetic predisposition to heart disease
(Marfan’s, etc)
Trauma
Hyperventilation, school stressors
Breast growth
Night cough
Cough, fever
Acid brash
History of sickle cell disease
History of cancer treatment (recent or
ongoing)
History of sympathomimetic ingestion
(pseudoephedrine, cocaine, etc)
History of pain on exertion, with syncope,
with dizziness, or with palpitations
History of congenital heart disease
Further investigation if positive
Consider pneumothorax
Disease dependant
Consider fracture
Consider functional, explore stressors
Consider puberty
Consider asthma
Consider bronchitis, pneumonia
Consider reflux
Consider acute chest
Consider PTE
Consider as cause
Consider cardiac cause
Consider as cause
University of South Alabama, Department of Family Medicine
June 30, 2008
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Adults:
Questions For Adults From 25 to 65
(Older adults (>65): The questions below are pertinent but the incidence of native cardiac
disease is so high that any complaint of chest pain should lead to concern about a cardiac
etiology)
Key Question Content
Further Investigation If Positive
Trauma
Consider fracture
Positional, worsening with movements
Consider musculoskelatal
Hyperventilation, panic symptoms
Consider functional, explore stressors
Cough, fever
Consider bronchitis, pneumonia
Acid brash
Consider reflux
History of recent or ongoing cancer treatment,
Consider PTE
immobilization, injury to lower extremity
History of sympathomimetic ingestion
Consider as cause
(cocaine, pseudoephedrine, etc)
Risk factor assessment:
Tobacco use (amount and years)
Hypertension (years and level of control)
Family history of premature CAD (age and
relation)
Upon confirmation that chest pain is
Hypercholesterolemia (years and control)
potentially cardiac in nature based on
Diabetes mellitus (years and control)
characterization of pain
Known heart disease
Documented angina
Known CAD
Prior myocardial infarction
Known congestive heart failure
Physical:
The physical exam is targeted primarily at confirming clinical suspicion from history and risk
factor assessment
Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure
General – Does the patient appear comfortable or in obvious pain? How is the patient sitting?
HEENT – n/c
Neck – probably normal but observe for JVD, auscultate for bruit
Chest wall – Palpate for reproduction of pain, note if positive
Heart – Note rate and rhythm, palpate for PMI, auscultate for gallop, rub
Lungs – Auscultate for rales, wheezes
Abdomen– (adults) Probably low yield but consider percussion and palpatation for
organomegaly or aneurysm, auscultation for bruits
Extremities – palpate for edema
Neuro –n/c
Musculoskeletal – See chest wall
Diagnostic studies (see Figures 1&2)
University of South Alabama, Department of Family Medicine
June 30, 2008
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General Guidelines
Patients under 25: The overwhelming majority of these patients with chest pain do not
have a cardiac etiology. (SOR - A) 1, 4 There are no evidence based decision rules at this time
to assist with diagnosis
o Initial evaluation should include sufficient data to rapidly determine need for
evaluation in hospital setting. This would include heart rate, respirations, pulse
oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature
and severity of pain (SOR - C). Patients who make an appointment for this complaint
over the phone should be offered a prompt appointment (SOR - C). Patients with a
recent history of cancer, ongoing cancer treatment, or sickle cell disease and this
complaint should receive expeditious evaluation (SOR - C).
o Musculoskelatal pain can be diagnosed on the basis of history and physical exam
alone without additional studies. A chest x-ray should be obtained for persistent pain
or excessive parental concern. (SOR - C).
o Functional pain can be diagnosed on the basis of history and physical alone. A chest
x-ray should be obtained for persistent pain or excessive parental concern. (SOR - C).
Unexplained pain that has worrisome features or is associated with excessive parental
concern should be referred for subspecialty evaluation before assigning to functional
category (SOR - C). Upon determining that the pain is functional in nature, further
work-up should be limited (SOR - C).
o Pain of a pulmonary etiology should be assessed on the basis of history and physical
with a chest x-ray and pulse oximetry being obtained almost as a matter of course
(SOR - C). For those patients at risk for a deep venous thrombosis and pulmonary
thromboembolism, a d-dimer or equivalent study should be obtained. A negative
study effectively rules out thromboembolic disease. A positive study should lead to
further imaging using high resolution CT scanning or nuclear imaging in an
emergency department setting (SOR - B). Presumed infectious causes should be
evaluated with a chest x-ray if the patient reports significant discomfort, or is febrile,
tachypneic, tachycardic, or the diagnosis is unclear in any way. A complete blood
count with differential should be obtained on patients with fevers, in particular if the
diagnosis is in doubt. In addition, a blood culture should be obtained if broad
spectrum antibiotics are being initiated (SOR - B). Possible masses or pneumothorax
should be evaluated with chest x-ray (SOR - B).
o Pain felt to be of GI origin may be treated empirically, with relief of symptoms
serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure
should be referred for subspecialty evaluation (SOR - C).
o Initial evaluation of cardiac pain should include a measurement of oxygen saturation.
If based on history and physical a congenital problem or rhythm disturbance is
suspected then a chest x-ray should be performed. Rhythm disturbances should
additionally be investigated with an EKG. Suspected structural problems should be
investigated with an echocardiogram (SOR - C). If the pain is predictably exertional,
or associated with syncope, or with lightheadedness then the patient should be
referred to a cardiologist for additional evaluation (SOR - C).
University of South Alabama, Department of Family Medicine
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o Over the counter stimulants can cause pain and palpitations. These include cough and
cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of
abstinence should result in resolution of symptoms (SOR - C). Cocaine or
methamphetamine related chest pain may be difficult to diagnose due to the patients
being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR
- C). If the pain is ongoing, further evaluation should occur in the hospital setting
(SOR - B). If the pain is remote, screening and treatment for addiction is warranted
(SOR - B).
Patients over 25: The majority of these patients with chest pain do not have a cardiac
etiology, although more so than in the younger age group. (SOR – A) 5,6 At any given age,
women are less likely to have heart disease than men, although that advantage is reduced
following hysterectomy and menopause (SOR - C). Patients above age 65 are more likely to
have cardiac disease, a dissecting aneurysm, and herpes zoster as a cause of chest pain (SOR
- C).7
o Initial evaluation should include sufficient data to rapidly determine need for
evaluation in hospital setting. This would include heart rate, respirations, pulse
oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature
and severity of pain (SOR - C). Patients who make an appointment for this complaint
over the phone should be offered a prompt appointment (SOR - C). Patients with a
recent history of cancer, ongoing cancer treatment, or known coronary artery disease
and this complaint should receive expeditious evaluation (SOR - C).
o Musculoskeletal pain can be diagnosed on the basis of history and physical exam
alone without additional studies. A chest x-ray should be obtained for persistent pain
or excessive concern. (SOR - C). Patients with multiple risk factors should have very
close follow-up and possibly an EKG at the time of the visit. If the pain is persistent
or clinical suspicion is heightened for any other reason, then an evaluation with a
gaited stress test or by a cardiology subspecialist is warranted (SOR - C). A
therapeutic trial of NSAIDS can be offered if not contra-indicated (SOR - C). Herpes
zoster can present as pain before the rash occurs.
o Pain felt to be of GI origin may be treated empirically, with relief of symptoms
serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure
should be referred for subspecialty evaluation, as should those people at risk for
esophageal cancer (history of long-term alcohol use, cigarette smoking, family history
of esophageal cancer (SOR - C).
o Evaluation of chest pain in the adult patient is based on certainty of diagnosis,
identification of risk factors and application of decision rules. For example, if the pain
is characteristic of angina (substernal pain, exertional in nature, and relieved by
nitroglycerin) and the patient is a male over 50 the chance of the pain being ischemic
cardiac pain is very high and should be expeditiously evaluated. In contrast, a 25
year old woman with exertional pain likely does not have ischemic coronary disease.
One such diagnostic decision cascade would be the following (SOR - C):
 Obtain EKG
High risk: New bundle branch block, transient elevation with pain, or
sustained V-tach
University of South Alabama, Department of Family Medicine
June 30, 2008
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


Intermediate risk: ST – T wave inversions > 0.2 mV or pathologic Q
waves
Low risk: Normal or unchanged, especially during pain
Characterize the pain based on known characteristics of angina (quality,
aggravating and alleviating factors)
High risk: Substernal, on exertion, relieved with NTG
Intermediate risk: 2 of three
Low risk: 1 of three
Identify presence of high risk pre-existing disease
Recent MI
Recent CABG
Recent PCI or stent placement
Quickly assess whether patient has known heart disease or diabetes from chart
review or patient history. Presence of either puts them at increased risk.
Assess and transfer if ischemia suspected
If the EKG and/or the pain history are high risk and there is a good chance that
the patient has disease based on risk factors, then the patient is given an aspirin
and sent to a hospital for further evaluation in a monitored setting. High risk for
unstable angina includes age over 65, characteristic pain for 20 minutes, ST-T
wave changes, or pulmonary edema
If the clinical suspicion remains low, continue evaluation in office
 Quickly assess other risk factors from chart review or additional history (Age,
Male sex, Presence of diagnosed hypertension, DM or hyperlipidemia,
Presence of tobacco use, Family history of early CAD)
Higher risk: Male over 50, Woman over 60
Higher risk: Longstanding hypertension, hyperlipidemia, tobacco use
Higher risk: Family history of disease in a first degree relative at the
patients age or younger
 Obtain clarifying labs
Lipid profile
CBC
Blood glucose (consider full chemistry)
Consider thyroid studies based on clinical suspicion
 Assess left ventricular function
For any concomitant signs of LV dysfunction (particularly dyspnea on
exertion), obtain echogardiogram as part of work-up
 Consider possibility of aortic aneurysm
In patients with Marfan body habitus or with history of long time
tobacco use and other risk factors such as age and hypertension, aortic
aneurysm should be considered as a cause of chest pain. If there is
reasonable clinical suspicion, an x-ray and/or CT of the chest should
be obtained. A normal mediastinum rules out the diagnosis
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June 30, 2008
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Make a clinical assessment of the likelihood of the coronary artery disease. One
such model is seen below (SOR – B):
Another more comprehensive model can be found at (SOR – B)
http://www.emedicine.com/splash/etools.asp?file=coronary_disease_score&prog=edecision
If the pretest probability is less than 30%, then further testing should be pursued only
with the understanding that the risk of a false positive test is high and that a negative test
does not rule out disease. If the pretest probability is greater than 30% but less than 60%
then further non-invasive testing is indicated. If the pre-test probability is greater than
60% then non-invasive testing should not be pursued and cardiac catheterization would
be the next step. The diagnostic testing decision is as follows:
 Intermediate probability of CAD, EKG with less than 1 mm ST depression
and/or RBBB, able to exercise - Dynamic exercise testing
 Intermediate probability of CAD or remote history of CAD, EKG with
greater than 1 mm ST depression, pre-excitation (WPW), paced rhythm,
LBBB, able to exercise - Dynamic exercise testing with additional
imaging
 Intermediate probability of CAD, EKG with or without less than 1 mm ST
depression, unable to exercise - Adenosine or dipyridamole myocardial
perfusion study
 It is unclear where the multi-slice CT scanner will fit into the
diagnostic algorithm for these patients at this time
If after the clinical assessment or after non-invasive testing there is a high probability of
left main or 3 vessel disease, uncertain diagnosis after non-invasive testing, or suspected
non-atherosclerotic etiology – Referral for possible cardiac catheterization
If after the clinical assessment or after non-invasive testing there is a low probability of
left main or 3 vessel disease – Work on risk factor modification
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o Pain of a pulmonary etiology should be assessed on the basis of history and physical
with a chest x-ray and pulse oximetry being obtained almost as a matter of course
(SOR - C).
 If clinically the diagnosis of DVT is entertained, elements of the history,
physical exam suggest PTE then a clinical decision should be made as to
whether or not a PTE is likely. Use of a validated decision rule such as the one
below can assist with this decision (SOR - B).
For those patients at risk for a deep venous thrombosis and pulmonary
thromboembolism, a d-dimer or equivalent study should be obtained. A
negative study effectively rules out thromboembolic disease. A positive
study should lead to further imaging using high resolution CT scanning or
nuclear imaging in an emergency department setting (SOR - B). If the DUniversity of South Alabama, Department of Family Medicine
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
dimer is positive but the clinical suspicion is relatively low and the imaging
study is negative then a venous doppler should be obtained and if negative
repeated in a week. If the suspicion is high, then pulmonary artery
catheterization would be indicated.
Presumed infectious causes should be evaluated with a chest x-ray if the
patient reports significant discomfort, is febrile, tachypneic, tachycardic, or
the diagnosis is unclear in any way. A complete blood count with differential
should be obtained on patients with fevers, in particular if the diagnosis is in
doubt. In addition, a blood culture should be obtained if broad spectrum
antibiotics are being initiated (SOR - B). If a chest x-ray is inconvenient to
obtain, a validated clinical rule can be used to determined the urgency with
which an x-ray is needed (SOR - B).

Complaints suggestive of masses or pneumothorax should be evaluated with
chest x-ray (SOR - B).
o Symptoms consistent with panic disorder should be evaluated with the following two
questions:
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• ―In the past six months, did you ever have a spell or an attack when all of a
sudden you felt frightened, anxious, or very uneasy?‖
• ―In the past six months, did you ever have a spell or an attack when for no
reason your heart suddenly began to race, you felt faint, or you couldn’t catch
your breath?‖
A yes on either question is considered a positive screen but the screen is neither
sensitive nor specific enough in a population with a high prevalence of coronary
artery disease to predict a lack of cardiac disease. Thus, in patients at significant risk,
a cardiac etiology should be pursued prior to attributing the pain to panic disorder.
o Over the counter stimulants can cause pain and palpitations. These include cough and
cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of
abstinence should result in resolution of symptoms (SOR - C). Cocaine or
methamphetamine related chest pain may be difficult to diagnose due to the patients
being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR
- C). If the pain is ongoing, further evaluation should occur in the hospital setting
(SOR - B). If the pain is remote, screening and treatment for addiction is warranted
(SOR - B).
o Functional pain is typically a diagnosis of exclusion in adults. Particularly in patients
with risk factors for another disease, diagnostic testing should be pursued. At a
minimum a chest x-ray should be obtained for persistent pain or concern and a
cardiac work-up should be pursued in patients who are at risk (SOR - C). Unusual
diagnoses such as recurrent PTE should be entertained over time. Unexplained pain
that has worrisome features or is associated with concern should be referred for
subspecialty evaluation before assigning to functional category (SOR - C). Once
comfortable that the pain is functional in nature, further work-up should be limited
(SOR - C).
Office Based Management:
Musculoskeletal Pain:
Non pharmacologic – Patients with acute chest wall pain require only conservative management
(SOR - C). Patients should be instructed to resume their normal activities as tolerated. Any
aggravating factors should be eliminated to the extent possible. Bed rest is not indicated. (SOR A)
Pharmacologic (SOR - C) – NSAIDS (see Appendix) relieve chest wall pain through their
analgesic properties and also reduce inflammation. Instruct patients to take NSAID regularly
until pain resolves. Acetaminophen is an alternative medications in patients for whom NSAID’s
are contraindicated. A short course of narcotic pain relievers can be used if the pain is severe
until NSAID’s can take effect but should not be used for recurrent pain.
Herpes zoster (SOR – B) 7 - The treatment of herpes zoster has three major objectives:
(1) treatment of the acute viral infection, (2) treatment of the acute pain associated with
herpes zoster and (3) prevention of postherpetic neuralgia. Antiviral agents, oral
University of South Alabama, Department of Family Medicine
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corticosteroids and adjunctive individualized pain-management modalities are used to
achieve these objectives.
Antivirals - Antiviral agents have been shown to decrease the duration of herpes zoster
rash and the severity of pain associated with the rash. However, these benefits have only
been demonstrated in patients who received antiviral agents within 72 hours after the
onset of rash. Antiviral agents may be beneficial as long as new lesions are actively being
formed, but they are unlikely to be helpful after lesions have crusted. The ―50-50-50‖ rule
has been proposed to identify who would most benefit from antivirals, that is those who
have had the symptoms for under 50 hours, and are over 50 or have more than 50 lesions.
(SOR-C) Acylovir (Zovirax) therapy appears to produce a moderate reduction in the
development of postherpetic neuralgia in these patients. Other antiviral agents,
specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as
effective as acyclovir. Dosages are available from commonly available references
Corticosteroids - Orally administered corticosteroids are commonly used in the
treatment of herpes zoster, even though clinical trials have shown variable results.
Prednisone used in conjunction with acyclovir has been shown to reduce the pain in
patients more than 50 years of age and is useful for reducing symptoms for zoster
involving the facial nerve. The dose in adults is generally 30 mg orally twice daily on
days 1 through 7; then 15 mg twice daily on days 8 through 14; then 7.5 mg twice daily
on days 15 through 21
Analgesics - The pain associated with herpes zoster ranges from mild to excruciating.
Patients with mild to moderate pain may respond to over-the-counter analgesics. Patients
with more severe pain may require the addition of a narcotic medication. When
analgesics are used, with or without a narcotic, a regular dosing schedule results in better
pain control, and less anxiety, than "as-needed" dosing.
Panic disorder – See Depression chapter
Pneumonia - See Pneumonia chapter
Gastroesophageal reflux disease: 8
Non-pharmacologic: Patients should be instructed to avoid large meals and should not
lie down immediately after eating (up to 3 hours). They should also be counseled that
acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate
symptoms and should be withdrawn initially; they can be added back as symptoms
permit. Reducing dietary fat should improve symptoms as should weight loss.
Medications known to cause reflux should be withdrawn if possible. These include
calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain
sedatives. The head of the bed should be elevated 4 – 8 inches. Tight clothing should be
avoided as should tobacco use.
Pharmacologic: After making diagnosis, it is reasonable to start with either an H2
blocker or a proton pump inhibitor. The choice is based on previous effective and
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ineffective therapy and cost to patient. (see appendix for choices and dosages) If the H2
blocker was used initially but is only partially effective, it may be necessary to switch to
a PPI. Once symptoms resolve, reduce dose to the lowest required to maintain patient
symptom free. Antacids may be added for additional symptom relief, especially early on
or when symptoms flair.
Chest pain with cardiac risk factors - Those patients who following diagnostic testing are
found to be of low immediate risk of having significant coronary artery disease should reduce
their risk factors if possible. The sex, age, and family history cannot obviously be change. On the
other hand patients can quit the use of tobacco products, reduce their blood pressure, monitor and
control their lipids and blood pressure, increase their physical activity and reduce their weight.
The ―stages of change‖ model identifies the likelihood of a patient making a significant lifestyle
change. Physicians are most likely to make a difference when the patient is in the contemplation
stage (by eliciting commitment) and in the preparation stage (by offering assistance)
Precontemplation is the stage at which there is no intention to change behavior in the
foreseeable future. Many individuals in this stage are unaware or underaware of their
problems.
Contemplation is the stage in which people are aware that a problem exists and are
seriously thinking about overcoming it but have not yet made a commitment to take
action.
Preparation is a stage that combines intention and behavioral criteria. Individuals in this
stage are intending to take action in the next month and have unsuccessfully taken action
in the past year.
Action is the stage in which individuals modify their behavior, experiences, or
environment in order to overcome their problems. Action involves the most overt
behavioral changes and requires considerable commitment of time and energy.
Maintenance is the stage in which people work to prevent relapse and consolidate the
gains attained during action. For addictive behaviors this stage extends from six months
to an indeterminate period past the initial action.
Risk Factor
Smoking
Hypertension
Hyperlipidemia (LDL)
Diabetes (A1c)
Target (no CAD)
Abstinence
140/85
130 (2 Risk factors)
n/a
Target (CAD or diabetes)
Abstinence
130/80
100 (consider 70)
7.0
Urgent referral to emergency department for evaluation under controlled conditions and
possible admission (SOR - B):
Suspected PTE based on history and risk factors
Pain associated with hypoxia, regardless of etiology
Suspected acute cardiac event
Pneumothorax
Referral to specialist (SOR - C):
Suspected congenital heart disease
Pain associated with syncope, exertion, or lightheadedness in child or adolescent
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Suspected cardiac ischemic pain in an adult
Gastroesophageal reflux associated with dysphagia, early satiety, iron deficiency anemia,
odynophagia, vomiting, weight loss or if not improved in reasonable time with
conservative measures. Consider referral if at risk for Barrett’s esophagus (i.e. white male
age >45 with long history of symptoms, history of long-term alcohol use, cigarette
smoking, family history of esophageal cancer. Consider referral if etiology needs to be
made clear and cardiology work-up non revealing)
Pain associated with cocaine use
Mass in chest
Follow-up (SOR - C):
Patients who are at risk for potentially life threatening disease should follow through on
recommended consultations and follow-up when problem has been evaluated.
For patients with musculoskeletal pain, schedule follow-up for two to four weeks but if the pain
resolves and the patient is not at risk for ischemic heart disease they may elect to cancel the
appointment. For patients with pain from herpes zoster, they should follow-up for infection or
non-resolution in 2 – 4 weeks
Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms
within 4 weeks and resolution within 8 weeks
Patients felt to be symptomatic from stimulant use, a visit following a week of abstinence is
usually sufficient. At that visit, counseling regarding excessive stimulant use should be provided.
For patients with multiple cardiac risk factors, aggressive risk factor modification should begin
when patient is amenable to change. The follow-up visit soon after a negative stress test will
often present itself as an opportunity for the physician to facilitate change. This follow-up should
occur within a week of the negative stress test.
Suggested for further reading:
Chapter 23 Chest Pain in Current Diagnosis & Treatment in Family Medicine. Jeannette E.
South-Paul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at
http://www.accessmedicine.com/home.aspx
Pnaju A, Hemmerlarn B, Guyatt G, Simel D. Is this patient having a myocardial infarction?
JAMA, 1998; 280: 1256 - 1268.
Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn
SD, Fraker TD Jr., Gardin JM, O’Rourke RA, Pasternak RC,Williams SV. ACC/AHA 2002
guideline update for the management of patients with chronic stable angina: a report of the
American College of Cardiology/ American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with
Chronic Stable Angina). 2002. Available at www.acc.org/clinical/guidelines/stable/stable.pdf .
University of South Alabama, Department of Family Medicine
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Resources for patients:
Chest pain, acute accessed on Familydoctor.org at http://familydoctor.org/x2587.xml
Chest pain, chronic accessed on Familydoctor.org at http://familydoctor.org/524.xml
Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at
http://familydoctor.org/087.xml
Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at
http://familydoctor.org/161.xml
References:
1. Pantell R, Goodman B. Adolescent chest pain: a prospective study. Pediatrics 1983
Jun;71(6):881-7.
2. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary
report from MIRNET. J Fam Pract 1994;38:345-52.
3. Cayley W. Diagnosing the Cause of Chest Pain Am Fam Physician 2005;72:2012-21.
4. Evangelista, JA, Parsons, M, Renneburg, AK. Chest pain in children: diagnosis through
history and physical examination. J Pediatr Health Care 2000; 14:3.
5.
Marsan R, Shaver K, Sease K, et al. Evaluation of a clinical decision rule for young adult
patients with chest pain. Academic Emergency Medicine 2005; 12: 26 – 32.
6. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB
Jr., Fihn SD, Fraker TD Jr., Gardin JM, O’Rourke RA, Pasternak RC,Williams SV.
ACC/AHA 2002 guideline update for the management of patients with chronic stable
angina: a report of the American College of Cardiology/ American Heart Association Task
Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the
Management of Patients with Chronic Stable Angina). 2002.
7. Stankus S, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and
postherpetic neuralgia Am Fam Physician 2000;61:2437-44,2447-8.
8.
DeVault K and Castell D. Updated guidelines for the diagnosis and treatment of
gastroesophageal reflux disease. Am J Gastroenterology 2005; 100:190-200.
University of South Alabama, Department of Family Medicine
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Appendix
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University of South Alabama, Department of Family Medicine
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Cough
786.2
Definition:
Cough – A rapid expulsion of air from the lungs typically in order to clear the lung airways of
fluids, mucus, or material; also called tussis.
General Approach to the patient:
Goals:
1. Identify specific or life-threatening causes of cough.
2. Arrange for definitive care of identified specific causes of cough at time of
presentation or with appropriate follow-up.
3. Provide symptomatic relief of patient complaints.
Age
Complaint
frequency
Commonly
diagnosed
diseases (in
descending order
of prevalence)
0-2 years
Very Common
2-14 years
Common
15-65 years
Common
>65 years
Common
URI
GERD
Croup
Asthma
URI
Postnasal drip
Asthma
Croup
GERD
Life threatening
diseases to
consider
Pneumonia
Foreign Body
Aspiration
Malignancy
URI
Postnasal drip
Asthma
GERD
Medication side
effect
Pneumonia
Malignancy
Fever
Shortness of
Breath
Fever
Shortness of
breath
Fever, shortness of
breath, orthopnea,
PND
Key elements of
exam
Pneumonia
Congenital
malformations
Foreign body
aspiration
Fever
Cyanosis
Respiratory
Distress
ENT
Lung
URI
Postnasal drip
Asthma
GERD
Medication side
effect
Pneumonia
Malignancy
ENT
Lung
ENT
Lung
Key diagnostic
study
Based on history
and physical
Based on history
and physical
Based on history
and physical
ENT
Lung
Cardiac
Based on history
and physical
Common
Treatment
Functional
limitations
Disease dependent
Disease
dependent
Based on
diagnosis
Disease
dependent
Based on
diagnosis
Disease
dependent
Based on
diagnosis
Key worrisome
features (history)
Based on
diagnosis
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Overview:
Cough is a very common complaint experienced by all age groups. Cough is a normal
mechanism of the body that clears secretions from the bronchial tree and trachea. Cough is an
involuntary reflex mediated through the vagal afferents. There is some degree of voluntary
control over this reflex. Voluntary control is manifested as cough inhibition (holding back a
cough) or voluntary cough. Involuntary cough is triggered by vagus nerve stimulation in the
back of the throat and bronchial tree. A large number of common diseases including asthma,
GERD, bronchitis, and post-nasal drip can cause cough through airway irritation. In addition,
there are life-threatening ailments like pneumonia and lung cancer that may present with cough
as a chief complaint. A thorough history and physical exam is important in determining the cause
of cough.
Chief Complaint:
Typically the complaint is ―Cough‖
Vitals:
Age, respiratory rate, pulse, temperature and weight should be noted prior to going into the room
through chart review and review of vital signs. Fever and/or tachypnea may suggest pneumonia
or other systemic illness.
General approach to history:
The history for cough is primarily to identify underlying causes of cough. Questions are directed
at determining the nature of the cough (productive vs. nonproductive), time course and
modifying factors.
Timing – How long have you been coughing? Is it getting better, staying the same, or getting
worse? When do you cough the most (night, day, etc)? Nighttime cough suggests asthma or
GERD.
Quality – Are you coughing anything up? If so, what color is it? Green or yellow sputum was
once thought to be suggestive of bacterial infection, although this remains controversial.
Severity – How much are you coughing? Are you coughing so much that you vomit?
Aggravating/Relieving factors – Does anything make it better or worse? (Eating, lying down,
going outside, pollen exposure, etc)
Associated symptoms – Are any other symptoms associated with the cough? (Chest pain,
dyspnea, acid brash, wheezing)
Symptom Review – Targeted at common causes of cough for patient’s age. See tables and
flowcharts.
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Physical:
The physical exam is targeted primarily at identifying underlying causes of cough and ruling out
serious pathology (i.e. pneumonia, severe COPD exacerbation)
General – Watch out for respiratory distress (labored breathing, accessory muscle use)
HEENT – Look for pharyngeal erythema (present with many causes of cough), Nasal drainage
(upper airway cough syndrome)
Neck – n/c
Heart – Listen for murmurs and arrhythmias particularly in older patients.
Lungs – Listen for wheezes (asthma), crackles (pneumonia) and rhonchi (bronchitis)
Abdomen– Assess for epigastric tenderness (GERD), although, most patients with GERD will
not have epigastric tenderness.
Extremities – n/c
Neuro –n/c
Musculoskeletal – n/c
Disease Specific Indicators:
Infants ages 0 – 2 years:
Disease
URI
GERD
Asthma
Croup (age 0-6 years)
Pneumonia
Suggestive findings on history and physical
Daycare attendance. Sick contacts. Duration of cough
<2 weeks. Nasal congestion.
Spitting up after feeding. Poor weight gain. Duration of
cough >2 weeks.
Nighttime cough. Wheezing. Cough worsened by
environmental exposure or change. Asthma, Allergies
or Eczema in siblings or parents. Coughing for >1
week with most URI’s.
―Barking‖ cough, inspiratory stridor, abrupt onset. Low
grade fever.
Productive cough, tachypnea, fever, ill appearance,
crackles on physical exam. SpO2 <95%
Children Ages 2-14 years:
Disease
URI
Asthma
GERD
Pneumonia
Bronchitis
UACS
(Upper Airway Cough Syndrome)
Suggestive findings on history and physical
Daycare attendance. Sick contacts. Duration of cough
<2 weeks. Nasal congestion. Sore throat.
Nighttime cough. Wheezing. Cough and/or dyspnea
on exertion. Family or personal history of asthma,
allergies or eczema. Coughing for >1 week with most
URI’s.
Bad taste in mouth, worsening symptoms after eating
acid or spicy foods, abdominal or chest pain after eating
acid or spicy foods. Duration >2 weeks or recurrent.
Productive cough, fever, shortness of breath, crackles
on physical exam. SpO2 <95%.
Productive cough, no fever, no shortness of breath.
Duration >2 weeks.
Runny nose, watery eyes, post-nasal drip. Sore throat
that is worse in morning and better throughout the day.
(This sore throat comes from post nasal drainage
irritating the back of the throat)
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Adults >15 years:
Disease
URI
Asthma
GERD
Pneumonia
Bronchitis
UACS
(Upper Airway Cough Syndrome)
ACEI
Smoking
Lung Cancer
Suggestive findings on history and physical
Sick contacts. Duration of cough <2 weeks. Sore
throat. Nasal congestion
Nighttime cough. Wheezing. Cough and/or
dyspnea on exertion. Family or personal history
of asthma, allergies or eczema. Coughing for >1
week with most URI’s. Beta blocker use may
worsen asthma.
Bad taste in mouth, worsening symptoms after
eating acid or spicy foods, abdominal or chest pain
after eating acid or spicy foods. Duration >2
weeks or recurrent.
Productive cough, fever, shortness of breath,
crackles on physical exam. SpO2 <95%. See
Diehr Rule Table below.
Productive cough, no fever, no shortness of breath.
Duration >2 weeks.
Runny nose, watery eyes, post-nasal drip. Sore
throat that is worse in morning and better
throughout the day. (This sore throat comes from
post nasal drainage irritating the back of the
throat)
Pt taking ACEI. Duration of cough >2 weeks.
May or may not correspond to starting or
increasing ACEI.
Patient continues to smoke (regardless of amount).
Weight loss, fatigue, hemoptysis, current or
former smoker
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Diagnostic studies:
General guidelines
Types of diagnostic studies will depend upon clinical suspicion of underlying cause. In some
cases a therapeutic trial may be used as a diagnostic study (i.e. trial of proton pump inhibitors for
cough secondary to GERD).
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Suspected cause
Study to order
Asthma
Spirometry
Asthma
Chest X-ray
GERD
Barium swallow
GERD
H.Pylori
GERD
Endoscopy (GI referral)
Pneumonia
Chest X-ray
UACS
Allergy testing
Croup
Soft-tissue film of neck
Lung Cancer
Chest X-ray
When to order
In patients >6 years old to
make diagnosis and follow
disease.
Initial presentation or
dramatic change in asthma
pattern
Infants
Adults who do not respond to
standard therapy
Patients who fail standard
therapy
All patients in whom
pneumonia is suspected
Patients who fail standard
therapy
All children in whom croup is
suspected.
All patients in whom lung
cancer is suspected.
Office Based Management:
URI – See URI handout
Non pharmacologic – Continue normal activity as tolerated. Hot showers (breathing warm,
moist air) and humidifiers may help clear the nasal passages. Hot soups and liquids such as tea
may also help clear nasal passages by a vapor action.
Pharmacologic – Cough suppressants. Combination products are available to target specific
constellations of symptoms and can be chosen on the basis of patient complaints. Antihistamines
are useful for runny nose and post-nasal drip. Decongestants are useful for nasal congestion and
sinus pressure. Cough suppressants and decongestants are not recommended for patients less
than 2 years of age. Most systemic cough suppressants suppress cough by action on the central
nervous system. Cough drops, numbing lozenges and OTC throat sprays are all useful for
symptom relief.
Follow-up – Patients should be told that most URI’s resolve within 7 days, but cough can persist
for several weeks after an upper respiratory infection. Patients should return for respiratory
difficulty, persistent high fever, or in 2 weeks if not better.
Asthma – See asthma chapter
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GERD:
Nonpharmacologic
Infants - Reduce amount given at each feed and increase frequency of feeding (i.e. If
currently taking 4 oz every 4 hrs, give 2 oz every 2 hrs). This will maintain adequate
calories, but limit gastric distention and pressure. Also keeping child upright after
feeding can minimize symptoms.
Children and adults - Limit intake of foods that provoke symptoms. Avoid lying down
for at least 30 minutes after eating.
Pharmacologic - A trial of H2 blockers or Proton Pump Inhibitors is often diagnostic and
therapeutic. In adults these are often started empirically and a response to the treatment is
considered diagnostic of GERD.
Follow-up - Cough secondary to GERD may persist for several weeks after initiating therapy.
Patients should follow up in 1 month if cough has not resolved or sooner for problems.
Upper Airway Cough Syndrome (UACS):
Non-pharmacologic - Avoid allergens. Formal allergy testing may be useful in identifying
allergic triggers. Pets (especially house cats and dogs) are common offenders as is thick
carpeting that tends to retain dust and other allergens. Removal of these offenders may
dramatically improve symptoms.
Pharmacologic - Antihistamines have traditionally been the mainstay of therapy. They are
effective, inexpensive and available OTC as well as by prescription. Inhaled nasal steroids are
very effective in treating post-nasal drip and UACS. They are not effective acutely, but if used
regularly will prevent most allergic mediated postnasal drip. Anticholinergics may be tried if
patients do not tolerate antihistamines and inhaled nasal steroids. Leukotriene modifiers are
approved for allergic rhinitis and may be considered although their role remains unclear.
Follow-up - UACS may persist for 1-2 weeks after treating post-nasal drip and allergic rhinitis.
Patients should return in 1 month if not better, sooner for problems.
Croup:
Non-pharmacologic – Cool humidified air may help with symptoms but no studies prove this.
Pharmacologic – Nebulized racemic epinephrine may help relieve symptoms temporarily.
Systemic steroids have been shown to prevent hospitalization and hasten recovery. Otherwise,
pharmacologic therapy is targeted toward symptoms.
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Follow-up - Patients should follow up in 1 week if not better and sooner for increasing work of
breathing. Croup is generally a self-limited illness, but occasionally children do require
intubation due to subglottic stenosis from croup. Parents should also be informed that symptoms
are likely to be worse at night than during the day.
Pneumonia:
Non pharmacologic – Relative rest can help with symptoms of dyspnea. Sitting up for at least
20 minutes per day may help with clearing pulmonary secretions. Frequent voluntary coughing
may aid in clearing secretions. Chest physical therapy may also be useful to loosen pulmonary
secretions.
Pharmacologic – Systemic antibiotics for 10-14 days. If patient is hypoxic or appears ill,
hospitalization and IV antibiotics are recommended. Supplemental O2 is given to keep O2 Sats
>90%. After patient is afebrile for 24 hrs, antibiotics may be changed to PO. Patients may be
discharged home when they are no longer oxygen requiring and are able to tolerate PO
antibiotics. See http://www.aafp.org/fpm/20060400/pneumoniaseverityindex.pdf for pneumonia
severity index to aid in decision whether to admit to hospital or treat as an outpatient.
Follow-up – Patients should follow up in 1 week if not better and sooner for worsening shortness
of breath or if still running fever for more than 72 hrs after starting antibiotics.
ACE Inhibitor induced cough:
ACE inhibitors are commonly used for treating HTN and nephropathy in diabetes. Cough is a
common side effect of these drugs thought to be mediated by elevations in the levels of
bradykinin. ACE inhibitors block the enzyme responsible for degrading bradykinin. Bradykinin
is thought to stimulate the cough centers directly. The cough may start anytime after initiating
ACE inhibitors but often begins about 1 month after starting the drug. Discontinuing the drug
will result in resolution of the cough within 2 weeks if this is the cause of the cough. ACE
inhibitors should be stopped in all patients with unexplained cough. Angiotensin receptor
blockers have a similar effect on blood pressure but do not result in bradykinin elevations and
may be used instead of ACE inhibitors in most patients.
Smoker’s cough:
Non pharmacologic - Smoking is a common cause of chronic cough. All patients who continue
to smoke should be advised to stop smoking, both for their health and as a diagnostic tool.
Pharmacologic – There are numerous pharmacologic aids to smoking cessation including
nicotine replacement and selected antidepressants. Patients should be offered pharmacologic
intervention if they are unable to stop smoking on their own.
Follow-up - In most smokers who present with a cough, the cough is secondary to smoking and
will resolve when smoking ceases or is reduced significantly. If the cough does not resolve
within 1 month of smoking cessation, other causes should be investigated.
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Lung Cancer:
Nonpharmacologic – Stop smoking. Potentially, lung or partial lung resections depending on
extent and type of cancer.
Pharmacologic – Depends on type of cancer. Numerous regimens are used by oncologists.
These patients will be co-managed with an oncologist.
When to refer to a specialist for further evaluation:
Asthma – Severe persistent asthma or asthma that does not respond to conventional therapy.
GERD – Symptoms that do not respond to PPI and H. Pylori eradication (if infection is present)
Lung Cancer – All patients with lung cancer should be seen by an oncologist.
Supplemental materials:
Free on-line resource covering diagnosis and management of cough on FP Notebook
http://www.fpnotebook.com/search.asp?QU=cough&CT=d%3A%5Cusers%5Csmoses%5Cdb
Suggested for further reading:
Chest Journal: Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice
Guidelines, http://www.chestjournal.org/content/vol129/1_suppl/
Resources for patients:
Chronic Cough Handout from Familydoctor.org - http://familydoctor.org/237.xml
References:
1. Irwin, R. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice
Guidelines. Chest 129: 1S-129S
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Major Depression
(Adult >16 y.o. ) ICD 9 311
Definition:
Major Depression – Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
(DSM-IV) criteria discussed below.
DSM-IV Criteria for Major Depressive Episode
A. Five or more of the following symptoms have been present and documented during the
same 2-week period and represent a change from previous functioning; at least one of the
symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
B. Note: Do not include symptoms that are clearly due to a general medical condition, or
mood-congruent delusions or hallucinations.
1.depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2.markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation made
by others)
3.significant weight loss when not dieting or weight gain (e.g., a change of more than
5% of body weight in a month), or decrease or increase in appetite nearly every day
4.insomnia or hypersomnia nearly every day
5.psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down)
6.fatigue or loss of energy nearly every day
7.feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
8.diminished ability to think or concentrate, or indecisiveness, nearly every day (either
by subjective account or as observed by others)
9.recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without
a specific plan, or a suicide attempt or a specific plan for committing suicide
C. The symptoms do not meet criteria for a mixed episode.
D. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hypothyroidism).
F. psychotic symptoms, or psychomotor retardation.
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The symptoms are not better accounted for by bereavement ( i.e., after the loss of a loved one),
the symptoms persist for longer than 2 months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness, suicidal ideation,
Dysthymic Disorder – Chronic (>2 years) and frequent low mood, often experienced as
emptiness or sadness, often accompanied with lethargy and self-criticism, and
requiring a least 2 other symptoms of depression.
Atypical Depression – Depressive symptoms not meeting criteria for another mood
disorder.
General approach to the patient:
Goals:
1. Identify patients a risk of developing major depression.
2. Identify patients who have signs and symptoms consistent with major depression.
3. Identify patients with risk of suicide.
4. Initiate appropriate therapy.
5. Continue surveillance for improvement or worsening.
Overview:
Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major
depression. Up to 50 percent of depressed patients are not recognized. The lifetime risk of major
depression in the community is 7 to 12 percent in men and 20 to 25 percent in women. "Normal
depression" occurs in the course of any active, eventful life. The most important single marker of
pathologic depression is that it interferes with the person's ordinary expectable function. This
expectable function can apply to self care, the maintenance of important relationships, the
performance of work-related tasks, and economic self-support. It is difficult to make a case for a
major depression, regardless of symptom severity, without observable interference with function.
The three subgroups of depressive disorder according to (DSM-IV) are major depression,
dysthymia, and atypical depression or depression not otherwise specified (NOS). A number of
medical conditions may present with depression, including stroke, diabetes, dementia, cancer,
hypothyroidism, chronic fatigue syndrome, fibromyalgia, systemic lupus erythematosus,
coronary heart disease, anxiety and panic disorders and some medications. Patients with medical
illnesses such as diabetes and heart disease have higher prevalences of major depression, with
estimates between 10 and 20 percent. Several depression screening instruments are available;
most instruments have relatively good sensitivity (80 percent to 90 percent) but only fair
specificity (70 percent to 85 percent).
Treatment may include antidepressants or specific psychotherapeutic approaches (eg, cognitive
behavioral therapy or brief psychosocial counseling), alone or in combination. In most patients
major depression is a relapsing, remitting illness. After a first episode there is a greater than 40
University of South Alabama, Department of Family Medicine
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percent rate of recurrence over a two-year period; after two episodes, the risk of recurrence
within five years is approximately 75 percent.
Contributory or predisposing factors
 Older age
 Physical illness, particularly if debilitating, painful, or life-threatening. Multiple
sclerosis, HIV/AIDS, and cancer carry an especially high risk. Physical illness is the
main precipitant of depression in later life
 Some medically prescribed drugs including alpha-methyldopa, beta-blockers (research
has shown no significant correlation), L-dopa, and interferon
 Drug and alcohol misuse
 Stress, especially recent adverse events, notably divorce or marital adversity.
Vulnerability to adverse events is increased by social isolation and by increasing age
 Poverty and unemployment
 Patients with other psychiatric diagnoses (e.g. personality disorders) also have a higher
risk of major depressive disorder
Patients encountered in the primary care setting with the following characteristics are at risk
for depression:





Personal or family history of depression
Multiple medical problems
Unexplained physical complaints
Chronic pain
Overutilization of medical services
Clinical presentation: Symptoms
 Depressed mood may have to be elicited by specific questioning. A patient may
complain initially of physical problems (e.g. persistent lethargy)
 Anhedonia (loss of interest and pleasure in usual activities) is usually present to some
degree
 Weight loss, or weight gain, is commonly associated with depression
 Disturbed sleep pattern with early morning waking is common; some patients can
present with hypersomnia
 Suicidality is the primary concern, and should be queried by direct questioning, such as
'Have you ever thought that life is not worth living?' or 'Have you ever thought of
harming yourself?' There is no evidence that such questions can put the idea of suicide
into a patient's mind for the first time. Feelings of guilt and/or unworthiness are
common; these can be of delusional intensity in that patients may feel that others are
avoiding them, or that they have committed some crime, or have delusions of poverty
 Physical symptoms, often without clear medical basis, may be a presenting feature.
Preoccupation with bodily function is common, especially with bowel function; these
feelings may be of delusional intensity (e.g. 'my bowels are stopped up'). But genuine
constipation is also common in depression, especially in older patients
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Signs


Weight loss is common. Malnutrition is a particular risk in the elderly
Activity disturbance may be a feature of severe depression. Psychomotor retardation is
common, with both slowed speech and movement. The voice may be toneless, the face
expressionless. Or agitation, reflected both in thinking and in bodily movement, may
be predominant. Both patterns can occur at different times in the same patient
Differential diagnosis
There are several medical conditions, such as hypothyroidism, which produce depressionlike symptoms that resolve when the underlying medical condition is treated.
Cardio
vascular
Medication
Metabolic/
Nutritional
Infections
Hematology/
Neurology
Oncology
Misc.
CHF
AntiHypertensives
Cushings
Hepatitis
Pernicious
anemia
CVA
COPD
Addison’s
HIV/
AIDS
malignancies
Huntington’s Hepatic
Chorea
failure
Cardio
Reglan
myopathy
M.I.
H2
blockers
Illicit
drugs
Chemotheraputic
Antiparkinson
Antiepileptics
Psychotropics
NSAIDS
OCP’S
PheoChromo
cytoma
Thyroid
Disease
Parathyroid
Dz
DM
Hypo
glycemia
Electrolyte
imbalance
Carcinoid
Ovarian
failure
Testicular
failure
Renal failure
Heavy metal
poisoning
Mono
nucleosis
Syphilis
TB
Multiple
sclerosis
Parkinson’s
disease
Alzheimer’s
disease
Lyme
disease
Narcolepsy
Encephalitis
Wilson’s
disease
Influenza
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Chief Complaint: Some patients present to their primary care physician with a chief complaint
of depressed mood. Others may not readily offer such a history, often because they do not
recognize that they are depressed, and sometimes because they are reluctant to acknowledge a
psychological basis for their symptoms.
History of present illness:
Determine history of present illness including:
- Onset may be gradual over months or years or may be abrupt.
- Severity of symptoms and degree of functional impairment.
- People diagnosed with major depression have a heterogeneous course from selflimiting to life-threatening. Predictors of poor outcome include severity at initial
assessment, lack of reduction of social difficulties at follow-up and low educational
level. Categorize severity of symptoms and degree of functional impairment as
follows:
o Mild: few, if any, symptoms in excess of those required to make the diagnosis
and only minor impairment in occupational and/or social functioning
o Moderate: symptoms or functional impairment between mild and severe
o Severe: several symptoms in excess of those necessary to make the diagnosis
and marked interference with occupational and/or social functioning
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-
-
Number and severity of previous episodes, treatment responses and suicide attempts.
Ask about concurrent psychiatric conditions. Obtaining a past psychiatric history is
important in terms of understanding prognosis and risk factors. For example,
knowledge of past episodes of major depression, past co-occurring mental/behavioral
health conditions, and past self-harm attempts is important for establishing risk and
need to involve other mental health professionals.
Psychosocial stressors (significant loss, conflict, financial difficulties, life change,
abuse).
Pertinent medical history that may complicate treatment includes: prostatism, cardiac
conduction abnormalities, and impaired hepatic function. A past medical history and brief review
of systems is generally sufficient to rule out medical disorders causing major depression.
Unlike younger persons with depression, elderly persons with depression usually have a medical
comorbidity. Major depression is more common in medically ill patients who are older than 70
years and hospitalized or institutionalized. Severe or chronic diseases associated with high rates
of depression include stroke (30 to 60%), coronary heart disease (8 to 44%), cancer (1 to 40%),
Parkinson's disease (40%), Alzheimer's disease (20 to 40%), and dementia (17 to 31%).
Physical:
Perform a routine physical examination to rule out physical causes of depression and pay
particular attention to:
Evidence of self-neglect, including weight loss
Signs of self-harm, such as scars on wrists or arms
Drug injection sites
Injuries (e.g. bruises resulting from falls) that might be the result of alcohol or drug misuse
Restlessness, agitation, and psychomotor retardation
Self-administered or professionally administered depression screening tools are useful adjuncts
to the clinical interview. Examples are: Patient Health Questionnaire (PHQ-9), the Deck
Depression Inventory, the Hamilton Rating Scale for Depression, Geriatric Depression Scale for
the elderly and the Quality Improvement for Depression scale.
Two-Item Screening Tool:
1. During the past month, have you felt down, depressed or hopeless?
2. During the past month, have you felt little interest or pleasure in doing things?
Five-Item Geriatric Depression Scale:
Are you basically satisfied with your life?
Do you often get bored?
Do you often feel helpless?
Do you prefer to stay at home rather than going out and doing new things?
Do you feel pretty worthless the way you are now?
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BATHE Mnemonic – can assist in identifying signs and symptoms of depression.
Background: ―What is going on in your life?‖
Affect:
―How do you feel about it?‖
Trouble:
―What troubles you most about the situation?‖
Handle:
―What helps you handle the situation?‖
Empathy: ―This is a tough situation to be in.‖
―Anybody would feel as you do.‖
―Your reaction makes sense to me.‖
SIG E CAPS Mnemonic – may be helpful for remembering the symptoms of major depression.
Sleep disorder (increased or decreased)
Interest deficit (anhedonia)
Guilt (worthlessness, hoplessness regret)
Energy deficit
Concentration deficit
Appetite disorder (increased or decreased)
Psychomotor retardation or agitation
Suicidality
Suicidal risk assessment:
The evaluation of a patient who may be suicidal includes an assessment of ideation, plan, and
intent. Components of an evaluation for suicide risk include the following:
Presence of suicidal or homicidal ideation, intent, or plan
Access to means for suicide and the lethality of those means
Presence of psychotic symptoms, command hallucinations, or severe anxiety
Presence of alcohol or substance use
History and seriousness of previous attempts
Family history of or recent exposure to suicide
Immediate psychiatric services, usually including hospitalization, are necessary in patients felt to
be at imminent risk for self-harm.
Substance abuse assessment:
Current alcohol or other drug problems can be assessed by the CAGE or CAGE(AID) screen.
CAGE(AID) questions are modified with text in parentheses. CAGE or CAGE(AID) questions
should be preceded by two questions:
1. Do you drink alcohol?
2. Have you experimented with drugs?
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CAGE Questions:
Have you ever:
C felt you ought to cut down on you drinking (or drug use)?
A had people annoy you by criticizing you drinking (or drug use)?
G felt bad or guilty about your drinking (or drug use)
E had a drink (or drug use) as an eye opener first thing in the morning to steady your
nerves or get rid of a hangover or to get the day started?
Each affirmative response earns one point. One point indicates a possible problem. Two points
indicate a probable problem.
Treatments:
Goals:






To protect the patient from the frequent and hazardous complications of depressive
illness - especially self-harm, self-neglect, malnutrition, substance misuse
To relieve the depressive illness
To relieve any disorders in addition to, or resulting from the, e.g. malnutrition,
substance misuse
To restore the patient to former levels of social and occupational functioning
To prevent recurrence of the depression
To prevent cardiovascular risks associated with depression
Depression is often most successfully treated with a combination of therapies, for example,
medication combined with some form of psychotherapy. There are four main treatment
choices:
Psychotherapy: Some forms of psychotherapy may be more or as effective as medication in
major depression. There is also good evidence that psychotherapy enhances the effect of
medication in depression. Psychotherapy can be a useful alternative for patients who will not
take or cannot tolerate medication, or who have a history of overdose. The forms of
psychotherapy best proven in depression are:





Cognitive behavior therapy (CBT), which is directed towards altering negative belief
systems and dysfunctional thinking and behavior
Brief psychotherapy, especially interpersonal therapy (IPT), which focuses on
relationships and how they affect functioning and self-esteem
Psychodynamic psychotherapy: longer-term treatment, with many US adherents; less
convincing evidence-based studies of its effectiveness to date
Counseling. A very broad category, from practical advice given by professionals to
trained volunteers. Generally, this takes a problem-solving approach, with a focus on
the present
Several self-help groups exist for people with depression. They are typically free of
charge and are facilitated by lay persons; they offer support and encouragement from
other persons with depression. Can be a useful adjunct to pharmacotherapy
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Non pharmacologic: Can take 8-10 weeks to show improvement.
Pharmocologic: (See Below Chart)









Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line therapy for
depression because of established efficacy, a favorable adverse effect profile, and their
relative safety in overdose. No single SSRI has an efficacy advantage over another.
Dropout rates in patients taking SSRIs are generally two thirds to one half those
of patients taking tricyclic antidepressants. The potential for a fatal overdose is
significantly lower with SSRIs than with tricyclic antidepressants. SSRIs cost more than
most other antidepressant agents, but this disadvantage is offset by a decreased need for
inpatient and outpatient care. SSRIs have been proved to be as effective as tricyclic
antidepressants in controlled clinical trials, with about 70 to 75 percent of patients
responding to treatment. Slight improvements in a patient's symptoms may be detected
within several days of starting treatment, but two to three months of therapy are necessary
to achieve the full benefit of treatment.
Dual mechanism antidepressants (venlafaxine, bupropion, and duloxetine) are also
considered first-line therapy for depression, with efficacy comparable to SSRIs
Mirtazapine may be especially useful in depression with comorbid anxiety, but should
be reserved for nonresponders of first-line therapy because of the potentially
bothersome adverse effects of weight gain and sedation
Tricyclic antidepressants (TCAs) have established efficacy comparable to SSRIs, but
are considered second-line therapy because of their associated adverse effects and
potential lethality in overdose. Secondary amine TCAs (i.e. desipramine) generally
have equal efficacy and fewer adverse effects than the parent tertiary amines (i.e.
amitriptyline, imipramine)
Monoamine oxidase inhibitors (MAOIs) are reserved for patients who do not respond
to first or second-line therapies because of the numerous and potentially severe
interactions with other medications. They may be particularly useful in patients with
depression with atypical features
Trazodone is structurally related to nefazadone. Due to its sedating effects, its use is
primarily reserved for patients with insomnia or anxiety. Nefazodone is not widely
used due to risk of hepatic damage and failure
St John's Wort is a herbal extract that is widely used over-the-counter in the treatment
of depression, and is efficacious in the treatment of mild-to-moderate depression
Transdermal selegilene is approved for the treatment of adults with major depressive
orders; however, its place in therapy is yet to be established
S-adenosyl-methionine (SAM) is involved in the methylation of neurotransmitters,
monoamines, and phospholipids. SAM synthesis is impaired in depressed patients, so
that supplementation results in increased levels of serotonin, dopamine, and
phosphatides and clinical improvement in depressive symptoms. Currently SAM is not
widely used in the practice setting
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A patient’s response to antidepressant treatment should be evaluated between 4 and 6 weeks. If
there is less than a 25% reduction in symptoms when evaluated, switch to a different medication.
If there is a partial response and there are no side effects, increase the dose.
First episode – treatment duration 6 to 12 months
Second episode – treatment duration 3 years
Second episode with complicating factors – lifetime treatment duration
Third episode – lifetime treatment duration
Complicating factors are those situations where there are higher rates of recurrence after
stopping antidepressants and include:
-
Pre-existing dysthymia
-
Recurrence
-
Inability to achieve remission of symptoms in response to previously attempted
lowering dose or discontinuation.
Referral to a behavioral health or substance abuse provider if there are personality disorders
and/or substance abuse issues present.
Physical treatments:




Electroconvulsive therapy (ECT) remains a valuable treatment, especially in the urgent
treatment of a patient who is acutely suicidal or severely malnourished
Electroconvulsive therapy (ECT) is a first-line option in patients with depression
and psychotic features who have not responded to antipsychotic and antidepressant
medications, and patients with severe nonpsychotic depression who have not responded
to adequate trials of two antidepressants. ECT is used most often in patients older than
age 60. Patients with delusions, psychomotor retardation, early morning awakening, and a
family history of depression are most likely to benefit from ECT. ECT may reverse the
memory loss and confusion associated with pseudodementia.
Contraindications include recent myocardial infarction, brain tumor, cerebral
aneurysm, and uncontrolled heart failure. ECT is an effective short-term therapy but has
higher relapse rates over six to 12 months; patients with a history of medication resistance
have higher relapse rates following ECT.
Transcranial magnetic nerve stimulation (TMS) is not yet clinically available, but is
being evaluated as an alternative to ECT
Phototherapy may be effective for seasonal depression (seasonal affective disorder)
Vagus nerve stimulation electrically stimulates the left vagus nerve at the cervical
level. The device is surgically implanted, and received FDA approval in July 2005 for
the treatment of treatment-resistant depression for individuals who have failed four
other treatment trials. Its efficacy remains to be fully evaluated
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Consider consult
 Suicide and homicidal risk
 Severe mental confusion, raising the question of dementia
 Severe delusions or hallucinations that do not have a clear depressive content,
suggesting schizophrenia or similar psychosis (or severe depression)
 Alcohol or drug abuse
 Bipolar disorder or question of bipolar disorder
 Depression that has not responded to typical measures
 Depression associated with any psychotic symptoms
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Pharmacologic:
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University of South Alabama, Department of Family Medicine
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Diabetes
Diabetes mellitus type 2: 250.xx
Definition:
Symptoms of diabetes and a casual (regardless of relationship to meals) plasma glucose of
200mg/dl. Symptoms are polyuria, poldipsia, and unexplained weight loss.
OR
Fasting plasma glucose of 126 mg/dl. This would be obtain following abstinence from caloric
intake for 8 hours.
OR
2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as
described by the World Health Organization, using a glucose load containing the equivalent of
75-g anhydrous glucose dissolved in water.
This chapter does not include patients with Type 1 diabetes, diabetes from genetic disorders or
chemically induced diabetes (such as from certain medications used to treat AIDS) although
many of the principles are the same. It also does not include gestational diabetes.
(N.B. Impaired fasting plasma glucose (IPG - FPG 100 mg/dl to 125 mg/dl) and impaired
glucose tolerance 2-h plasma glucose (IGT - 140 mg/dl to 199 mg/dl) are considered risk factors
for future diabetes and cardiovascular disease. Patients with this finding should be monitored
closely for development of frank diabetes and should have counseling regarding optimizing
weight and exercise regimen)
Overview:
Diabetes mellitus is a disease characterized by hyperglycemia. Type 2 diabetes mellitus is the
most common form of this disease and is both due to an under secretion of insulin as well as
inadequate activity of the endogenous circulating insulin. It affects over 15 million people in the
United States and accounts for over 15% of all healthcare costs. The mortality rate in patients
with the disease is higher by a factor of 10. Patients with diabetes are much more likely to suffer
from blindness, renal failure, and have a lower extremity amputation. 1
The recommendations in this chapter are from the Standards of Medical Care in Diabetes - 2008. 2
This report provides an evidence-based approach to the prevention and management of diabetes
mellitus, as well as prevention and management of complications. The American Diabetes
Association has worked on an ongoing basis to monitor evidence from English language, peer
reviewed articles published between 1988 and 2006. The professional practice committee of the
American Diabetes Association updates the recommendations and publishes them annually in
this report.
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Goals of the care process:
1. Identify patients at risk of developing diabetes and implement risk factor modification
strategies to prevent diabetes from manifesting.
2. Identify patients who have developed clinical diabetes prior to development of end-organ
damage.
a. Detect and treat secondary causes.
b. Offer counseling to assist with correction through diet and exercise.
c. Offer counseling to reduce or eliminate concomitant lifestyle risk factors such as
tobacco abuse or obesity.
3. Initiate treatment using medication known to be effective in combinations known to be
effective for all components of the metabolic syndrome including achieving glycemic
control, blood pressure control, and lipid reduction.
4. Monitor for reduction in and maintenance of blood sugar, blood pressure, and lipids at
physiologic levels that are associated with elimination of end-organ damage.
5. Continue surveillance for concomitant conditions which magnify untoward effects of
diabetes.
Screening Rules of Thumb:
Age
<18
Frequency of
impaired
Glucose
tolerance
Risk
factors
Recommendation
for screening
Rare in people with
BMI < 85th percentile
without 2 risk factors
Family history of type 2
diabetes in first or
second-degree
relative
Race/ethnicity (Native
American, African
American, Latino,
Asian American,
Pacific Islander)
Signs of insulin
resistance or
conditions associated
with insulin resistance
(acanthosis nigricans,
hypertension,
dyslipidemia, or
PCOS)
Maternal history of
diabetes or GDM
Obesity with 2 risk
factors
18-29
30-45
45-and above
Rare in people with
BMI < 25 without
risk factors
Uncommon in
people with BMI >
25, more common
with risk factors
Common in people
with BMI > 25
Previous plus:
Previous impaired
glucose
tolerance
Indicated for BMI
> 25 with 1 risk
factor
University of South Alabama, Department of Family Medicine
All of Previous
plus:
All of Previous
Inactivity
High risk ethnic
group
Delivery of baby >
9 lbs
History of
gestational
diabetes
Hypertension
HDL < 35
Triglyceride > 250
History of vascular
disease
Indicated for BMI >
25 with 1 risk factor
Indicated
Regardless of risk
factors
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Prevention/Delay
in high risk
patients,
particularly
those with IPG
or IGT
Make patients aware of benefits of weight loss and physical activity
Patients with Impaired Fasting Glucose or Impaired Glucose Tolerance should be
strongly encouraged to lose weight and exercise
Follow-up visits should be scheduled with attention to risk factor reduction
Glucose screening should occur every 2 years if impairment detected until diabetes
diagnosed, otherwise should occur periodically
Other risk factors should be attended to
Medication not recommended
If tests are normal, repeat testing should be carried out at least at 3 year intervals (SOR - E)
Approach to the Patient:
Chief Complaint:
Typically the condition is detected via lab result following complaint of symptoms or when end
organ damage has occurred. The symptom based complaint (polydipsia, polyuria, or weight loss)
leads to testing, following which the disease is diagnosed and management is initiated. The visit
should be an initial or follow-up for diabetes and management. Outcomes should improve as
more screening of asymptomatic individuals either in the community or in the office setting
occurs. Because of the complex nature of the disease, care should be taken to avoid casual
initiation of therapy.
Vitals:
Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures,
current blood pressure (with confirmation in opposite arm if warranted) should be noted and
compared to age related norms prior to going into the room through chart review and review of
vital signs.
History of Present Illness (new evaluation):
Patient should be queried regarding disease. Patient should then be queried regarding major risk
factors for cardiovascular disease; should be reassessed periodically. (SOR - C)
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74
Specific areas to be addressed:
AREA OF CONCERN
Symptoms of diabetes and
control
CONTENT
Symptoms
Previous control
Current and previous treatments
Complications
Complications of control
Infectious complications
End organ damage
Lifestyle modification
Comorbid illness which affect
treatment
Possibility of reducing dietary
caloric intake
DATA COLLECTION
Presence of polyuria, polydipsia,
weight loss
A1C, blood sugar log
Document current meds, previous
meds, meal history, beliefs and
attitudes regarding disease and
treatment
Frequency and severity of
ketoacidosis and hyperglycemia
Prior or current infections,
particularly skin, foot, dental, and
genitourinary infections
Symptoms and treatment of chronic
eye; kidney; nerve; genitourinary
(including sexual), bladder, and
gastrointestinal function; heart;
peripheral vascular; foot; and
cerebrovascular complications
associated with diabetes
Current eating patterns, nutritional
status, weight history, growth
history if adolescent
Possibility of increasing exercise
Exercise history and current
activity
Screening for depression
Age appropriate depression screen
Medication review for medicines
associated with hyperglycemia
Pertinent family, social history
Risk of pregnancy
Contraception and reproductive and
sexual history
Family history
Family history of endocrine
disorders, diabetes
Social history
Lifestyle, cultural, psychosocial,
educational, and economic factors
that might influence the
management of diabetes
Use of substances which might
affect diabetes
Psycho-Social assessment and
care
Alcohol, and/or controlled
substance use
Use of tobacco
Ask, advise, assess, assist, arrange
Attitudes about the illness,
Expectations of medical
management, outcomes, quality of
life and resources
Screen for Psycho-Social problems,
depression, anxiety, eating
disorder, cognitive impairment
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History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about
self management goals and progress towards achievement. Inquire about side effects of
medications. Inquire about status of lifestyle modification. Consider review of Risk Factors
and/or target organ questions approximately every 12 to 24 months, more frequently if poor
control
If previously under control but no longer or resistant (SOR - C):
Further investigation if
Possible cause
Key Question Content
positive
Drug induced
Drug use:
Prescription
Herbal
OTC
Illicit/recreational
Foods
Environmental
exposure
Alcohol use
Frequency of alcohol use
Lack of adherence
―Some people have trouble taking
medications. Do you?‖
University of South Alabama, Department of Family Medicine
Inquire in non-judgemental way
Encourage patient to bring in all
medications
Correlate use with blood pressure
measurements
Stages of change model
Establish office systems to
facilitate adherence
Educate patient about treatment
Collaborate with other health
professionals
Individualize regimen
Promote social support
Minimize economic barriers
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Target organ surveillance (SOR - B):
Complication
Key risk factor Recommendations
Hypertension,
blood pressure
control
Target <130
systolic,< 80
diastolic
Heart
Dyslipidemia
Target
HDL ≥ 40 in men
and ≥50 in women
Triglycerides < 150
Target without
CAD
LDL < 100
Target with CAD
LDL < 70
Antiplatelet
Target
ASA (75 – 162
mg/day)
Smoking cessation
CHD screening and
treatment
Measure blood pressure at each visit
If SBP between 130 and 139 and DBP 80-89, and not at target after 3
months of diet, add ACEI or ARB
If ≥ 140 systolic, and DBP ≥ 90 treat with drug class demonstrated to
reduce CVD events in patients with diabetes (ACE inhibitors,
ARBs, B-blockers, diuretics, Thiazide diuretic if GFR ≥50 ml/min
and loop diuretic if GFR ≤50 ml/min and calcium channel
blockers) with ACEI being initial choice
If renal insufficiency and macroalbuminuria develops, ARB delays
progression
Elderly should have blood pressure reduced slowly
Initiate lifestyle modification focusing on weight loss and increased
activity, reduction of saturated fat, trans fat, cholesterol intake
Begin statin if they have Coronary vascular disease (CVD), or over
the age of 40
If under age 40, begin statin if lifestyle modifications in-effective and
LDL >100 or in those with multiple CVD risk factors
May consider adding fibrate to improve HDL and triglycerides but
combination with statins not tested
Statin contraindicated in pregnancy
Indications
Known CAD
Increased CAD risk (age >40, family history of CVD, hypertension,
smoking, dyslipidemia, or albuminuria).
Not indicated in under 21
Indicated with clopidrogel or other agent if disease severe or
progressive
If allergic, bleeding, on coumadin, or otherwise not a candidate;
consider other agents
All patients advised abstinence
Cessation counseling and other forms of treatment should be offered
to all smokers
In asymptomatic patients, evaluate risk factors to stratify patients by
10-year risk, and treat risk factors accordingly. (B)
In patients with known CVD, ACE inhibitor, aspirin, and statin
therapy (if not contraindicated) should be used to reduce the risk of
cardiovascular events. (A)
Add B-blocker if prior MI to reduce mortality.
In patients >40 years of age with another cardiovascular risk factor,
ACE inhibitor, aspirin, and statin therapy (if not contraindicated)
should be used to reduce the risk of cardiovascular events. (B)
Use caution with hypoglycemics if patient has CHF, Metformin and
TZD are contraindicated in patients with treated CHF (C)
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Complication
Key risk factor
Recommendations
Prevention of
disease
Detection of
disease
Optimize blood sugar control
Optimize blood pressure control
Screening for microalbuminuria and measure serum creatinine atleast
annually
ACEI and ARB used if any evidence of albuminuria (micro or macro)
unless contraindicated
ARB has been shown to delay progression of nephropathy in patients
with type 1 DM with hypertension and microalbuminuria
One can substitute for intolerance
If disease develops, avoid excess protein
Refer to nephrologist when GFR falls below 60, blood pressure or
hyperkalemia difficult to control
Optimize blood sugar control
Optimize blood pressure control
Aspirin therapy for cardioprotection does not increase the risk of
retinal hemorrhage
Should have dilated eye exam upon diagnosis and annually, exam is
required more frequently if retinopathy is progressing.
Should have eye exam prior to pregnancy
Laser therapy is effective and patients with disease detected should be
referred for treatment
Kidney
Treatment to
prevent progression
Prevention of
disease
Eye
Detection of
disease
Treatment to
prevent progression
Prevention of
disease
Neuropathy
Autonomic
neuropathy
Detection of
disease
Annually screen using monofilament and 128 – Hz tuning fork
Treatment to
prevent progression
Referral to specialized center indicated for patients with insensate feet
Manage autonomic neuropathy symptomatically (tricyclic drugs,
gabapentim, duloxitine)
Prevention of
disease
Optimize blood sugar control
Detection of
disease
Treatment to
prevent progression
Foot care
Optimize blood sugar control
Educate patients regarding self care
Prevention of
disease
Detection of
disease
Foot Care con’t.
Treatment to
prevent progression
Surveillance for resting tachycardia, exercise intolerance, orthostatic
hypotension, constipation, gastroparesis, erectile dysfunction,
pseudomotor dysfunction, impaired neurovascular function, ―brittle
diabetes,‖ and hypoglycemic autonomic failure
Evaluation of bladder dysfunction should be performed for individuals
with diabetes who have recurrent urinary tract infections,
pyelonephritis, incontinence, or a palpable bladder
Optimize blood sugar control
Treat symptoms
Optimize blood sugar control
Perform comprehensive annual foot exam. Educate patients about
general foot care
Use monofilament, tuning fork, palpation, visual exam
Screen for peripheral artery disease with claudication history and
pedal pulse palpitation
Consider ABIs for any symptoms or if high risk
Refer patients with prior lower extremity complications to specialized
center
Refer for claudication or positive ABI for definitive repair
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Complication
Key risk factor
Preconception/
Pregnancy care
Prevention of
complications and
poor outcomes
Geriatric care
Prevention of
complications and
poor outcomes
Recommendations
HGB A1c should be normal < 7% prior to conception
Pregnancies should be planned. Educate about the need for good
glucose control
Medications should be reviewed prior to conception
Tight glycemic control should be considered in relatively healthy
patients whose life expectancy is > 10 years
Screening for diabetic complications should be individualized in older
adults, but particular attention should be paid to complications that
would lead to functional impairment. (E)
Polypharmacy, depression, cognitive impairment all may dictate less
aggressive care
Evidence is strongest for blood pressure control, less strong for blood
sugar and lipid control
All patients with diabetes admitted to the hospital should have
their diabetes clearly identified in the medical record. (E)
Diabetes care in
the hospital
Prevention of
complications and
poor outcomes
All patients with diabetes should have an order for blood glucose
monitoring, with results available to all members of the health
care team. (E)
Physical:
The physical exam is targeted at identification of risk factors or target organ damage, and
progress in modification or elimination of risk factors. Complete exam should be performed
initially and elements repeated periodically as indicated
General – General body habitus. Sexual maturation stage (if pubertal),
HEENT
Fundi - Visualize looking for vascular disease
Oral – Visualize for potential dental problems, gum disease
Thyroid – Palpate for nodule if thyroid disease suspected
Neck – Auscultate for bruits
Heart – Auscultate for valvular disease and evidence of failure
Lungs – Auscultate for evidence of failure
Abdomen - Palpate abdomen looking for hepatosplenomegaly
Extremities – Palpate femoral, pedal pulses periodically, check for pedal edema
Neuro – Complete exam of extremities including 10 – g monofilament and 128 Hz tuning fork
vibration test
Musculoskeletal – Hand/finger exam, particularly if using glucometer requiring finger sampling
Skin – Injection site problems and acanthosis nigricans
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Lab Testing (SOR - B):
Lab test
Reason
Initial
Follow-up
Thyroid stimulating
hormone
Assess blood sugar
control
End-organ damage
End-organ damage
Monitoring for medication
effect, particularly ACEI
and ARB
Common symptom
complex
Creatinine
Estimate GFR
Yes
Every 6 to 12 months and when
medication change dictates
Lipid profile
HDL-C
LDL-C
Triglyceride
Cardiovascular risk factor
Yes
If at target (LDL < 100 mg/dl, HDL> 50
mg/dl, Triglycerides < 150) repeat every
2 years
Urinary albumin excretion
Detect early nephropathy,
monitor disease
Yes
Annual
Hemoglobin A1c
Urinalysis
Electro-cardiogram
Potassium
Yes
Yes
Point of care if possible, biannual if at
goal, quarterly if not
Annual if normal
For symptoms and periodic
Yes
(Chem 8)
Every 6 to 12 months and when
medication change dictates
No
For symptoms
Yes
Office Based Management:
Therapeutic goals should be individualized with the following being the ideal:
Achieve glycemic control as measured by
o Hemoglobin A1c < 7.0 (key target)
o Preprandial capillary plasma glucose 90 – 130 mg/dl
o Peak postprandial CPG (if measured) < 180 mg/dl
Achieve blood pressure control
o Blood pressure consistently below 130/80
Achieve lipid control as measured by
o LDL < 100 mg/dl
o Triglycerides < 150 mg/dl
o HDL >50 mg/dl
Take into account the special requirements of children, pregnant women, and
elderly when setting targets
Tighter control (Hgb A1c < 6)may be attempted to reduce complications but it may
be at a cost of increased hypoglycemia
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Non-pharmacological (SOR - B)
Disease Self
Reason
Management
Self monitoring of blood
glucose (SMBG)
Has been shown to assist
with tight control
Confirm self reported
blood glucose with
hemoglobin A1c
Identifies average level of
blood glucose over past 3
months (see appendix)
Negotiate and set
glycemic goal
HgbA1c at 7% or below
has been shown to reduce
microvascular and
neuropathic complications
and possibly
macrovascular disease
Encourage patient to
become educated through
Diabetic Self
Management Education
classes
Management
Follow-up
Reach agreement with
patient on frequency and
timing based on
hypoglycemic medication
and therapeutic goals
3 or more times daily for
patients using multiple
insulin injections or
insulin pump
Perform initially and then
twice a year if 7% or
under or quarterly in
patients whose therapy
was changed, or if A1C
over 7%. Using point of
care testing allows for
timely decision on therapy
change when needed.
Goal of 7% is optimal for
most patients but highly
motivated patients can
attempt to achieve
euglycemia (< 6%) and
the very young or very old
may require less stringent
goals
Educated patient more
likely to be compliant
Arrange for classes,
encourage compliance
Reason
Management
Weight loss to achieve
BMI 18.5 -24.9 kg/m2
Moderate weight loss of
7% body weight
improves glyemic control,
and prevents development
of disease in those at risk
Exercise increase, 150
min per week of moderate
intensity aerobic physical
activity (50 to 70% of
max heart rate), calorie
reduction, referral to
dietician for Medical
Nutritional Therapy.
Monitor types and sources
of calories, select foods
low in calories and only
45 – 65% of intake should
be carbohydrate
Improves blood sugar
control, faclitates weight
loss
Lifestyle
Modification
Follow up
Individualized eating plan
University of South Alabama, Department of Family Medicine
Monitor at each visit
Have patient bring
values to office at
frequent intervals.
Encourage enhanced
non-pharmacologic care
or change medication
regimen if not at target
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Reducing protein if renal
insufficiency a concern
Reduces rate of
progression
Limit to 10% total
calories (0.8 g/kg/day)
Reduce saturated fat,
minimize trans fats
Reduces rate of
progression of heart
disease
Limit to < 7% total
calories
Encourage use of reduced
calorie sweeteners
Substitutes for empty
calories
Increase aerobic activity
Weight loss, glycemic
control
Limit alcohol
Reduction to 1 oz (≤1
drinks/day) in men or 0.5
oz ( ≤0.5 drink/day) in
women shown to reduce
BP
Eliminate tobacco
Additional risk factor
reduction
Immunize against
influenza and pneumonia
Illness leads to more
severe illness and death in
diabetic patients
Encourage use of reduced
calorie sweeteners
Substitutes for empty
calories
If patient not at target,
negotiate a combination
of enhanced compliance,
enhanced self monitoring
to identify problem, and
medication change
Offer repeat as needed
Diet beverages should be
substituted for sugar based
drinks
Regular moderateintensity physical activity;
at
least 30 min of
continuous/intermittent
(preferably 60
min) 5 d/wk, but
preferably daily
Inquire regarding intake
on diagnosis. Periodically
inquire. Employ stages of
change model
Inquire regarding use on
diagnosis. Periodically
inquire. Employ stages of
change model
Administer pneumovax
once and again at 65,
administer influenza
annually
Diet beverages should be
substituted for sugar based
drinks
University of South Alabama, Department of Family Medicine
Monitor weight at each
visit, inquire about diet
and exercise, encourage
referral and compliance
with recommendations
Encourage at every visit
Encourage at every visit
Encourage at every visit
Encourage at every visit
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Pharmacologic Treatment:
Hypoglycemic agents:
Indication: Failure of lifestyle modifications to achieve goal (SOR - A)
Class Of Medication
Mechanism Of Action
Cautions
Oral sulfonylurea
Thiazolidinediones
Biguanides
Glinides
Glucagon-like peptide 1 agonist
Amylin agonist
Alpha-glucosidase inhibitors
Stimulates pancrease to make more
insulin
Sensitize the body to insulin and/or
control hepatic glucose production
Sensitize the body to insulin and/or
control hepatic glucose production
Stimulates pancrease to make more
insulin, short acting
Stimulates pancrease to make more
insulin, administered sub-Q
Slows gastric emptying, inhibits
glucagon production, administered
sub-Q
Slow the absorption of starches
Caution in renal insufficiency
Contraindicated with abnormal
LFTs and CHF
Contraindicated for creatinine
> 1.4 in women or 1.5 in men
or CHF (lactic acidosis)
High frequency of nausea (and
weight loss)
High incidence of nausea, must be
used with insulin
Contraindicated in inflammatory
bowel disease or cirrhosis
Commercial combinations
Any class of drug (including insulin) can be used in combination with any other class but the following are
available commercially:
Sulfonylurea + Biguainide
As above
As above
Thiazolidinedione + Biguanide
As above
As above
Strategy for instituting hypoglycemic agents 1-3
Give interventions adequate time before reassessing; if not at goal, reassessment should
incorporate evaluation of compliance and frank discussion of medication use. Once goal has
been achieved, continually reassess regarding medication reduction and compliance.
Lifestyle modifications and metformin
IF A1c not at goal reassess and THEN
Combination with sulfonylurea OR glitazone OR Insulin
IF A1c not at goal reassess and THEN
Combination of two hypoglycemic or add or intensify insulin
IF A1c not at goal reassess and THEN add or intensify insulin
Ultimately combination may include insulin, metformin with or without a glitazone
Other meds can be used as adjunct or when patient is intolerant of above meds.
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Insulin therapy: 3
Indication: Failure of lifestyle modifications and oral agents to achieve goal
Insulin Category
Type
Onset/Peak/Duration
15
min/1
hour/ 2-5 hours
Immediate Acting
Insulin lispro solution
Insulin aspart solution
15 min/1.5 hour/ 3-5 hours
Regular
45 min/3 hour/ 8-12 hours
Prompt insulin zinc solution
75 min/6 hour/ 12-16 hours
Intermediate-Acting
Isophane insulin suspension NPH
120 min/8 hour/ 24 hours
Long-Acting
Lente
Ultralente
Lantus
120 min/11 hour/ 24 hours
360 min/20 hours/ 30 hours
60 min/5 hours/24 hours
Rapid-Acting
Strategy for instituting insulin agents:
Give interventions adequate time before reassessing; if not at goal, reassessment should
incorporate evaluation of compliance and frank discussion of medication use. Insulin is
routinely subcutaneous though occasionally insulin pumps are used. Newer delivery systems
via inhalation will be available soon. Once goal has been achieved, continually reassess
regarding medication reduction and compliance.
Begin with combination of hypoglycemics AND Insulin
o Single dose of intermediate or long acting in the evening (10 units or 0.2
units/kg)
o Check fasting daily and increase dose every 3 days until at target
o Reduce by 10% if hypoglycemic
IF A1c not at goal at 2-3 months reassess and THEN
o If fasting at target check during day, add fast acting
IF A1c not at goal reassess and THEN
o Check 2 hour post-prandial
Glycemic goals for adults with diabetes
A1C:
<7.0%
Preprandial capillary plasma glucose:
70–130 mg/dl (3.9–7.2 mmol/l)
Peak postprandial capillary plasma glucose:
<180 mg/dl (<10.0 mmol/l)
Hypoglycemia: Recommendations
Glucose (15–20 g) is the preferred treatment for the conscious individual with
hypoglycemia, although any form of carbohydrate that contains glucose may be used. If
SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be
repeated. Once SMBG glucose returns to normal, the individual should consume a meal
or snack to prevent recurrence of hypoglycemia. (E)
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Glucagon should be prescribed for all individuals at significant risk of severe
hypoglycemia, and caregivers or family members of these individuals should be
instructed in its administration. Glucagon administration is not limited to health care
professionals. (E)
Individuals with hypoglycemia unawareness or one or more episodes of severe
hypoglycemia should be advised to raise their glycemic targets to strictly avoid further
hypoglycemia for at least several weeks in order to partially reverse hypoglycemia
unawareness and reduce risk of future episodes. (B)
Antihypertensive agents: 4
Indication: Failure of lifestyle modifications to achieve goal
See Hypertension Chapter For Implementation Strategy
Indication
Initial therapy
If not at target, add
MI, CAD or high risk for CAD
Kidney disease
Medication
ACEI or ARB
Thiazide-type diuretic, if GFR
≥50ml/min and loop diuretic if GFR
≤ 50ml/min
Add BB, Aspirin, statin
ACEI and/or ARB
Notes
Aim for <130 mmHg for systolic
DCCB do not delay progression of
kidney disease
Goal: Below 130/80
Lipid lowering agents: 5
Indication: Failure of lifestyle modifications to achieve goal
See hyperlipidemia chapter for in-depth discussion of meds and implementation strategy
Indication
Medication
Notes
Statin
LDL not at target
Bile acid sequestrants
Nicotinic acid
Fibric acid
HDL not at target
Triglycerides not at target
Nicotinic acid
Fibric acid
Statin
Bile acid sequestrants
Fibric acid
Nicotinic acid
Statin
Bile acid sequestrants
University of South Alabama, Department of Family Medicine
Expensive and effective. Statin
should be started, in addition to life
style therapy regardless of baseline
lipid levels for patients with CVD
and for patients over the age of 40
and has 1 or more risk factor
Less expensive and less effective
Inexpensive and much less effective
Expensive and much, much less
effective
Inexpensive and somewhat effective
Expensive and less effective
Expensive and much less effective
Not indicated
Expensive and effective
Inexpensive and somewhat effective
Expensive and much less effective
Not indicated
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Strategy for instituting anti-hyperlipidemic agents:
Give interventions adequate time before reassessing, if not at goal, reassessment should
incorporate evaluation of compliance, frank discussion of medication use. When goal achieve,
continually reassess regarding medication reduction and compliance
Lifestyle modifications and blood sugar control
IF profile not at goal reassess and THEN
Initiate statin therapy
IF profile not at goal reassess and THEN
Consider combination of two classes of medications
o Patient should be apprised of risk of myopathy and rhabdomyolisis
Additional agents: 2
Indication
Prevention of MI
Smoking cessation assistance
Weight loss
Medication
ASA, clopidigrel for failure or
allergy
Nicotine delivery via various
methods, bupropion
Orlistat
Notes
Aggranox third choice
Remember ―stages of change‖
Side effects include oily spotting on
underwear, flatulence, urgent bowel
movements, fatty or oily stools,
increased number of bowel
movements
Situations requiring urgent attention (SOR - B):
Pregnant patient
Suspected or diagnosed diabetic ketoacidosis as diagnosed by hyperglycemia and
ketonuria or ketonemia.
Suspected or diagnosed hyperosmolar state as diagnosed by profound hyperglycemia, and
symptoms of polyuria, polydipsia, mental confusion, etc, and/or lab evidence of excess
serum osmolarity
Evidence of rapidly progressing end organ damage such as acute coronary syndrome,
retinal hemorrhage, renal failure, or transient ischemic attack
Return visit (SOR-C)
Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with
particular attention to worrisome symptoms that are consistent with end-organ damage
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Post-visit Assessment
Concern
Normal Blood Sugar
Interval development
of disease
Impaired Glucose Tolerance
Progression
Diabetes diagnosed, A1c < 7
Progression
Diabetes diagnosed, A1c 7 – 8,
blood pressure or lipids not at goal
Progression, long
term sequelae
Diabetes diagnosed, A1c < 8,
Progression, long
term sequelae
Diabetes diagnosed, A1c >8, lipids
and blood pressure controlled
Assess efficacy,
monitor for compliance
Diabetes diagnosed, A1c >8, or
lipids and blood pressure not
controlled
Assess efficacy,
monitor for compliance
Blood pressure, lipids, and glucose
controlled with medications
Monitor for side
effects, progression
University of South Alabama, Department of Family Medicine
Periodicity
Recheck every 3 years. Encourage lifestyle
modifications. Encourage participation in
community screening opportunities.
Recheck every 1year. Encourage lifestyle
modifications. Reduce or eliminate modifiable
risk factors. Weight loss of 5-10% of body
weight, Exercise 150 min per week. Encourage
participation in community screening
opportunities.
Follow-up q 3-6 months, monitor lifestyle
changes and A1c until no longer at risk of
progression or until decision is made to begin
medication. Reduce or eliminate modifiable risk
factors. Facilitate lifestyle modifications.
Suggest self-monitoring. Particular attention to
surveillance
Follow-up q 3months, monitor lifestyle changes
and A1c until no longer at risk of progression. If
no progress in 3 months consider medication.
Facilitate lifestyle modifications. Reduce or
eliminate modifiable risk factors. Attention to
self-monitoring. Particular attention to
surveillance
Follow-up q 3months, monitor lifestyle
changes, A1c until no longer at risk of
progression. If no progress on glucose in 3
months consider medication. Facilitate lifestyle
modifications. Work on blood pressure and lipid
reduction at each visit. Attention to selfmonitoring. Particular attention to surveillance
Follow-up q 2-4 months, monitor lifestyle
changes and A1c (q 3 m) until reduced. If no
rapid progress consider medication. Facilitate
lifestyle modifications. Reduce or eliminate
modifiable risk factors. Particular attention to
surveillance
Follow-up q 2-4 months, monitor lifestyle
changes A1c (q 3 m), blood pressure, lipids
until reduced. If no rapid progress consider
medication. Particular attention to surveillance
and drug SE. Facilitate lifestyle modifications.
Reduce or eliminate modifiable risk factors.
Office visit every 3 – 4 months, labs every 6 –
12 months, control other risk factors and comorbidities as needed. Particular attention to
surveillance and drug SE. Facilitate lifestyle
modifications. Reduce or eliminate modifiable
risk factors.
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87
Supplemental Materials:
On-line resource outlining a series on encounters with patients with chronic illnesses
www.fammed.usouthal.edu/clerkship/video/back
American diabetes association resources for health professionals
http://care.diabetesjournals.org/content/vol29/suppl_1/#INTRODUCTION
Suggested for further reading:
The Standards of medical care in diabetes – 2008accessed at
http://care.diabetesjournals.org/cgi/content/full/31
Management of Hyperglycemia in Type 2 Diabetes: A consensus algorithm for the initiation and
adjustment of therapy Diabetes Care (2006) 29: 1963-1972 accessed at
http://care.diabetesjournals.org/cgi/content/full/29/8/1963?ijkey=421676ae7a0905af338028d499
6e0a875089f3a6&keytype2=tf_ipsecsha on 5/14/2007
Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician
2005;71:469-76. Accessed at http://www.aafp.org/afp/20050201/469.html
U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003
accessed at http://www.ahrq.gov/clinic/uspstf/uspshype.htm
Onusko E. Diagnosing secondary hypertension Am Fam Physician
2003;67:67-74. accessed at http://www.aafp.org/afp/20030101/67.html
Resources for patients:
Diabetes patient handout
http://www.aafp.org/afp/20001215/2645ph.html
Diabetes and Diet
http://www.diabetes.org/nutrition-and-recipes/nutrition/overview.jsp
Exercise Prescription on the Net
http://www.exrx.net/index.html
References:
Florence J, Yeager B. Treatment of Type 2 Diabetes American Family Physician1999.
58(10) 2835 – 2846
2. American Diabetes Association. Standards of Medical Care in Diabetes – 2006. Diabetes
Care 2006. 29, (S 1): S4 – S43
3. Schoof M, Ehlers K. Short-acting insulin analogues vs. human insulin for diabetes.
American Family Physician 72 (5): 805
1.
University of South Alabama, Department of Family Medicine
June 30, 2008
88
4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The
seventh report of the Joint National Committee on prevention, detection, evaluation, and
treatment of high blood pressure: the JNC 7 report [Published erratum in JAMA
2003;290: 197]. JAMA 2003;289:2560-72. accessed at http://www.nhlbi.nih.gov/ on
2/06/06
5. Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am Fam Physician. 2000 Jun
1;61(11):3371-82.
Appendix:
University of South Alabama, Department of Family Medicine
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Appendix 2
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University of South Alabama, Department of Family Medicine
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91
Hyperlipidemia
mixed (Adult >20) 272.4
Definition
Adult: Total cholesterol, LDL, HDL, triglycerides not at risk factor specific goal on a validated
lab
This chapter does not cover all necessary information for children or patients with diabetic
dyslipidemia, (see diabetes chapter), very high LDL cholesterol, or markedly elevated
triglycerides. This chapter does include information regarding patients with concomitant
hypertension.
General Approach to the patient
Goals of the care process
1. Identify patients who are at significant risk to develop complication from
hyperlipidemia and implement risk factor modification strategies to meet
lipid goals.
2. Identify patients who are at risk of a major cardiac event (20%) and
implement intensive lipid lowering therapy
a. Detect and treat secondary causes
b. Offer counseling to assist with correction through diet and exercise
c. Offer counseling to reduce or eliminate concomitant risk factors such as
tobacco abuse or obesity
d. Initiate treatment using medication known to be effective.
3. Identify patients who are at a reduced risk of a major cardiac event (10% 20%) and implement lipid lowering activities
a. Detect and treat secondary causes
b. Offer counseling to assist with correction through diet and exercise
c. Offer counseling to reduce or eliminate concomitant risk factors such as
tobacco abuse or obesity
d. Initiate treatment using medication known to be effective in combinations
known to be effective should lifestyle modifications not be effective
4. Identify patients who are at a low risk of a major cardiac event (<10%) and
implement lipid lowering activities and medication when necessary
a. Detect and treat secondary causes
b. Offer counseling to assist with correction through diet and exercise
c. Offer counseling to reduce or eliminate concomitant risk factors such as
tobacco abuse or obesity
d. After adequate trial of lifestyle and risk factor modification, initiate
treatment using medication known to be effective in combinations known
to be effective.
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Rules of Thumb
Age
Frequency of
hyperlipidemia
Frequency of
ischemic cardiac
disease
Risk factors
20-35 (men)
20-45 (women)
Common
35-45 (men)
45-55 (women)
Common
45-65 (men)
55-65 (women)
Common
>65
Rare
Rare but can
progress rapidly
Common
Common
Cigarette
Cigarette
smoking
smoking
Hypertension
Hypertension
Low HDL
Low HDL
Fm Hx in first
Fm Hx in first
degree relative degree relative
Recommendation Every 5 years if
> 1 RF
for screening
Fasting lipid
profile (total
cholesterol,
LDL, HDL,
triglyceride)
LDL goal
Every 5 years
Fasting lipid
profile (total
cholesterol,
LDL, HDL,
triglyceride)
CHD and CHD
CHD and CHD
risk equiv <100
risk equiv
Multiple
<100
(2+) risk
Multiple
factors
(2+) risk
<130
factors
Zero to one risk
<130
factor <160
Zero to one risk
factor <160
Common
Cigarette
smoking
Hypertension
Low HDL
Fm Hx in first
degree
relative
Every 5 years
Fasting lipid
profile (total
cholesterol,
LDL, HDL,
triglyceride)
Current level
likely consistent
with previous
levels, risk
factors same as
to younger
patients
Screening
interval
uncertain if not
already
elevated, No
screen if life
expectancy < 10
years
CHD and CHD CHD and CHD
risk equival
risk equival
<100
<100
Addition
Addition
al risk
al risk
factors
factors
<130
<130
Zero risk factor Zero risk factor
<160
<160
CHD risk equivalents:
Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic
aneurysm, and symptomatic carotid artery disease);
Diabetes
Multiple risk factors that confer a 10-year risk for CHD >20%.
CHD and CHD risk equivalents give a >20% risk of a CHD event within 10 years.
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Overview
Coronary heart disease (CHD) is the single leading cause of death in the United States,
accounting for more than one in five deaths each year, or approximately 900,000 fatalities. It is
the leading cause of death in women at this time as well. An estimated $403 billion is spent
annually to care for patients with CHD. 1, 2 Consistent evidence from long-term, prospective
studies indicates that high levels of total cholesterol and LDL and low levels of HDL are
important risk factors for coronary heart disease, the leading cause of morbidity and mortality in
the United States. The risk for coronary heart disease increases with increasing levels of total
cholesterol and LDL, and declining levels of HDL, in a continuous and graded fashion with no
clear threshold of risk. According to National Center for Health Statistics data from 1988 to
1994, 17.5 percent of men and 20 percent of women 20 to 74 years of age had high levels of total
cholesterol (240 mg per dL [6.20 mmol per L] or higher).3
The following recommendations are from the Third Report of the National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (ATP III). 2 This report provides an evidence-based approach to the
prevention and management of the most common variants of hyperlipidemia, with emphasis on
primary and secondary prevention of coronary artery disease. It makes extensive use of
population based evidence such as the Framingham projections to assist the clinician with
identification of persons in need of more intensive treatment. Evidence from peer reviewed
articles published between 1995 and 2000 was selected and graded by the ATP III working
group and was used to formulate a set of recommendations which formed the basis for the
guideline. These were updated to reflect the results from large randomized controlled trials
completed in the early 2000s in 2004. The working group focused on Patient-oriented outcomes,
primarily reduction in myocardial events. The reduction in morbidity as well as mortality from
this disease is reflected in the following recommendations. Because the therapy is considered
relatively innocuous, little attention was paid to other patient factors, such as well being, for
these recommendations. These recommendations may not be appropriate for patients who suffer
from unrelated diseases that may limit lifespan to less than 10 years or patients who find
medication use onerous. In addition, patients who must make choices regarding medications
because of cost should be made aware that the medications used to treat this condition are
expensive and should be strongly encouraged to manage the condition with lifestyle
modifications initially and perhaps offered extra time to do so.
The Encounter
Chief Complaint:
Typically the condition is detected through screening of asymptomatic individuals either in the
community or in the office setting. The complaint is typically regarding the evaluation or followup of hyperlipidemia although it may be that the initiation of treatment occurs with an incidental
finding the patient has multiple risk factors or the level is markedly elevated. A complaint of
University of South Alabama, Department of Family Medicine
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94
chest pain that is assessed as non-cardiac will often generate a serum lipid profile that may
indicate the patient is at an elevated risk of cardiac disease.
Vitals
Initial and subsequent visits: Age, gender, weight/height (BMI), blood pressure, (previous and
current) should be noted prior to going into the room through chart review and review of vital
signs.
History of Present Illness (new evaluation): Patient should be encouraged to identify what
concerns exist. Patient should then be queried regarding major risk factors for cardiovascular
disease. Should be reassessed periodically. (SOR - B)
Presence of CAD
Key Question Content
Known or suspected CAD
(Risk 100%)
Anginal type chest pain,
previous MI, coronary stent
placement, CABG
Other ASCVD (Risk 100%)
History of peripheral artery
disease, abdominal aortic
aneurysm, angina,
claudication
Diabetes (Risk > 20%)
Current status of blood
sugar (if known)
Major Risk Factor
Key Question Content
Tobacco use
Current use of tobacco
Past use of tobacco
Hypertension, blood
pressure control
Target 140 systolic, 90
diastolic
Use of antihypertensives,
results of previous
screenings
University of South Alabama, Department of Family Medicine
Further investigation if
positive
Evaluate chest pain, obtain
records, communicate with
cardiologist, aggressive RF
reduction
Obtain records,
communicate with
cardiologist, investigate
based on suspicion,
aggressive RF reduction
Assess blood sugar, if
diabetes need stricter
control (See diabetes
mellitus chapter),
aggressive RF reduction
Further investigation if
positive
Counsel regarding
cessation, assess stage of
change
Measure blood pressure at
each visit
If above140 and not at
target after 3 months of diet
and exercise add drug in
class demonstrated to
reduce CVD events
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Low HDL cholesterol (< 40
mg/dL)
Results of previous
screenings
Family history of premature
CHD
CHD in male first degree
relative <55 years; CHD in
female first degree relative
<65 years
men >45 years; women >55
years
Age
Diet, exercise, consider
addition of fibrate if
unsuccessful
Aggressive modifiable RF
reductions as indicated by
additional risk factors
Aggressive modifiable RF
reductions as indicated by
additional risk factors
Risk analysis based on major risk factor inventory
0-1 risk factor, 10 year risk < 10%
> 2 risk factors, risk analysis based on Framingham risk scores found in ATP III
or at http://hp2010.nhlbihin.net/atpiii/calculator.asp
o Risk assigned as <10%, 10% - 20%, or > 20%
Life habit risk factors
Obesity
Current weight (from vitals) Calculate BMI
Physical inactivity
Athrogenic diet
Emerging risk factors
lipoprotein (a),
homocysteine,
prothrombotic and
proinflammatory factors,
impaired fasting glucose,
and evidence of subclinical
atherosclerotic disease.
Assess for metabolic
syndrome
Current physical activity
Past physical activity
Current diet
Past diet
Counsel regarding activity,
assess stage of change
Counsel regarding diet,
assess stage of change
Familial history, body
habitus, unusual symptoms
Investigate as indicated by
history, clinical suspicion,
refer to specialist if
concerned following initial
investigation, consider use
of aspirin and aggressive
statin use
Truncal obesity, weight
gain, elevated blood
pressure
Abdominal Obesity*
Waist Circumference
Men >102 cm (>40 in)
Women >88 cm (>35 in)
Triglycerides ³150 mg/dL
HDL cholesterol
Men <40 mg/dL
Women <50 mg/dL
Blood pressure >130/85
Fasting glucose >110
mg/dL
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Red Flags
Secondary hyperlipidemia considered when suggested by age, history, physical, severity, or lab
findings (SOR - C)
Secondary cause
Key signs or symptoms
Further investigation if
positive
Diabetes
Polyuria, polydipsia,
Fasting or random blood
obesity, weight changes
sugar
Hypothyroidism
Weight gain, cold
T4, TSH
intolerance
Obstructive liver disease
Right upper quadrant pain,
Liver associated enzymes,
jaundice
coagulation studies
Chronic renal failure
History of hypertension or
Serum BUN and creatinine
diabetes, oliguria
Drug induced
History of progestin,
Abstinance and repeat
anabolic steroid or
studies
corticosteroid use
LDL cholesterol goals and strategies (SOR - A)
Risk category
LDL goal
10 year risk between < 130 (consider <
10% and 20%
100)
LDL level to
institute
therapeutic
lifestyle change
> 100 (consider
> 70)
> 130 (consider
> 100)
10 year risk > 20%
<100
10 year risk < 10%
> 160
< 160
University of South Alabama, Department of Family Medicine
LDL level to consider
drug Therapy
> 100 concurrent with
lifestyle changes
> 130 concurrent with
lifestyle changes but
can initiate between
100 and 129 by choice
> 190 (160 – 189
optional after lifestyle
changes ineffective)
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History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about
changes in status, focusing on possible development of cardiac disease. Inquire about side effects
of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors
approximately every 12 to 24 months, more frequently if poor control.
If previously under control but no longer or resistant (SOR - C)
Possible cause
Key Question Content
Further investigation if
positive
Drug induced
Drug use
Inquire in non-judgemental way
Progestin
Encourage patient to bring in
Anabolic steroid
all medications
Corticosteroid use
Correlate use with lipid
measurements
Lack of adherence
―Some people have
trouble taking
medications. Do you?‖
Establish office systems to
facilitate adherence
Educate patient about treatment
Collaborate with other health
professionals
Individualize regimen
Promote social support
Minimize economic barriers
Physical
The physical exam is targeted at identification of risk factors or target organ damage, and
progress in modification or elimination of risk factors.
General – Look for evidence of tobacco use, general body habitus looking for truncal obesity,
acanthosis nigricans.
HEENT
Fundi – N/A
Neck – Ausculate for carotid bruits initially and periodically
Thyroid – Palpate for nodule if thyroid disease suspected
Heart – Auscultate for valvular disease and evidence of failure
Lungs – Auscultate for evidence of failure
Abdomen – Listen for abdominal bruits initially and periodically and (adults over 40) palpate
abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is
suspected.
Extremities – Palpate femoral, pedal pulses periodically, check for capillary refill initially and
periodically
Neuro –N/A
Musculoskeletal – N/A
Skin – Observe for xanthomas
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Lab Testing (SOR - C)
Lab test
Reason
Lipid profile
Monitor effect of
HDL-C
therapy, progression of
LDL-C
disease
Triglyceride
Electrocardiogram Cardiac disease
Dynamic cardiac
testing
Glucose
BUN, creatinine
Liver associated
enzymes
Initial
Yes
No
No
Additional risk factor,
identify metabolic
syndrome
Additional risk factor,
monitor for side effect
Yes
Monitor effect of meds
Optional
No
Follow-up
Every 6 weeks until
at goal if at medium
or high risk, then
every 6 months.
For symptoms of
possible angina
For symptoms of
possible angina
When moving from
sedentary to more
active lifestyle
Follow USPSTF
guidelines
Chem 8 may be
useful if on meds
that affect kidneys
or if suspicion of
occult disease
Upon initiation of
statins or nicotinic
acid, or medication
change
Office Based Management
Non pharmacologic (SOR - B)
Lifestyle
Reason
Modification
Weight loss to
Loss of as little as
achieve BMI 18.5 - 10 lbs reduces or
24.9 kg/m2
prevents
hyperlipidemia
Reduce saturated
Improves lipid
fats, dietary
control, facilitates
cholesterol, Increase weight loss
fiber intake
Increase aerobic
Weight loss, BP
activity
reduction
Eliminate tobacco
Additional risk
factor reduction
Management
Follow-up
Exercise increase,
calorie reduction
Encourage at every
visit
Therapeutic lifestyle Encourage at every
changes (TLC)
visit
eating plan
30 minutes on most
days
Inquire regarding
use on diagnosis.
Periodically inquire.
Employ stages of
change model
University of South Alabama, Department of Family Medicine
Encourage at every
visit
Per stages of change
model
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99
Pharmacologic treatment
General Principles 4
Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management.
TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL
lowering.
TLC Features:
○ TLC diet: Saturated fat <7% of calories, cholesterol <200 mg/day.
Consider increased viscous (soluble) fiber (10-20 g/day) and plant
stanols/sterols (2gm/day) as therapeutic options to enhance LDL lowering.
○ Weight management
○ Increased physical activity
In high-risk persons, the recommended LDL-C goal is 100 mg/dL.
o An LDL-C goal of < 70 mg/dL is a therapeutic option especially for patients at very
high risk.
o If LDL-C is >100 mg/dL, an LDL-lowering drug is indicated simultaneously with
lifestyle changes.
o If baseline LDL-C is < 100 mg/dL, institution of an LDL-lowering drug to achieve
an LDL-C level 70 mg/dL is optional on the basis of available clinical trial evidence.
o If a high-risk person has high triglycerides or low HDL-C, consideration can be given
to combining a fibrate or nicotinic acid with an LDL-lowering drug. When
triglycerides are > 200 mg/dL, non-HDL-C is a secondary target of therapy, with a
goal 30 mg/dL higher than the identified LDL-C goal.
For moderately high-risk persons (2 risk factors and 10-year risk 10% to 20%), the
recommended LDL-C goal is < 130 mg/dL; an LDL-C goal < 100 mg/dL is optional.
o When LDL-C level is between 100 to 129 mg/dL, at baseline or on lifestyle therapy,
initiation of an LDL-lowering drug to achieve an LDL-C level 100 mg/dL is optional.
Any person at high risk or moderately high risk who has lifestyle-related risk factors (eg,
obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a
candidate for TLC to modify these risk factors regardless of LDL-C level.
When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons,
intensity of therapy should be sufficient to achieve at least a 30% to 40% reduction in LDL-C
levels.
For people in lower-risk categories, the recommended LDL-C goal is 160 mg/dL.
o When LDL-C level is > 190 mg/dL, at baseline or on lifestyle therapy, initiation of an
LDL-lowering drug to achieve an LDL-C level 160 mg/dL is an option.
o When LDL-C level is between 160 to 189 mg/dL, at baseline or on lifestyle therapy,
initiation of an LDL-lowering drug to achieve an LDL-C level <160 mg/dL is an
option.
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100
Lipid lowering agents 5
Indication: Failure of lifestyle modifications to achieve goal
Indication
LDL not at target
Medication
Statin
Bile acid sequestrants
Nicotinic acid
Fibric acid
HDL not at target
Nicotinic acid
Fibric acid
Statin
Triglycerides not at target
Bile acid sequestrants
Fibric acid
Nicotinic acid
Statin
Bile acid sequestrants
Notes
Expensive and effective
Less expensive and less
effective
Inexpensive and much less
effective
Expensive and much, much
less effective
Inexpensive and somewhat
effective
Expensive and less effective
Expensive and much less
effective
Not indicated
Expensive and effective
Inexpensive and somewhat
effective
Expensive and much less
effective
Not indicated
Strategy for instituting anti-hyperlipidemic agents
Give interventions adequate time before reassessing, if not at goal, reassessment should
incorporate evaluation of compliance, frank discussion of medication use. When goal
achieved, continually reassess regarding medication reduction and compliance and encourage
maintenance of lifestyle modifications
Lifestyle therapies
o Emphasize reduction of saturated fat and cholesterol
o Encourage physical activity
o Dietary counseling
IF profile not at goal in 6 weeks reassess and THEN
Intensify LDL-lowering therapy
o Reinforce reduction in saturated fats and cholesterol
o Consider adding plant stanols
o Increase fiber
o Dietary counseling
IF profile not at goal in 6 weeks reassess and THEN
Consider initiation of statin, bile acid sequestrant, or nicotinic acid therapy
o Monitor and offer therapy for metabolic syndrome
o Intensify weight and physical activity counseling
o Dietary counseling
IF profile not at goal in 6 weeks reassess and THEN
Consider intensification of statin, bile acid sequestrant, or nicotinic acid therapy
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IF profile not at goal in 6 weeks reassess and THEN
Consider combination of two classes of medications
o Patient should be apprised of risk of myopathy and rhabdomyolisis
Consider referral to lipid specialist
Situations requiring urgent attention (SOR - B)
Triglyceride > 1000 mg/dl because of association with acute pancreatitis requires urgent
treatment beyond the scope of this discussion
LDL > 220 mg/dl because of association with accelerated cardiovascular disease requires
urgent treatment
Follow-up (SOR - B)
Monitor and comply with age appropriate health maintenance protocols. Attention to acute
complaints with particular attention to worrisome symptoms that are consistent with endorgan damage (see following table)
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Post-visit assessment
Normal lipids (lipids at
target)
Concern
Progression
Metabolic syndrome
Progression
Lipids above target but not
at treatment threshold in
low risk patient.
Progression
Lipids above target but not
at treatment threshold in
medium risk patient.
Progression
Lipids above target but not
at treatment threshold in
low risk patient with a
single severe risk factor
(heavy smoking,
uncontrolled hypertension,
etc), multiple life habit
measures or 10 year risk
approaching 10%
Lipids above target but not
at treatment threshold in
medium risk patient with
severe risk factor(s) (heavy
smoking, uncontrolled
hypertension, etc), multiple
life habit measures or 10
year risk approaching 20%
Lipids above treatment
threshold.
Progression,
development of
cardiac disease
Controlled lipids
Monitor for side
effects,
progression
Periodicity
Recheck 5 years. Screen for metabolic
syndrome. Encourage lifestyle
modifications. Encourage participation
in community screening opportunities.
Follow-up six months to one year.
Encourage lifestyle modifications,
weight reduction. Monitor glucose,
lipids, consider aspirin.
Follow-up every 6-12 months until
reduced or until decision is made to
begin therapy. Encourage lifestyle
modifications.
Follow-up every 6 weeks to 3 months
until reduced. Strongly consider
medication therapy. Encourage lifestyle
modifications.
Follow-up every 3 - 6 months until
reduced. Strongly consider medication
therapy if unable to reach goal.
Encourage lifestyle modifications.
Progression,
development of
cardiac disease
Follow-up every 6 weeks until reduced.
Strongly consider medication therapy if
unable to reach goal. Encourage
lifestyle modifications.
Progression,
development of
cardiac disease
Follow-up every 6 weeks until reduced.
Strongly consider medication therapy
after 3 months if unable to reach goal.
Encourage lifestyle modifications.
Office visit every 3 – 6 months, lipids
annually, additional labs on medication
change or periodically, monitor and
control other risk factors and comorbidities as needed. Consider low
dose aspirin. Encourage lifestyle
modifications.
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103
Supplemental materials
On-line resource outlining a series on encounters with patients with chronic illnesses
www.fammed.usouthal.edu/clerkship/video/back
Suggested for further reading
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III) Executive Summary accessed at
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp_iii.htm
Lockman A, Tribastone A, Knight K, Franko J . Treatment of Cholesterol Abnormalities. Am
Fam Physician 2005;71:1137-1142. Accessed at http://www.aafp.org/afp/20050315/1137.pdf
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults. Release date July
2001 accessed at http://www.ahrq.gov/clinic/uspstf/uspschol.htm
Safeer R, Ugalat P. Cholesterol Treatment Guidelines Update Am Fam Physician 2002;65:87180. accessed at http://www.aafp.org/afp/20020301/871.pdf
Resources for patients
Cholesterol patient handout
What should I know about cholesterol? - Patient Information Handout
http://www.aafp.org/afp/20050315/1147ph.html - March 15, 2005
10 year risk calculator
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub
Live Healthier, Live Longer (NHLBI)
http://www.nhlbi.nih.gov/chd/index.htm
Introduction to the TLC diet
http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi
Be Heart Smart!
Eat Foods Lower in Saturated Fat and Cholesterol
http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/smart1.htm
Exercise Prescription on the Net
http://www.exrx.net/index.html
University of South Alabama, Department of Family Medicine
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104
References
6. American Heart Association. Heart disease and stroke statistics update. Accessed online June
2006, at: http://www.americanheart.org/presenter.jhtml?identifier=1928.
7.
National Cholesterol Education Program. Third report of the expert panel on detection,
evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III).
Accessed online June 2006, at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.
8.
Berg AO. Screening adults for lipid disorders. Recommendations and rationale. Am J
Prev Med 2001;20(3 suppl):73-6.
9.
Grundy S, Cleeman J, Merz N, et al. Implications of recent clinical trials for the National
Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation.
2004;110:227-239. Accessed June 2006 at http://www.circulationaha.org.
10. Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am
Fam Physician. 2000 Jun 1;61(11):3371-82.
Appendix
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105
Drugs, trade name, and type
Advicor
lovastatin/niacin
Statin/niacin combo 20/500,20/750,20/1000 SR)
Altoprev
lovastatin
statin (10,20,40,60 SR)
Antara
fenofibrate micronized
fibric acid(43,130)
Caduet
amlodipine/atorvastatin CCB/Statin
(2.5/10,2.5/20,2.5/40,5/10,5/20,5/40,5/80,10/10,10/20,10/40,10/80)
cholestyramine
cholestyramine
binding agent (pwdr)
Colestid
colestipol
binding agent (1 g tabs; 5 g granule packets)
Crestor
rosuvastatin
statin (5,10,20,40)
gemfibrozil
gemfibrozil
binding agent (600)
Lescol
fluvistatin
statin
(20,40)
Lescol XL
fluvistatin
statin
(80SR)
Lipitor
atorvastatin
statin
(10,20,4080)
Lipofen
fenofibrate
fibric acid (50, 100, 150)
Lofibra capsules
fenofibrate micronized
fibric acid(67, 134, 200)
Lofibra tablets
fenofibrate
fibric acid (54, 160)
Lopid
gemfibrozil
fibric acid (600)
lovastatin
lovastatin
statin (10,20,40)
Mevacor
lovastatin
statin (10,20,40)
niacin
niacin
Niaspan
niacin
nicotinic acid
niacin
nicotinic acid (50,100,250,500; IM; IV)
nicotinic acid (500,750,1000 SR)
nicotinic acid (50,100,250,500; IM; IV)
Omacor
omega-3-acid ethyl esters (1 g)
Pravachol
pravastatin
statin (10,20,40,80)
pravastatin
pravastatin
statin (10,20,40)
Pravigard PAC
aspirin, buffered/pravastatin (81/20,81/40,81/80,325/20,325/40,325/80)
Questran
cholestyramine
binding agent (pwdr)
Slo-Niacin
niacin
nicotinic acid (250,500,750 SR)
Tricor
fenofibrate
fibric acid (48, 145)
Triglide
fenofibrate
fibric acid (48, 145)
Vytorin
ezetimibe/simvastatin
statin/binding (10/10, 10/20, 10/40, 10/80)
WelChol
colesevelam
binding agent
Zetia
ezetimibe
binding agent
Zocor
simvastatin
statin (5,10,20,40,80)
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107
Essential Hypertension
(Adult >16) 401.1
Definition:
Adult
Hypertension > 140/90 on at least two separate readings
Stage 1 140 – 159/90-99
Stage 2 >160 /100
Normal blood pressure <120/80
Prehypertension 120-139/80-89
This chapter does not pertain to patients with diabetes mellitus or known coronary artery
disease. This chapter does include patients with concomitant hyperlipidemia (272.4)
(N.B. Pediatric hypertension is a growing problem (associated with obesity and genetic factors)
and should be identified and managed appropriately. In that population hypertension is
identified as blood pressure > 95th percentile on 3 separate occasions)
General Approach to the patient:
Goals of the care process
1. Identify patients at risk of developing hypertension and implement risk factor
modification strategies to prevent hypertension from manifesting
2. Identify patients who have developed clinical hypertension prior to
development of end-organ damage
a. Detect and treat secondary causes
b. Offer counseling to assist with correction through diet and exercise
c. Offer counseling to reduce or eliminate concomitant risk factors such as
tobacco abuse or obesity
3. Initiate treatment using medication known to be effective in combinations
known to be effective
4. Monitor for reduction in and maintenance of blood pressure at physiologic
levels that are associated with elimination of end-organ damage
5. Continue surveillance for concomitant conditions which magnify untoward
effects of hypertension
Rules of Thumb:
Age
Frequency of
pre-hypertension
Frequency of
hypertension
Most common
cause of
refractory
hypertension
18-29
30-39
Common
Common
Uncommon
Common
Noncooperation,
Alcohol, Oral
contraceptives
(in women)
Non-cooperation,
Alcohol,
Oral
contraceptives (in
women)
40-59
Common
Common
Noncooperation,
Alcohol, Oral
contraceptives
(in women)
University of South Alabama, Department of Family Medicine
60-69
>70
Common
Uncommon
Very common
Approaches 90%
Noncooperation,
Thyroid
disease
Non-cooperation,
Thyroid disease,
Atherosclerotic
renal artery
stenosis
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Red Flags:
Secondary Hypertension (considered when suggested by 1) age, history, physical, severity, or
lab findings 2) Poor response to drug therapy 3) An increase after initial period of good control
4) Sudden onset (SOR - C)
Secondary Cause
Pheochromocytoma
Key Signs or Symptoms
Labile hypertension and/or
Paroxysmal hypertension associated with
headache, palpitatons, pallor, perspiration
Further Investigation if
Positive
24 hour urine for metanephrines
and normetanephrines
Suspected fibromuscular
dysplasia:
(Women between 15 and 50)
digital subtraction angiography
Renovascular hypertension
Elevated serum creatinine with use of ACEI or
ARB, Known atherosclerosis, flash pulmonary
edema, abdominal bruit
Coarctation of aorta
Diminished lower extremity pulses and/or
delayed or absent femoral pulses
CT angiogram
Cushings syndrome/ other
mineralocorticoid excess
Truncal obesity, glucose intolerance, purple
striae
Serum K+, 24 hour urine for
aldosterone or other
mineralocorticoids
Sleep apnea
Hyperparathyroidism
Hyperthyroidism
Hypothyroidism
History of snoring, daytime somnolence, neck
over 17 inches
Hypercalcemia, nonspecific pains, fatigue,
kidney stones
Palpitations, weight loss, sweats
Weight gain, cold intolerance
Suspected atherosclerosis
Renal function normal
High risk: angiogram
Moderate risk: CT, MR, or US
Low risk: No study
Renal insufficiency
US Doppler or MRA
Sleep study
Intact PTH, ionized calcium
T4, TSH
T4, TSH
Overview:
Hypertension (high blood pressure) is a disorder characterized by an elevated blood
pressure over that of the ―normal‖ population that if left untreated is associated with damage to
kidneys, heart, and blood vessels of the extremities and eyes. It is a disease of rising prevalence
with 50 million Americans potentially in need of treatment. It is the most common diagnosis
given to patients over 65 following an office visit. Unfortunately estimates are that 30% of the
population is unaware that they suffer from hypertension, 40% of those who have a diagnosis of
hypertension are not being treated and of those that are being treated 66% are not controlled.
Hypertension as a finding increases with patient age, patient weight, and a patient diet that is
high in sodium and low in fresh fruits and vegetables. The lifetime risk, in fact, approaches 90%
by age 90.1 Reduction of systolic blood pressure by 5 mm Hg over the entire population will
result in a 14% overall reduction in mortality from stroke, a 9% reduction in death from CAD,
and a 7% decrease in all-cause mortality.2 In addition in clinical trials, antihypertensive therapy
has been associated with reductions in stroke incidence (averaging 35–40 percent); myocardial
infarction (averaging 20–25 percent); and heart failure (averaging >50 percent).3
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The following recommendations are from the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). (5) This report
provides an evidence-based approach to the prevention and management of hypertension.
Evidence from English language, peer reviewed articles published between 1997 and 2003 was
selected and graded by the JNC7 working group and was used to formulate a set of
recommendations which formed the basis for the guideline. They focused on Patient-oriented
outcomes that included not only mortality but also other outcomes that affect patients’ lives and
well-being, such as sexual function, ability to maintain family and social roles, ability to work,
and ability to carry out daily living activities. As these outcomes are strongly affected by
nonfatal stroke, HF, CHD, and renal disease, this morbidity as well as mortality from these
diseases is reflected in the following recommendations.
The Encounter
Chief Complaint:
Typically the condition is detected through screening of asymptomatic individuals either in the
community or in the office setting. The complaint is typically regarding the evaluation or followup of hypertension although it may be that the initiation of treatment occurs with an incidental
finding if it is Stage 2 or greater. A complaint of headache, epistaxis, (not harbingers of
hypertension) will often generate a blood pressure reading that may indicate pre-hypertension or
hypertension.
Vitals:
Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures,
current blood pressure (with confirmation in opposite arm if warranted) should be noted prior to
going into the room through chart review and review of vital signs.
History of Present Illness (new evaluation): Patient should be encouraged to identify what
concerns exist. Patient should then be queried regarding major risk factors for cardiovascular
disease. Patient should be reassessed periodically. (SOR - B)
Risk Factor
Tobacco use
Oral contraceptive use
Obesity
Physical inactivity
Dyslipidemia
Diabetes mellitus
Reduced kidney function
Family history of
premature cardiovascular
disease or death
Key Question Content
Current use of tobacco
Past use of tobacco
Use of oral
contraception
Current weight (from
vitals)
Current physical activity
Past physical activity
Current lipid status (if
known)
Current status of blood
sugar (if known)
Current kidney function
(if known)
First degree relatives and
age of CV disease or
death
Further Investigation if Positive
Counsel regarding cessation, assess stage of change
Actual risk 41/10,000 use years, either need to
discontinue or continue combined with antihypertensive
therapy if no other contraception method appropriate
Calculate BMI
Counsel regarding activity, assess stage of change
Assess lipids, counsel regarding activity and diet, assess
stage of change
Assess blood sugar, if diabetes need stricter control (See
diabetes mellitus chapter)
Assess kidney function (serum and urine), if reduced
function for age need stricter control
If strong family history consider stricter control
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All patients with newly identified hypertension should have an investigation via history, physical
exam, and laboratory to identify possible target organ damage
Questions that assess potential target organ damage (SOR - B):
Target Organ
Heart
Carotid arteries
Other peripheral arteries
Kidneys
Eyes
Key Question Content
Dyspnea, chest pain (especially on
exertion),
Episodic unilateral weakness
Claudication
Length of time from disease onset,
control of blood pressure
Vision changes
Further Investigation if Positive
Stress test, ECHO
Carotid dopplers
Peripheral artery dopplers
Serum creatinine, urine for
microalbuminuria
Dilated eye exam
History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about
changes in status. Inquire about side effects of medications. Inquire about status of lifestyle
modification. Consider review of Risk Factors and/or target organ questions approximately every
12 to 24 months, more frequently if poor control
If previously under control but no longer or resistant (SOR - C):
Possible Cause
Drug induced
Alcohol use
NSAID use
Lack of
adherence
Key Question Content
Drug use
Prescription
Herbal
OTC
Illicit/recreational
Foods
Environmental
Frequency of alcohol use
Frequency of NSAID use
Further Investigation if Positive
-Inquire in non-judgemental way
-Encourage patient to bring in all
medications
-Correlate use with blood pressure
measurements
exposure
―Some people have trouble taking medications. Do
you?‖
-Stages of change model
-Substitute acetaminophen
-Establish office systems to facilitate
adherence
-Educate patient about treatment
-Collaborate with other health
professionals
-Individualize regimen
-Promote social support
-Minimize economic barriers
Physical:
The physical exam is targeted at identification of risk factors or target organ damage, and
progress in modification or elimination of risk factors.
General – Look for evidence of tobacco use, general body habitus looking for striae, moon
facies. Observe for neurologic asymmetry suggestive of cerebrovascular damage, determine
whether cuff size was correct.
HEENT
Fundi - Visualize looking for vascular disease initially and periodically
Neck – Ausculate for carotid bruits initially and periodically
Thyroid – Palpate for nodule if thyroid disease suspected
Heart – Auscultate for valvular disease and evidence of failure
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Lungs – Auscultate for evidence of failure
Abdomen – Listen for abdominal bruitsinitially and periodically and (adults over 40) palpate
abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is
suspected.
Extremities – Palpate femoral, pedal pulses periodically, check for pedal edema initially and
periodically
Neuro –N/A
Musculoskeletal – N/A
Lab Testing (SOR - B):
Lab Test
Urinalysis
Electrocardiogram
Calcium
Reason
End-organ damage
End-organ damage
Secondary cause, monitoring for
effect of medication
Secondary cause
Initial
Yes
Yes
Yes
(Chem 8)
Yes
Creatinine
Estimate GFR
Yes
Glucose
Additional risk factor
Hematocrit
Lipid profile
HDL-C
LDL-C
Triglyceride
Urinary albumin
excretion
Secondary cause
Yes (Chem
8)
Yes
Additional risk factor
Yes
Follow ATP-III guidelines
Additional risk factor, monitor
disease progression
Optional
Unknown
Potassium
Follow-up
Annual if normal
For symptoms and periodic
Every 6 to 12 months and when
medication change dictates
For symptoms
Every 6 to 12 months and when
medication change dictates
Follow USPSTF guidelines
For symptoms and periodic
Office Based Management:
Non pharmacologic (also appropriate for pre-hypertensive patients) (SOR - B):
Lifestyle
Modification
Weight loss to achieve
BMI 18.5 -24.9 kg/m2
Increasing fruits,
vegetables, potassium,
calcium.
Reason
Management
Follow-up
Loss of as little as 10 lbs reduces
or prevents hypertension
Exercise increase, calorie
reduction
Encourage at
every visit
Improves blood pressure,
facilitates weight loss
DASH eating plan
Encourage at
every visit
Reducing sodium
Reduction to 2.4 g per day
correlated with reduction in BP
DASH eating plan
Increase aerobic
activity
Weight loss, BP reduction
30 minutes on most days
Limit alcohol
Reduction to 1 oz (2 drinks/day) in
men or 0.5 oz (1 drink/day) in
women shown to reduce BP
Eliminate tobacco
Additional risk factor reduction
Inquire regarding intake on
diagnosis. Periodically inquire.
Employ stages of change model
Inquire regarding use on
diagnosis. Periodically inquire.
Employ stages of change model
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Encourage at
every visit
Encourage at
every visit
Per stages of
change model
Per stages of
change model
112
Pharmacologic treatment (Figure):
General Principles:
Systolic blood pressure target 130 for patients with diabetes or kidney disease, 140
otherwise. Diastolic will follow systolic. The lower without symptoms, the better
Lifestyle modifications much more important for long-term, especially in patients on
medication
For stage 1, a thiazide-type diuretic is a safe, inexpensive first choice
For stage 2, dual drug therapy often needed. Many combinations include a thiazide
diuretic and are good first choices
Pay attention to compelling indications
Pay attention to additional risk factors and focus on reduction or elimination
In the face of resistance, think non-adherence
Self-monitoring can be helpful. This entails monitoring in home, office, or other settings
such as drug stores where blood pressure cuffs are maintained.
Initiation of therapy, choosing a medication:
Initiation of therapy (SOR - A)
Compelling Indication
First Line
None
Thiazide-type diuretic
Post myocardial infarction
Thiazide-type diuretic, ACEI, ARB,
BB, aldosterone agonists
BB, ACEI, aldosterone agonists
CAD or high risk for CAD
Thiazide-type diuretic, ACEI, BB
Heart failure
Chronic kidney disease
Thiazide-type diuretic, ACEI, ARB,
CCB
ACEI, ARB
Recurrent stroke prevention
Thiazide-type diuretic, ACEI
Older patient
Thiazide-type diuretic, CCB
Diabetes
Other Considerations
ACEI, ARB, CCB also indicated.
BB may not offer equal protection
from CVA
CCB not indicated
If angina not controlled can add
long-acting dihydropyridine or
nondihydropyridine CCB
Follow more stringent diabetic
guidelines
Goal 130/80
Use caution during ongoing
ischemia. BB may not offer equal
protection from CVA
Maintaining systolic < 160 lowers
stroke risk by 33%. BB may not
offer equal protection from CVA
Situations requiring urgent attention (SOR - B):
Pregnant patient
Hypertensive crisis as defined by BP > 180/120 and evidence of impending or
progressive organ dysfunction. BP must be immediately reduced to prevent or limit organ
damage. Examples of diseases needing urgent attention include hypertensive
encephalopathy, intracerebral hemorrhage, acute MI, acute LVF with pulmonary edema,
unstable angina, dissecting aortic aneurysm, or ecclampsia
Hypertensive urgency as defined by severe elevation in blood pressure (above stage II)
but lack of end-organ damage. Symptoms might include severe headache, shortness of
breath, epistaxis, or severe anxiety
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Follow-up (SOR - B):
Monitor and comply with age appropriate health maintenance protocols. Attention to acute
complaints with particular attention to worrisome symptoms that are consistent with end-organ
damage
Post-visit assessment
Concern
Normal Blood Pressure
Progression
Pre-hypertension
Progression
Stage 1 hypertension, pre-treatment
Progression
Stage 1, initiation of treatment
Assess efficacy, monitor for
compliance
Initiation of treatment, stage 2
hypertension
Assess efficacy
Controlled blood pressure
Monitor for side effects, progression
Periodicity
Recheck 2 years. Encourage
lifestyle modifications. Encourage
participation in community
screening opportunities.
Follow-up six months to one year.
Encourage lifestyle modifications.
Encourage participation in
community screening opportunities.
Follow-up bi-monthly until
controlled or until decision is made
to begin medication. Encourage
lifestyle modifications. Consider
suggesting self-monitoring
Follow-up monthly until target
achieved, obtain labs for
monitoring. Encourage lifestyle
modifications. Consider suggesting
self-monitoring
Follow-up monthly or more
frequently until target achieved,
obtain labs for monitoring.
Encourage lifestyle modifications.
Consider suggesting self-monitoring
Office visit every 3 – 6 months,
Potassium, creatinine every 6 – 12
months, control other risk factors
and co-morbidities as needed. Low
dose aspirin when control achieved.
Encourage lifestyle modifications.
Consider suggesting self-monitoring
Supplemental materials:
On-line resource outlining a series on encounters with patients with chronic illnesses
www.fammed.usouthal.edu/clerkship/video/back
Reference card from The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf
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Suggested for further reading:
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure accessed at http://www.nhlbi.nih.gov/ on 3/06/08
Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician
2005;71:469-76. Accessed at http://www.aafp.org/afp/20050201/469.html
U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003
accessed at http://www.ahrq.gov/clinic/uspstf/uspshype.htm
Onusko E. Diagnosing secondary hypertension Am Fam Physician
2003;67:67-74. accessed at http://www.aafp.org/afp/20030101/67.html
Moser, Marvin, Setaro, John F.Resistant or Difficult-to-Control Hypertension N Engl J Med
2006 355: 385-392 accessed at http://content.nejm.org/cgi/content/full/355/4/385 (subscription)
Resources for patients:
Hypertension patient handout
http://www.fammed.usouthal.edu/clinicresources/Handouts&old/hypertension.htm
DASH Diet
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
Exercise Prescription on the Net
http://www.exrx.net/index.html
References:
National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on
Cardiovascular, Lung, and Blood Diseases. Accessed November 2003.
http://www.nhlbi.nih.gov/resources/docs/cht-book.htm and 1999–2000 unpublished data
computed by Wolz M and Thom T, National Heart, Lung, and Blood Institute. June 2003.
Vasan RS, Larson MG, Leip EP, Evans JC, O’Donnell CJ, Kannel WB, et al. Impact of high
normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh
report of the Joint National Committee on prevention, detection, evaluation, and treatment of
high blood pressure: the JNC 7 report [Published erratum in JAMA 2003;290: 197]. JAMA
2003;289:2560-72. accessed at http://www.nhlbi.nih.gov/ on 2/06/06
Wiysonge CS, Bradley H, Mayosi BM, Maroney R, Mbewu A, Opie LH, Volmink J.. Betablockers for hypertension. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.:
CD002003. DOI: 10.1002/14651858.CD002003.pub2 accessed at
http://www.cochrane.org/reviews/en/ab002003.html
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Modified from JNC VII (5)
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Appendix – Antihypertensive drugs (taken from JNC7)
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Joint Pain
719.4x
Definition:
Joint Pain – pain derived from the articulating surfaces of bones and is divided into 3 categories.
Monoarticular joint pain – Pain in 1 joint
Oligoarticular joint pain – Pain in 2 – 4 joints
Polyarticular joint pain – Pain in more than 4 joints
General Approach to the patient:
Goals:
1. Identify specific or life-threatening causes of joint pain.
2. Arrange for definitive care of identified specific causes of joint pain at time of
presentation or with appropriate follow-up.
3. Provide symptomatic relief of patient complaints.
4. Avoid ordering unnecessary tests on low risk patients.
Rules of Thumb:
Age
Complaint
frequency
Commonly
diagnosed
diseases (in
descending
order of
prevalence)
Life
threatening
diseases to
consider
Key
worrisome
features
(history)
Key elements
of exam
Key
diagnostic
study
Common
Treatment
Functional
limitations
1-10
Occasional
Trauma
Infection
Avascular
necrosis
Hemarthrosis
11-16
17-50
Common
Common
Overuse
Trauma
Overuse
Trauma
Crystals
Arthritis
Cancer
Infection
Cancer
Infection
Fever
Vitals
Lymph
Joint exam
X-rays of
affected and
surrounding
joints
Disease
dependent
Based on
diagnosis
50-70
Common
>70
Common
Trauma
Overuse
Arthritis
Crystals
Osteoarthritis
Trauma
Crystals
Cancer
Infection
Cancer
Infection
Cancer
Infection
Fever
Fever
Fever
Fever
Vitals
Lymph
Joint exam
Vitals
Lymph
Joint exam
Vitals
Lymph
Joint exam
Vitals
Lymph
Joint exam
X-ray
X-ray
X-ray
X-ray
NSAID
NSAID
Typically
limited by pain
Typically
limited by pain
NSAID
Alter activities
Typically
limited by pain
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Disease
dependent
Based on
diagnosis
120
Overview:
Almost 100% of people experience joint pain at some point in life. Many cases of joint
pain are treated without seeing a physician using OTC analgesics, ice packs, heating pads and
other home remedies. The differential diagnosis of joint pain is quite broad (see tables) and
often presents a diagnostic dilemma. Due to the high prevalence of benign, self-limited
conditions and the varied presentations and overlap of different types of inflammatory arthritis,
there is no single widely accepted approach for evaluating the patient with joint pain. There are
numerous guidelines and rules for interpreting diagnostic tests, but most diagnostic data is based
on expert opinion. There is better evidence for diagnosis and treatment of some of the more
common diseases such as rheumatoid arthritis that are based on randomized controlled trials.
Tests that are available for diagnosing inflammatory arthritis are neither sensitive nor specific
and may lead to confusion if ordered indiscriminately. Synovial fluid tests (microscopy, cell
counts and culture) can be diagnostic in some cases and are almost always helpful when a joint
effusion is present.
Chief Complaint:
Typically the complaint is ―Joint pain‖ with or without reference to a specific joint
Vitals:
Age, gender, temperature, and weight loss or gain should be noted prior to going into the room
through chart review and review of vital signs.
General approach to history:
The history for joint pain is targeted at identifying the cause of joint pain and determining if
infection is a potential cause of the joint pain.
Timing – When did your joint pain begin? What were you doing when you first noticed it? Is
your pain worse in the morning or at night?
Location – Does it hurt in the joint or the skin or muscles around the joint? (Patients sometimes
mistake muscular pain or bursitis for joint pain) Have you had pain in any other joints?
Quality – What kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc)
Severity – How bad is the pain on a scale of 1-10?
Aggravating/Relieving factors – Does anything make it better or worse? (Sitting, lying down,
lifting, bending over, etc) Is the pain or stiffness worse after you rest for more than 30 minutes?
Associated symptoms – Are any other symptoms associated with the joint pain? (Recent heavy
lifting, trauma, morning stiffness, fevers)
Symptom Review – Consider asking about fever, weight loss, lymphadenopathy, fatigue
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Age specific concerns:
Toddlers and young children: Children will often present with a limp or simply quit using the
affected joint rather than complaining directly about the pain. Pediatric limp has a broad
differential diagnosis. Septic arthritis and osteomyelitis should always be entertained in the
differential, particularly if there is a joint effusion and/or fever present. Nursemaid’s elbow is a
common cause of elbow pain and disuse in young children. This is due to subluxation of the
radial head (often occurs after child is lifted by the arm)
Adolescents: By far most common causes of joint pain in this age group are trauma and overuse
injuries. Fever, joint effusions and lymphadenopathy may suggest joint infections. Ankle sprains
are a particularly common cause of joint pain in this age group. Systemic symptoms,
involvement of multiple joints, and duration of pain >8 weeks may suggest rheumatologic
causes.
Adults: Although trauma and overuse are still very common causes of joint pain in this age
group, adults are more likely than other age groups to present with rheumatologic diseases that
respond to specific interventions. Rheumatologic disorders should be strongly suspected in
patients who have joint pain for more than 8 weeks.
Older adults: Osteoarthritis is the most common cause of joint pain in the elderly.
Occasionally, rheumatologic disorders present in the elderly. Osteoporosis and pathologic
fractures are also considerations in this age group.
Physical:
The physical exam is targeted primarily at identifying joint effusions, palpating for bony
tenderness and examining range of motion in the affected joints.
General – Does the patient appear ill? Are they sitting in an awkward position due to pain?
Musculoskeletal – Inspect joint for swelling, redness and effusion. Palpate joint for bony
tenderness, effusion and warmth. Test active and passive range of motion. True intra-articular
processes will limit both types of motion whereas periarticular pathology (bursitis, etc) will limit
active range of motion more than passive range of motion due to placing more strain on tendons.
This examination can be useful in deciding whether to get an X-ray of the affected joint. If there
is suspicion of fracture (bony tenderness or trauma), plain films are indicated. If there is a joint
effusion, a therapeutic and diagnostic arthrocentesis is important to rule out infection.
Elbow – Consider lateral epicondylitis (tennis elbow) – patient will have tenderness over lateral
epicondyle and pain over lateral epicondyle on resisted extension of wrist.. No pain on passive
movement of elbow.
Hip – Consider trochanteric bursitis (tender to palpation over greater trochanter). No pain on
passive movement of hip.
Listed below in the tables are some findings that may be present on physical exam to provide
clues in the setting of polyarticular joint pain.
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Laboratory Findings:
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Diagnostic Studies:
Acute joint pain and no signs of infection – Consider X-rays.
Acute joint pain and ANY suspicion of septic arthritis – Urgent arthrocentesis mandatory.
Consider X-rays
Chronic joint pain without systemic signs/symptoms – X-ray affected joints.
Chronic joint pain with systemic signs/symptoms (fever, fatigue, etc) – CBC, ESR as an
initial screen for inflammatory disorders. Consider ANA and rheumatologic work-up if ESR is
elevated. X-ray affected joints.
Although there are many more tests that can be ordered in the evaluation of joint pain (as listed
in tables above), most of the diseases they detect are rare. It is a waste of health care resources to
order an extensive laboratory work-up on all patients presenting with joint pain. Exhaustive
work-up should be reserved for those patients with persistent symptoms or symptoms strongly
suggestive of rheumatologic disease as listed above.
Office Based Management:
Sprains/strains – Generally diagnosed on basis of history of trauma or overuse and absence of
fracture on X-ray.
Non-pharmacologic:
Rest – Relative rest until pain is improving
Ice – Apply cold compresses for 20 minutes at a time several times a day
Compression – Ace Bandages may help with swelling
Elevation – Keeping affected joint elevated may help with swelling
Pharmacologic:
NSAIDs – Help with pain and inflammation. Have patient take medication on a regular basis for
several days to one week and then on an as needed basis.
Osteoarthritis – Generally diagnosed by history and degenerative changes on X-ray.
Non pharmacologic:
Rest will improve symptoms to some degree. Modify behaviors that exacerbate symptoms
(running, repetitive joint movements, etc).
Pharmacologic:
Tylenol is first-line. NSAIDs may be used but are potentially dangerous if used long term (GI
Bleeds). Narcotics may ultimately be needed in older patients if other therapies fail.
Corticosteroid injections may be of benefit, but should not be given more than 4 times per year
due to systemic effects of corticosteroids and the potential for worsening osteoarthritis if they are
overused.
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Lateral epicondylitis - Generally diagnosed by history of overuse and physical exam.
Non pharmacologic:
Rest is the definitive treatment. Special brace that puts pressure over extensor carpii insertion
onto lateral epicondyle may be of benefit.
Pharmacologic:
NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections
have been shown to be helpful.
Trochanteric Bursitis - Generally diagnosed by history of overuse and physical exam.
Non pharmacologic:
Rest.
Pharmacologic:
NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections
have been shown to be helpful.
Rheumatologic Disorders:
Nonpharmacologic:
Rest. Avoid activities that aggravate symptoms.
Pharmacologic:
Disease dependent. Patients are generally referred to rheumatologist for initiation of disease
modifying therapies.
Follow-up:
Patients should follow up in 1-2 weeks if not improving, sooner for development of any signs of
septic arthritis (fever, joint effusion, etc).
Suggested for further reading:
Sloane, P. Essentials of Family Medicine 4th edition. Chapters 20, 22, and 42.
References:
Richie, A.M. et al. Diagnostic Approach to PolyArticular Joint Pain. American Family
Physician Sept 15, 2003; Vol 68. No. 6 p.1151-1160.
Chokkalinhan, S. Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the
Family Physician. American Family Physician July 1, 2003; Vol 68 No. 1 p. 83 – 90.
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Low Back Pain
724.2
Definition:
Acute low back pain: Back pain of <1 month duration, typically under 7 days upon presentation.
Subacute low back pain: Back pain of 1-2 months duration.
Chronic low back pain: Back pain of >2 months duration.
Goals:
1. Identify specific or life-threatening causes of low back pain.
2. Arrange for definitive care of identified specific causes of low back pain at time of
presentation or at follow-up.
3. Provide symptomatic relief of patient complaints.
4. Avoid ordering unnecessary tests on low risk patients.
Rules of thumb:
Age
Complaint
frequency
1-10
11-16
17-50
50-70
>70
Rare
Rare
Common
Common
Uncommon
Commonly
diagnosed
diseases
Trauma
Infection
Functional
Functional
Trauma
Scoliosis
Functional
Disc disease
Functional
Fracture
Osteoarthritis
Cancer
Fracture
Functional
Life
threatening
diseases to
consider
Cancer
Infection
Cancer
Infection
Cancer
Infection
Cancer
Infection
Cancer
Infection
History of
cancer
History of back
surgery
Reflexes
Straight leg
raise
Plain films,
CBC, ESR,
based on clinical
suspicion
Disease
dependent
Based on
diagnosis
Key worrisome
historical
features
Night pain
Night pain
Bowel or
bladder
incontinence
Key elements
of exam
Based on
clinical
suspicion
Spinal curvature
Reflexes
Straight leg
raise
History of
cancer
History of back
surgery
Reflexes
Straight leg
raise
Key diagnostic
studies
Based on
clinical
suspicion
Typically none
indicated unless
red flags present
Typically none
indicated unless
red flags present
Typically none
indicated unless
red flags present
Common
treatment
Functional
limitations
Disease
dependent
Based on
diagnosis
NSAID
Alter activities
Typically
limited by pain
NSAID
NSAID
Typically
limited by pain
Typically
limited by pain
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Overview:
Over 90% of people will experience an episode of acute low back pain during life. The
overwhelming majority (over 90%) of these episodes of low back pain will be due to
nonspecific, ―functional‖ causes, such as muscle strains and other ill-defined causes. The vast
majority of patients will improve regardless of treatment and resume all normal activities within
3 months. In most cases low back pain will be managed conservatively, and can be expected to
resolve without specific interventions. Functional low back pain is most common in the middle
years of life. It is important to keep in mind when seeing people complaining of low back pain
that a small percentage will have severe underlying pathology. It is important to recognize these
causes in a timely fashion, especially if they will be responsive to specific interventions. If lifethreatening causes such as cancer, osteomyelitis, or abdominal aortic aneurysm are suspected,
then urgent work-up should be initiated. To identify that subset of patients at risk for serious
underlying pathology and order appropriate diagnostic studies, ―red flags‖ have been identified
through retrospective studies and meta-analyses of studies on low back pain that are associated
with serious causes of low back pain. The most efficient strategy is to screen patients who
present with a complaint of back pain using history, physical exam, and a knowledge of disease
epidemiology, performing diagnostic studies only on those patients who have an intermediate
risk of non-functional pain or a significant risk of life threatening illness. Patients fitting the
profile of functional low back pain typically have a benign and self-limiting course, and thus it is
important to avoid exposing them to unnecessary tests and procedures.
The evidence for diagnosis and management of low back pain is primarily based on consensus
and expert opinion, as there are no results from large, high quality, randomized, double blind
trials available. Such studies are very difficult to undertake for low back pain, given that the
overwhelming majority of patients improve rapidly regardless of treatment. As a result, the
available studies for low back pain examine red flags, the identification of ominous signs and
symptoms, and their association with pathology.
Chief complaint:
Typically the complaint is ―low back pain.‖
Vitals:
Age, gender, fever, and weight loss or gain should be noted prior to going into the room, through
review of the chart and vital signs.
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General approach to history:
The history for low back pain is targeted primarily to identify red flags. If no red flags are
present, the history allows the provider to characterize and document the nature of the pain
experienced by the patient. This information may be useful if the pain does not spontaneously
resolve.
Timing—When did your back pain begin? What were you doing when you first noticed it?
Location—Where does your back hurt? (Ask patient to point with one finger to place of most
severe pain.)
Quality—What kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc.)
Severity—How bad is the pain on a scale of 1-10?
Aggravating/Relieving factors—Does anything make it better or worse? (Sitting, lying down,
lifting, bending over, etc.)
Associated symptoms—Are any other symptoms associated with the pain? (Recent heavy
lifting, trauma.)
Symptom Review—Consider asking about fever, weight loss, dysuria, hematuria, leg weakness
or numbness, bowel or bladder incontinence, groin numbness.
Age specific concerns:
Infants and school aged children: It is uncommon for children to complain of low back pain of
such severity as to occasion a physician’s office visit. When children do present with back pain
to the office, the history is key in determining whether the complaint is related to a functional
problem or a somatic disorder. The younger the patient is, the more likely it is a somatic cause.
Conversely, as children approach middle school age, functional low back pain is likely. The pain
is commonly a function of book carrying methods or improper footwear.
Adolescents: Patients in this age group are more likely to present to the office with a complaint
of back pain than younger patients. Suspicion of functional back pain becomes more common
with book bags greater than 25% of body weight, improper footwear, overuse or awkward
athletic maneuvers, or prolonged sitting or standing. Resolution depends on identification of the
underlying cause and correction of the functional problem. Scoliosis is likely to present as back
pain in this age group.
Questions for parents of children or for adolescents:
Key Question Content
Further Investigation if Positive
Trauma
Consider fracture
Night pain
Consider cancer, infection, rheumatologic
New onset of severe pain in child who has never had
similar complaint
Consider cancer, infection, rheumatologic
Associated with school (both sexes)
Investigate book bag weight
Associated with school (female)
Investigate footwear
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Adults: Functional low back pain is by far the most common cause of low back pain in this age
group. Risk stratification is based on red flags.
Questions for adult:
Age
Any
Key Question Content
Trauma
Radiation in dermatome
distribution
Previous surgery, history of
alcoholism or injection drug use
Fever, persistent pain
Bowel or bladder dysfunction,
saddle anesthesia
Inconsistent response, overreaction
Physical activity, overuse
Night/rest pain
Any female over age 14
> 50
> 60
Flank pain, fever, dysuria
History of cancer
History of uncontrolled
hypertension, smoker
Further Investigation if Positive
Consider fracture
Disc herniation, varicella zoster
Discitis
Discitis, rheumatologic
Cauda equine syndrome
Malingering, non organic pain
None needed, alter activities to
protect back
Cancer, ankylosing spondylitis,
infection
Pyelonephritis, PID
Metastatic disease
Abdominal aortic aneurysm
Physical:
The physical exam is targeted primarily at identifying red flags and assessing range of motion.
General—Posture (Is pain causing patient to sit or move in an awkward fashion?)
HEENT—N/C
Neck—N/C
Heart—N/C
Lungs—N/C
Abdomen (adults over 60)—Listen for abdominal bruits and palpate abdomen looking for large
pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Palpate for suprapubic
and CVA tenderness if UTI/pyelonephritis is suspected.
Pelvic—Check for cervical/urethral discharge and adnexal masses if sexually transmitted disease
(PID) is a possibility.
Extremities—See neuro exam.
Neuro—Strength in hip, leg and foot. Assess DTR’s in knee and ankle. Perform sensory exam
if patient reports numbness. Unilateral numbness or weakness suggests acute disk herniation.
Musculoskeletal—Palpate spinous processes of lumbar spine (curvature, alignment, tenderness).
Palpate paraspinal muscles to assess for tenderness or muscle spasm. Assess range of motion
(flexion, extension, rotation, side-to-side bending). Perform straight leg raise test to assess pain
when sciatic nerve is stretched.
University of South Alabama, Department of Family Medicine
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Straight-leg-raise test:
Purpose Of Test
Maneuver
Positive Finding
Negative Finding
Interpretation of
Positive Result
Detect sciatic nerve root entrapment
Lie patient flat on table. Slowly raise heel while keeping leg straight. Stop when
patient reports pain, resistance is felt, or 70 degree angle between bed and leg is
reached. Note angle of elevation where patient reports pain.
Shooting pain from back to below the knee on the side of leg being raised.
No pain, back pain during maneuver, upper leg pain, pain in other leg.
Indicates nerve root entrapment. Suggests acute disk herniation.
Diagnostic studies:
General guidelines
No diagnostic studies are indicated in the absence of red flags.
Plain films are indicated in all ages for pain following trauma, pain greater than 4 weeks
duration, persistent or severe neurologic deficit, or fever.
Cervical swabs and perhaps pelvic ultrasound are indicated if sexually transmitted disease (PID)
a possibility.
Dip urinalysis is indicated for females with any urinary symptoms or if pyelonephritis is
otherwise clinically suspected.
OFFICE BASED MANAGEMENT
Functional Low Back Pain:
Nonpharmacologic—There is general agreement among physicians that patients with acute
nonspecific lower back pain require only conservative management. Patients should be
instructed to resume their normal activities as tolerated. Any aggravating factors should be
eliminated to the extent possible. Bed rest is not indicated, and has actually been shown to delay
recovery in patients with low back pain. Back pain education booklets provide lots of
information to patients, and teach exercises, postures, and lifting techniques that may be useful in
preventing back pain. Both physical therapy and chiropractic spinal manipulation have been
shown to offer small short-term benefits, but significantly increase the cost of medical care, and
do not decrease the recurrence of back pain or change long-term outcomes.
Pharmacologic—NSAIDs relieve low back pain through their analgesic properties and also
reduce inflammation. Instruct patients to take the NSAID regularly until back pain resolves.
Acetaminophen is an alternative medication in patients for whom NSAIDs are contraindicated.
Skeletal muscle relaxants may be useful in low back pain where muscle spasm is identified.
They are prescribed to be taken regularly until back pain resolves, but no longer than 4 weeks.
Avoid narcotic pain relievers unless pain is severe and not improved with NSAIDs and muscle
relaxants.
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Acute disc herniation:
Nonpharmacologic—Bed rest for 2-3 days is recommended to avoid aggravating the injury,
thereby increasing inflammation and ultimately worsening nerve root impingement. Patients
should then gradually resume normal activities as tolerated. Low back exercises and educational
booklets may be of some benefit. Most patients with radicular findings (even decreased reflexes
and strength) will significantly improve over time with conservative management. Surgical
intervention has not been conclusively shown to be of long-term benefit, though more rapid
initial recovery may occur.
Pharmacologic—Same as for functional low back pain with one exception. If patient is unable
to take NSAIDs, consider a high dose oral corticosteroid for 5-7 days to reduce inflammation,
although there are no controlled prospective studies to support corticosteroid use in low back
pain.
Pyelonephritis—See UTI chapter.
Referral to specialist for further evaluation and treatment:
Possible scoliosis noted on physical exam with or without confirmatory plain films.
Urgent referral to specialist for further evaluation and treatment:
Possible primary or metastatic cancer as identified on imaging studies.
Possible infectious etiology as identified through blood work or on imaging studies.
Progressive neurologic deficits involving bowel, bladder, or saddle anesthesia.
Possible abdominal aortic aneurysm greater than 4 cm as identified on imaging studies.
Follow-up:
Patients should follow up if back pain has not resolved in 4 weeks, or sooner for fever, dramatic
increase in pain level, or new onset of numbness or weakness. Non-resolution of symptoms
should prompt investigation for structural causes, rheumatological causes, as well as reevaluation
for the possibility of infection and cancer. If all symptoms resolve with therapy, the patient need
follow up only for regularly scheduled health maintenance visits.
University of South Alabama, Department of Family Medicine
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Flow chart:
University of South Alabama, Department of Family Medicine
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Suggested further reading:
Chapter 23: Low Back Pain in Current Diagnosis and Treatment in Family Medicine; Jeannette
E. South-Paul, Samuel C. Matheny, and Evelyn L. Lewis, editors; accessible by subscription at
http://www.accessmedicine.com/home.aspx.
Patel, A.T. and A.A. Ogle; Diagnosis and Management of Acute Low Back Pain; Am Fam
Physician; 2000 Mar 15;61(6):1779-86, 1789-90; accessible online at
http://www.aafp.org/afp/20000315/1779.html.
Humphreys, S.C., J.C. Eck, and S.D. Hodges; Neuroimaging in Low Back Pain; Am Fam
Physician 2002;65: 2299-306; accessible online at http://www.aafp.org/afp/20020601/2299.html.
Resources for patients:
Back Pain—Low; accessed on Medline Plus at
http://www.nlm.nih.gov/medlineplus/ency/article/003108.htm.
Low Back Pain: Tips on Pain Relief and Prevention; accessed on Familydoctor.org at
http://familydoctor.org/117.xml.
Relieving Low-Back Pain With Exercise; by Brian Shiple, DO; The Physician and Sportsmedicine;
Vol 25, No. 8, August 97; accessed at
http://www.physsportsmed.com/issues/1997/08aug/shiplepa.htm.
References:
Frymoyer, J.D.; Back Pain and Sciatica; N Engl J Med 1988;318: 291-300.
Carey, T.S., J. Garrett, A. Jackman, C. McLaughlin, J. Fryer, D.R. Smucker DR; The Outcomes
and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners,
Chiropractors, and Orthopedic Surgeons: The North Carolina Back Pain Project; N Engl J Med
1995;333:913-917.
Malmivaara, A., U. Hakkinen, T. Aro, et al; The Treatment of Acute Low Back Pain: Bed Rest,
Exercises, or Ordinary Activity?; N Engl J Med 1995;332:351-355.
Cherkin, D.C., R.A. Deyo, M. Battle, J. Street, and W. Barlow; A Comparison of Physical
Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment
of Patients with Low Back Pain; N Engl J Med 1998:339:1021-1029.
Weber, H; Lumbar Disc Herniation: A Controlled, Prospective Study With Ten Years of
Observation; Spine 1983;8:131-40.
Wheeler, A.H.; Pathophysiology of Chronic Low Back Pain;
http://www.emedicine.com/neuro/topic516.htm
University of South Alabama, Department of Family Medicine
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Migraine Headaches
346.XX
Definition:
Migraines are a common form of headaches that are genetically based and occur in 18% of
women and 6% of men. They affect either one side or both sides of the head and are widely
associated with various gastrointestinal, autonomic and Neurologic symptoms.
Goals:
1. Establishing a diagnosis
2. Encourage use of a headache diary to establish frequency of headaches, severity of
attacks, and uncover triggers.
3. Establish an individualized treatment regiment based on headache frequency and severity
as well as impact on the patient’s daily routine.
4. Provide education to the patient aimed at reducing migraine frequency through trigger
avoidance and life style modifications.
Red Flags:
The following symptoms and signs warrant investigations (mainly brain imaging) directed
towards exclusion of secondary headaches:
Red Flags for a Secondary Headache Disorder
A new or different headache
"Thunderclap" headache (peak intensity within seconds to minutes)
Worst headache ever
Focal neurologic signs or symptoms, such as papilledema, motor weakness, memory loss, papillary
abnormalities, or sensory loss
Change in existing headaches
New onset headache after age 50
Headache associated with systemic symptoms (fever, weight loss, jaw claudication)
Overview:
Migraine headache patients are frequently encountered in a primary care physician’s
office. The direct and indirect costs of migraine have been estimated at approximately $17
billion per year. Migraines may present with or without auras (an aura being a wide variety of
gastrointestinal, autonomic, or neurologic symptoms). Migraines without auras are the most
frequent type, occurring in approximately 80% of migraine patients. They are described as a
deep and dull headache if mild or moderate but throbbing in severe ones. They are typically
University of South Alabama, Department of Family Medicine
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worsened by rapid head movements, sneezing, or straining and are associated in typical cases
with some degree of photophobia and phonophobia. Typical migraines usually last 4 hours or
more if left untreated. They are described to be unilateral in 60-70% of cases and bifrontal or
global in up to 30% of cases. They are frequently first encountered in the 2nd and 3rd decade of
life, but may also be encountered in children as well. Multiple factors are thought to be involved
in the etiology of migraines. Some of the factors put forward include a genetic role, a vascular
role, as well as a possible role of Serotonin.
The Encounter
Chief Complaint:
The patient may present to the office for an acute migraine attack wanting quick relief of his
headache or present with a history of chronic migraine headaches expressing a desire to decrease
the frequency and severity of the attacks. Even though, the patient presenting with an acute
attack needs quick relief of his medication, a detailed history of his migraines must be elicited
with the goal of therapy to decrease his attack rate and severity.
History of Present Illness:
Acute Migraine Attack:
Classical Migraines:
Classical migraine patients present with unilateral dull to throbbing headaches that are
positional and are exacerbated by loud noises or bright light. Patients tend to seek dark quiet
rooms during an acute attack. There attacks usually start in the morning and very rarely does it
wake them up from sleep. They are preceded by an aura that is temporary and typically lasts less
than an hour.
Auras:
Neurological symptoms:
Visual disturbances (most common)
Numbness and/or tingling in the face or fingers. (2nd most common)
Autonomic symptoms:
Nasal congestion or rhinorrhea
Tearing
Color and temperature change
Changes in pupil size
Some patients may report migraine triggers. These triggers commonly include stress,
menstruation, lack of sleep, hunger, head trauma, some medication like oral contraceptives and
certain foods and beverages.
Atypical migraines may present with only some of the above symptoms making it difficult at
times to differentiate it from other forms of headaches.
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Key Questions to ask the Patient:
How frequent are your headaches?
How can you characterize your headaches?
Which part of your head is affected during the headache?
How long do your headaches last, if left untreated?
When do these headaches occur during the day?
Have you noticed any triggers to your migraines?
When you are having a headache, what makes it worse?
What do you do to relieve your headaches?
Do you have any other symptoms during the headaches?
Can you tell if you are about to have a headache? If yes, what symptoms do you have
before the headache starts?
Does anyone in your family have similar headaches?
Migraine Variants:
Hemiplegic Migraines:
These migraines are associated with motor and sensory deficits which may last
longer that the headaches itself and at times lasting for a few weeks.
Basilar type Migraines
These are associated with dysarthria, vertigo, diplopia, tinnitus, decreased
hearing, ataxia, or altered consciousness.
Migrainous vertigo
This may cause episodes of vertigo that frequently is misdiagnosed.
IHS Criteria for Migraine with Typical Aura:
A At least 2 attacks fulfilling criteria B
B
C
D
Aura consisting of at least one of the following, but no motor weakness:
Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines)
and/or negative features (i.e., loss of vision)
Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative
features (i.e., numbness)
Fully reversible dysphasic speech disturbance
At least two of the following:
Homonymous visual symptoms and/or unilateral sensory symptoms
At least one aura symptom develops gradually 5 minutes or more and/or different aura symptoms
occur in succession over 5 or more minutes
Headache fulfilling criteria for migraine without aura beginning during the aura or follows the aura within 60
minutes
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IHS Criteria for Migraine without Aura
Headache Descriptions (Any 2)
Unilateral
Pulsatile quality
Moderate to severe pain intensity
Aggravation by or causing avoidance of routine physical
activity
Associated Symptoms (Any 1)
Nausea and/or vomiting
Photophobia and phonophobia
Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last
4–72 hours
Physical Examination:
The physical examination in a migraine patient is usually normal; however, a
comprehensive neurologic exam is necessary to rule out focal neurological deficits, which are
seen in secondary headaches.
Lab Testing:
Patients with classical migraines do not require any lab testing.
Differential Diagnosis:
Tension Type Headaches (TTH):
This is the most common type of primary headaches. Unlike migraine headaches they are
not as severe and are not described as throbbing. Rapid head movements do not aggravate them.
They are very rarely associated with nausea, vomiting, photophobia or phonophobia. Patients
with TTH may present with episodic attacks (<15 days/month) or chronic tension type headaches
(>15 days/month).
Cluster Headaches:
Cluster headaches are less frequently encountered in an office than migraine headaches.
They are thought to be worse in intensity than any other primary headache. Cluster headaches
start more commonly in the 3rd and 4th decade of life. They are associated with symptoms of
sympathetic hypofunction and parasympathetic hyperfunction.
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Characteristics of Primary Headache Disorders:
Migraine
Location
Intensity
Duration
Quality
Associated symptoms
Gender
Unilateral
Moderate/severe
4 to 72 hours
Throbbing
Yes
Female > male
Tension-Type*
Bilateral
Mild/moderate
30 min to 7 days
Pressing/tightening
No
Female > male
Cluster
Strictly unilateral
Severe
15 to 90 min
Severe
Yes -- autonomic
Male > female
Management of Migraine Headaches:
Therapy of migraines is divided into treatment of acute attacks as well as preventive therapy
targeted to patients with frequent disabling headaches.
Acute Treatment:
Non-Pharmacologic Therapies:
The following therapies may be used in conjunction with pharmacologic therapy:
Relaxation Training
Thermal biofeedback with relaxation training
EMB biofeedback
Cognitive-behavioral therapy
Pharmacologic Therapy:
Concepts of Pharmacologic Therapy:
1) Use NSAIDs in the treatment of mild-to-moderate migraine headaches.
2) Use migraine-specific agents in patients with moderate-to-severe migraines or in patients
with mild-to-moderate migraines who fail to respond to NSAIDs.
3) Use of non-oral routes to administer medications in patients with significant nausea or
vomiting. (Anti-emetics may play an important role in alleviating these symptoms)
4) Medication-overuse headaches (rebound headache) are caused by frequent use of acute
medications. Patients requiring frequent rescue medications should use preventive
therapy.
Migraine-Specific Medications:
Triptans (Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan):
Effective and relatively safe in the treatment of Migraine headaches and may be used as the first
line therapy in patients with moderate-to-severe headaches. Triptans may be administered via an
intranasal or subcutaneous route in patients with significant nausea or vomiting.
Ergot Alkaloids and derivatives:
Ergotamine PO/PR and caffeine combinations may be considered in the treatment of selected
patients with moderate-to-severe migraine. Dihydroergotamine may be administered through an
intravenous, intramuscular, subcutaneous, or intranasal route and are reasonable treatment
choices in the therapy of moderate-to severe migraines.
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Nonspecific Medications:
NSAIDs, and other nonopiate analgesics:
NSAIDs and combination medications are a reasonable first-line therapy for mild-to-moderate
migraine headaches. Acetaminophen alone, however, is not recommended for migraines.
Butalbital-containing analgesics:
These are effective in the treatment of migraines, however, should be limited and patients should
be carefully monitored due to overuse, medication-overuse headaches, and withdrawal concerns.
Opiate Analgesics:
These are also effective in the treatment of migraine headaches, but, however, carry the risk of
overuse and dependence. Non-oral routes play an effective role in the rescue therapy for acute
migraine headache resistant to other medications provided the sedation side effect will not put
the patient at risk.
Preventive Therapy:
Goals of Preventive Therapy:
1) Reduce attack frequency, severity, and duration
2) Improve responsiveness to treatment of acute attacks
3) Improve function and reduce disability
Indications of Preventive Therapy (one or more of the following):
1) Recurring migraines that significantly interfere with daily routine despite acute treatment.
2) Frequent headaches.
3) Contraindications to or failure or overuse of acute therapy.
4) Adverse effects with acute therapies.
5) Presence of uncommon migraine conditions (migraine variants) mentioned previously.
6) Patient preference
Follow-up
Frequent follow up may be necessary initially to assess adequacy of response to therapy. Patients
are encouraged to use their headache diary to assist the physician in adjusting the dose and type
of medication most appropriate for his/her symptoms. However, when initiating preventive
therapy it may take 2-3 months to achieve full therapeutic effect of the medication.
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Acute Therapies
Acute Therapies
Triptans (serotonin1B/1D receptor agonists)
Sumatriptan nasal spray
Oral triptans
Naratriptan
Rizatriptan
Sumatriptan
Zolmitriptan
Sumatriptan SC
Ergot alkaloids and derivatives
DHE IV
DHE SC/IM
DHE IV plus antiemetics
DHE nasal spray
Ergotamine
Antiemetics
Chlorpromazine IM/IV
Metoclopramide IM
PR/IV
Prochlorperazine PR/IM
IV
NSAIDs and nonopiate analgesics
Acetaminophen
Ketorolac IM
Oral NSAIDS
Aspirin
Diclofenac K
Flurbiprofen
Ibuprofen
Naproxen
Naproxen sodium
Combination analgesics
Acetaminophen, aspirin, caffeine
Barbiturate hypnotics
Butalbital, ASA, caffeine
Butalbital, ASA, caffeine, codeine
Opiate analgesics
Butorphanol nasal spray
Opiates—oral combinations
Acetaminophen, codeine combinations
Opiates—parenteral
Butorphanol IM
Meperidine IM/IV
Methadone IM
Other medications
Corticosteroids
IV plus antiemetics
Dexamethasone
Hydrocortisone
Isometheptene compound
Lidocaine IN
Quality of
evidence
Scientific
effect
A
+++
Occasional
A
A
A
A
A
++
+++
+++
+++
+++
Frequent
B
B
B
A
B
++
+++/++
+++
++
+
Frequent
Occasional
Frequent
Occasional
Frequent
C/B
B
B
B
B
++
+
Mild to moderate
Infrequent to occasional
+++
+++
Occasional
B
B
0
+
Infrequent
Infrequent
Occasional
A
B
B
A
B
A
++
++
+
++
+
++
A
+++
Infrequent
C
B
?
++
Occasional
A
A
+++
++
Frequent
Occasional
B
++
Frequent
C
+
Infrequent
B
B
+
++
Infrequent
Frequent
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Adverse effects
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Preventive Therapies
Preventive Therapies
Antiepileptics
Carbamazepine
Divalproex sodium/sodium valproate
Gabapentin
Topiramate
Antidepressants
Tricyclic antidepressants
Amitriptyline
Nortriptyline
Protriptyline
Doxepin, imipramine
Selective serotonin reuptake inhibitors
Fluoxetine
Fluvoxamine, paroxetine, sertraline
Monoamine oxidase inhibitors
Phenelzine
Other antidepressants
Bupropion, mirtazepine, trazodone,
venlafaxine
Beta-blockers
Atenolol
Metoprolol
Nadolol
Propranolol
Timolol
Calcium channel blockers
Diltiazem
Nimodipine
Verapamil
NSAIDs
Aspirin
Fenoprofen
Flurbiprofen
Mefenamic acid
Ibuprofen
Ketoprofen
Naproxen/naproxen sodium
Serotonin antagonists
Cyproheptadine
Methysergide
Other
Feverfew
Magnesium
Vitamin B2
Quality of
evidence
Scientific
effect
B
A
B
C
++
+++
++
?
Occasional to frequent
Occasional to frequent
Occasional to frequent
Occasional to frequent
A
C
C
C
+++
?
?
?
Frequent
Frequent
Frequent
Frequent
B
C
+
?
Occasional
Occasional
C
?
Frequent
C
?
Occasional
B
B
B
A
A
++
++
+
++
+++
Infrequent to occasional
Infrequent to occasional
Infrequent to occasional
Infrequent to occasional
Infrequent to occasional
C
B
B
?
+
+
Infrequent to occasional
Infrequent to occasional
Infrequent to occasional
B
+
Infrequent
C
B
B
?
+
+
Infrequent
Infrequent
Infrequent
C
A
?
+++
Frequent
Frequent
B
B
B
++
+
+++
Infrequent
Infrequent
Infrequent
Adverse effects
Adapted from the AAN Evidence-based guidelines for Migraine Headache
University of South Alabama, Department of Family Medicine
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Migraine Algorithm
Initial Visit
Detailed History
Diagnostic Screening & Differential Diagnosis
Assess illness severity:
Attack frequency and duration
Pain severity
Impact
Non-Headache symptoms
Patient history and preferences
Intermittent mild-to-moderate migraine
Intermittent moderate-to-severe migraine
Behavioral Therapies
Oral/Nasal/SC Triptans
or DHE
Aspirin/NSAID (large dose)
Aspirin/acetaminophen + antiemetic
Rescue
If Initial Treatment Unsuccessful
Alternative oral/Nasal/SC Triptan
Oral Triptan
If Unsuccessful
Consider prophylaxis & acute treatment
for breakthrough migraines
Frequent Headaches
4 attacks / month
If Unsuccessful
Consider Referral
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Supplemental Material
http://www.neurology.org/cgi/reprint/63/12/2215.pdf
http://www.neurology.org/cgi/reprint/55/6/754.pdf
http://www.guideline.gov/algorithm/4002/NGC-4002_3.pdf
Resources for Patients:
http://www.aan.com/professionals/practice/pdfs/Headache_Peds_Patients.pdf
http://www.aan.com/professionals/patient/hakit/pdf/pat_hea_dia.pdf
http://www.aan.com/professionals/patient/hakit/pdf/pat_hea_tri.pdf
References:
American Academy of Neurology Evidence-based guidelines for migraine headache
International Headache Society headache classification
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New Onset Headache
784.0, 346.XX, 307.81
Definition:
Headache, or cephalalgia, is defined as diffuse pain in various parts of the head General
Approach to the patient
Overview:
Headache is among the most common pain problems encountered in family practice. One
epidemiologic study1 found that 95 percent of young women and 91 percent of young men
experienced headache during a 12-month period; 18 percent of these women and 15 percent of
these men consulted a physician because of their headache.
Missed workdays and medical benefits associated with headache cost American industry
approximately $50 billion annually.
Chief Complaint:
Patients will present complaining of headaches of different descriptions depending on the
etiology. Most patients with primary headaches will present after trying OTC remedies.
History of Present Illness:
A systematic case history should include the following:
Age at onset
Presence or absence of aura and prodrome
Frequency, intensity and duration of attack
Time and mode of onset
Quality site and radiation of pain
Precipitating and relieving factors
Associated symptoms and abnormalities
Effect of activity on pain
Number of headache days per month
Family history of migraine
Relationship with food/alcohol
Response to any previous treatment
Any recent change in vision
Association with recent trauma
Any recent changes in sleep, exercise, weight, or diet
State of general health
Change in work or lifestyle (disability)
Change in method of birth control (women)
Possible association with environmental factors
Effects of menstrual cycle and exogenous hormones (women)
University of South Alabama, Department of Family Medicine
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Diagnostic instruments:
The brief headache screen, adopted by the American Academy of Neurology, appears to be well
suited to identify migraine in the primary care setting. This screen includes the following
questions:
Use the frequency of severe and mild headache and medication use to categorize patients as
migraine (i.e.: episodic, severe), daily headache and/or medication overuse.
Q1. How often do you get severe headaches (i.e. without treatment it’s difficult to
function)?
This question alone identifies migraine. Any patient with severe headaches which are episodic
should be assumed to have migraine.
Q2. How often do you get other (milder) headaches?
Daily headaches should always be evaluated for "worrisome" features. Patients with daily
headaches (at times severe and migrainous) may have "transformed migraine," often due
to medication overuse.
Q3. How often do you take headache relievers or pain pills?
Use of symptomatic medications more than 3 days/week represents medication overuse. The
label, "drug rebound headache," should not be applied without a complete evaluation that has
considered secondary and "worrisome" headaches. When drug rebound headache is recognized,
symptomatic medications must be withdrawn for the patient to improve.
Q4. Has there been any recent change in your headaches?
The best screening question for "worrisome" headaches. A patient with a stable pattern
of headache for 6 months has the same likelihood of an underlying tumor as a patient
without headache.
Q5. How often do you miss work (or leisure activities) because of headache?
Good question for headache-related disability.
Q6. Are you satisfied with your current headache medicine?
Rapidly assesses acute therapy.
Q7. Are you on a preventive medicine for headache? If not, would you like to
be?Determines the patient's preference for prophylaxis.
―MIGRANES IN A MINUTE‖MIGRAINE IN A MINUTE
Adapted from Morris Maizels, MD, Kaiser Permanente
University of South Alabama, Department of Family Medicine
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Danger signs:
Headaches may be the presenting symptom of a space-occupying mass or vascular lesion,
infection, metabolic disturbance, or a systemic problem.
Symptom
Sudden onset of headache
New headache in patients under the age of five or over
the age of 50 may suggest underlying pathology.
The "first" or "worst" headache of my life
A worsening pattern
Focal neurologic symptoms other than typical visual or
sensory aura
Fever associated with headache
Change in mental status
The rapid onset of headache with strenuous exercise
Head pain that spreads into the lower neck and between
the shoulders
New headache type in a patient with cancer
New headache type in a patient with Lyme
New headache type in a patient with HIV suggests
Headache during pregnancy or postpartum
Possible Diagnosis
Subarachnoid hemorrhage Cluster headache may
sometimes be confused
Intracranial hemorrhage, CNS infection, or a space
occupying lesion
Intracranial hemorrhage or central nervous system (CNS)
infection
A mass lesion, subdural hematoma, or medication
overuse headache
A mass lesion, arteriovenous malformation, or collagen
vascular disease
Intracranial, systemic, or local infection
Intracranial hemorrhage, CNS infection, or a space
occupying lesion
Carotid artery dissection or intracranial hemorrhage
Irritation due to either infection or subarachnoid blood
Metastasis.
Meningoencephalitis
Opportunistic infection or tumor
Preeclampsia, cortical vein or venous sinus thrombosis,
carotid dissection, and pituitary apoplexy
Other features suggesting a specific headache source
Chronic nasal stuffiness or chronic respiratory infection suggests a diagnosis of sinusitis.
Impaired vision suggests the presence of glaucoma.
Visual field defects suggest the presence of a lesion of the optic pathway.
The presence of nausea, vomiting, worsening of headache may be caused by a tumor.
Sudden, severe, unilateral vision loss suggests the presence of optic neuritis.
Headache, fatigue, generalized aches and pain, and night sweats in subjects age 55 years
or older suggest the presence of temporal arteritis.
Intermittent headaches with high blood pressure are suggestive of pheochromocytoma.
Physical:
The majority of patients with headache complaints have a completely normal physical and
neurologic examination. If a complete and careful history does not point to a primary etiology,
further examination is warranted in the following areas:
Obtain blood pressure and pulse
Listen for bruit at neck
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles
A comprehensive neurologic examination
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Danger Signs on Exam:
Sign
Neck stiffness
Papilledema
Focal neurologic signs
Possible Diagnosis
Meningitis
Intracranial mass lesion, pseudotumor cerebri,
encephalitis, or meningitis
Intracranial mass lesion, arteriovenous malformation, or
collagen vascular disease.
Indications for imaging studies
Patients with any of the danger signs noted above need urgent brain imaging:
Recent significant change in the pattern, frequency or severity of headaches
Progressive worsening of headache despite appropriate therapy
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Orbital bruit
Onset of headache after age 40 years
NOTE: Neuroimaging is usually not warranted for patients with migraine and a
normal neurologic examination.
The data are insufficient to recommend CT or MRI when neuroimaging is necessary. A
head CT scan (with and without contrast) is likely to be sufficient in most patients. An MRI
along with MRA are indicated when posterior fossa or vascular lesions are suspected.
As many as 90 percent of all benign headaches fall under a few categories, including: migraine,
tension-type, and cluster headache. While a population-based study found that the one-year
prevalence of episodic tension-type headache was 38 percent, most of these people do not
present to physicians for care.
Characteristics of Primary Headache Disorders:
Location
Intensity
Duration
Quality
Associated symptoms
Gender
Migraine
Unilateral
Moderate/severe
4 to 72 hours
Throbbing
Yes
Female > male
Tension-Type*
Bilateral
Mild/moderate
30 min to 7 days
Pressing/tightening
No
Female > male
Cluster
Strictly unilateral
Severe
15 to 90 min
Severe
Yes -- autonomic
Male > female
MIGRAINE HEADACHES
See Chapter on Migraines
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TENSION TYPE HEADACHE
IHS Criteria for Diagnosis of Tension Type Headaches
Headache Description (Any 2)
Pressing or tightening
Mild to moderate intensity
Bilateral location
No worsening with exertion
Associated Symptoms (Any 1)
No nausea or vomiting
Photophobia or phonophobia (1 allowed)
Must have had >10 previous headache episodes and no evidence of a secondary headache disorder
Tension type headache is the most common headache syndrome. Tension type headaches feel
like pressure or tightness all around the head and have a tendency to wax and wane in intensity.
The revised IHS classification distinguishes three subtypes of tension type headache:
Infrequent episodic TTH with headache episodes less than one day a month
Frequent episodic TTH with headache episodes 1 to 14 days a month
Chronic TTH with headaches 15 or more days a month
Treatment:
Episodic:
Simple analgesics such as acetaminophen, aspirin and other nonsteroidal antiinflammatory drugs
(NSAIDs) are the drugs of choice for abortive therapy. Combination drugs containing
ergotamine, caffeine, butalbital and codeine should be avoided due to the potential for drug
dependency and analgesic overuse (rebound) headaches.
Chronic headaches:
Prophylactic therapy is indicated for patients with chronic headaches requiring daily
analgesics. Tricyclic antidepressants, specifically amytriptyline, has shown benefit. Mirtazapine
showed positive results in one randomized controled trial. SSRIs have shown mixed results.
Biobehavioral techniques ( mind-body therapies) can be useful for managing chronic tension
type headaches, either alone or in combination with antidepressant medications. Psychotherapy,
relaxation therapy, and biofeedback all may be useful. Physical therapy also may reduce the
frequency of headaches in some cases.
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Table 2. Recommended Mind-Body Therapies for Headache
Therapy
Evidence rating
Migraine headache
Behavioral therapy with prophylactic drug therapy
B
Cognitive behavior therapy
A
Combination of progressive muscle relaxation and biofeedback
A
Electromyographic biofeedback
A
Relaxation training
A
Thermal biofeedback (alone or in combination with relaxation training)
A
Tension headache
Cognitive behavior therapy
B
Cognitive behavior therapy in children and adolescents with chronic
headache
A
Home-based behavioral therapies
B
Muscular biofeedback
B
Progressive muscle relaxation
B
Relaxation training in children and adolescents with chronic headache
A
Stress management training
B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For
information about the SORT evidence rating system, see http://www.aafp.org/afpsort.xml.
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CLUSTER HEADACHES
IHS Criteria for the General Diagnosis of Cluster Headache
Headache Description (All 4)
Severe headache
Unilateral
Duration of 15–180 min
Orbital, periorbital, or temporal location
Autonomic Symptoms (Any 2)
Rhinorrhea
Lacrimation
Facial sweating
Miosis
Eyelid edema
Conjunctival injection
Ptosis
*No evidence of a secondary headache disorder.
CLUSTER HEADACHE — Cluster headaches are characterized by repetitive headaches that
occur for weeks to months at a time, followed by periods of remission.
Cluster headache is relatively uncommon; the prevalence is less than 1 percent. Men are affected
more commonly than women, with a peak age of onset of 25 to 50 years.
The pain of cluster headache begins quickly without any warning and reaches a crescendo within
a few minutes. The headache is usually deep, excruciating, continuous, and explosive in quality,
although occasionally it may be pulsatile and throbbing. The pain usually begins in or around the
eye or temple; less commonly it may start in the face, neck, ear, or hemicranium. The pain is
always unilateral; it remains on the same side of the head during a single cluster, but can switch
sides during the next cluster in a small percentage of patients. Some patients report superimposed
paroxysms of stabbing ice pick-like pain in the periorbital region that lasts for a few seconds and
occur once or several times in rapid succession.
Cluster headaches are associated with ipsilateral lacrimation and redness of the eye, stuffy nose,
rhinorrhea, sweating, pallor, and Horner's syndrome. Nausea and vomiting may occur.
Photophobia occurs ipsilateral to the pain. Focal neurologic symptoms are rare other than
Horner's syndrome. Over 50 percent of sufferers report that alcohol is a potent precipitant of
cluster headaches during a cluster bout; this sensitivity to alcohol ceases when the cluster ends.
A typical cluster headache lasts from 15 minutes to three hours. The frequency of attacks
depends upon the type of cluster:
Episodic cluster headaches are most common, occurring in about 80 to 90 percent of patients
suffering from this disorder. They are characterized by one to three attacks of periorbital pain
per day over a six to twelve week period, followed by an average pain free interval of six
months to one year. The remission may last for years.
Chronic cluster headaches are characterized by the absence of sustained periods of remission.
Either form of cluster headache can transform into the other. Attacks of pain tend to recur at the
same hour each day for the duration of a single cluster; attacks occur between 9 pm and 9 am in
up to 80 percent. Most patients experience one cluster per year, but this is not predictable.
University of South Alabama, Department of Family Medicine
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Management:
Abortive therapy — Abortive therapy of cluster headaches can be difficult because of the short
duration of each episode. Nevertheless, a number of medications have proven effective
Oxygen — Acute cluster headaches can be aborted by inhalation of 100 percent oxygen
in the majority of patients. Oxygen inhalation should be given for 20 minutes in an
upright sitting position.
Triptans — are helpful in aborting an acute cluster attack.
Octreotide —appears to be effective and well tolerated in the treatment of acute cluster
headaches.
DHE — Intranasal dihydroergotamine has been shown to relieve the pain of an acute
cluster attack.
Prophylaxis — Prophylactic therapy should be started as soon as possible at the onset of
a cluster episode.
Verapamil was found to be effective for prophylaxis but there is a four to six week delay
before the headaches remit.
Prednisone is highly effective for prophylaxis, but should not be used chronically due to
side effects.
Lithium appears to be particularly effective for the chronic form of cluster headaches.
Ergotamine, Cyproheptadine, and Indomethacin have also been shown to be
effective.
Prophylactic medications can be tapered after the expected duration of the cluster has passed.
The drugs can be restarted if symptoms recur at the lowest effective dose.
Strength of Recommendations
Key clinical recommendation
Label
The first-line treatments for acute cluster headache are oxygen or sumatriptan, or a
combination of the two.
Less well-studied alternatives for acute treatment include intranasal dihydroergotamine,
intranasal lidocaine, and intranasal capsaicin.
Verapamil, in a dosage of 360 to 480 mg daily, can effectively reduce the number of attacks
during a cluster headache period.
Less well-studied alternatives for prophylaxis include prednisone and antiepileptic drugs;
they should only be considered if verapamil is not tolerated or not effective.
A
B
A
B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series.
Surgical Therapy:
Patients with chronic cluster headaches that do not respond to medications may be
considered for surgical therapy aimed at the trigeminal nerve. A case series found that 15 of 17
patients who underwent complete or partial section of the trigeminal nerve had complete or nearcomplete relief of symptoms.
University of South Alabama, Department of Family Medicine
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Diagnosis and Treatment of Headache Algorithm
Diagnosis algorithm
• Evaluate type of headache
• Take a detailed history and
assess functional impairment
• Rule out causes for concern
• Consider secondary headaches
• Refer to specialist
Migraine Treatment
• Categorize and select
treatment based on severity
and functional impairment
• Patient education and
lifestyle modifications
Tension-type Headache
Cluster Headache
• Establish diagnosis
• Acute treatment
• Prophylactic treatment
• Establish diagnosis
• Acute treatment
• Prophylactic treatment
• Patient education and
lifestyle modifications
• Patient education and
lifestyle modifications
Resources for Patients:
http://www.aafp.org/afp/20020901/805ph.html
http://www.aafp.org/afp/20051101/1816ph.html
http://www.aafp.org/afp/20050215/728ph.html
http://www.aafp.org/afp/20041215/2313ph.html
References:
International Headache Society headache classification
American Academy of Neurology Evidence-based guidelines for migraine headache
Evaluation of Acute Headaches in Adults; American Family Physician, February 15, 2001
Tension-Type Headache; American Family Physician, September 1, 2002
Management of Cluster Headache; American Family Physician, February 15, 2005
http://www.aafp.org/afp/20071115/1518.html
http://www.aafp.org/afp/20070701/bmj.html
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Acute Pharyngitis
034.0 Streptococcal sore throat (GABHS pharyngitis)
462 Acute pharyngitis
465.0 Acute laryngopharyngitis
472.1 Chronic pharyngitis
472.2 Chronic nasopharyngitis
Definition:
A complaint of throat discomfort with or without cough or fever.
General Approach to the patient:
Goals:
7. Identify specific or life-threatening causes of throat pain
8. Obtain adequate information to develop a working diagnosis in an efficient manner
9. Arrange for definitive care of identified specific causes of throat pain at time of
presentation or with appropriate follow-up
10. Detect and treat streptococcal pharyngitis in a timely manner
11. Allay fears of patient and family regarding symptom if cause is benign
12. Provide symptomatic relief of patient complaints
13. Avoid exposure to antibiotics when not indicated
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Rules of Thumb:
Age
Complaint
frequency
Commonly
diagnosed
diseases (in
descending order
of prevalence)
Life threatening
diseases to
consider
Key worrisome
features
(history)
Key elements of
exam
0-18 months
Very
uncommon
Thrush
Ulcerative
pharyngitis
(herpesvirus
Herpangina
Hand-footmouth
Mouth
breathing
from URI
GABHS
Meningitis
Epiglottitis
Inconsolability
Toxic
appearance
Assess
hydration
status
Key diagnostic
study
None
Common
Treatment
Depends on
clinical
situation
Functional
limitations
Depends on
clinical
situation
18 m- 5 y
5 y-15 y
15-45
>45
Uncommon
Common
Uncommon
Very Uncommon
Herpangina
Group A B
hemolytic strep
(GABHS)
Allergic
rhinitis
Hand-footmouth
Mouth
breathing
Ulcerative
pharyngitis
(herpesvirus)
Meningitis
Epiglottitis
Kawasaki
Disease
C diphtheriae
Drooling
Toxic
appearance
Prolongued
febrile illness
GABHS
Allergic
rhinitis
Mouth
breathing
Infectious
mononucleosis
Gonococcal
pharyngitis
Meningitis
Abcess
Palatal
Cellulitis
C diphtheriae
Cancer
Infectious
mononucleosis
Allergic
rhinitis
GABHS
Gonococcal
pharyngitis
Abcess
Palatal
Cellulitis
Meningitis
Cancer
C diphtheria
HIV
Assess
hydration status
Abscense of
nuccal rigidity
Assess
hydration status
Visualize
pharynx
Determine if
cough, rhinitis
is present
Abscense of
nuccal rigidity
Voice
changes
Dehydration
Severe sore
throat
Assess
hydration status
Visualize
pharynx
Determine if
cough, rhinitis
is present
Abscense of
nuccal rigidity
Assess prior
probability for
GABHS. If over
30%, Rapid
antigen test
If GABHS,
PCN
If non-GABS,
supportive care
Out until treated
for 24 hrs if
GABHS
If prior
probability for
GABHS over
30%, Rapid
antigen test
If GABHS,
PCN
If non-GABS,
supportive care
Out until treated
for 24 hrs if
GABHS
If prior
probability for
GABHS over
30%, Rapid
antigen test
If GABHS,
PCN
If non-GABS,
supportive care
Out until treated
for 24 hrs if
GABHS
Voice
changes
Dehydration
University of South Alabama, Department of Family Medicine
June 30, 2008
Allergic
rhinitis
Rhino-sinusitis
Viral
pharyngitis
GABHS
Abcess
Palatal
Cellulitis
Cancer
Meningitis
HIV
Autoimmunie
disorder
Environmental
exposure
Voice changes
Mental status
changes
High fevers
Ulcerstion
Brief mental
status exam
Abscense of
nuccal rigidity
Visualize
pharynx
Assess breath
for fetid nature
Depends on
clinical situation
Depends on
clinical situation
Depends on
clinical situation
156
Overview:
Chief Complaint: Typically the complaint is ―Sore throat‖
Vitals:
Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse,
respiratory rate, and pulse oximeter if applicable should be noted.
General approach to history:
The history for pharyngitis is primarily to establish risk of the symptom being caused by a life
threatening condition and to determine whether the patient has streptococcal pharyngitis. This is
done initially by observing the patient for signs of toxicity, and listening to the quality of the
patient’s voice. Following this, the time course of the illness and associated symptoms will give
important clues as to whether this is infectious due to bacterial causes, infectious due to viral
causes, inflammatory, or related to another disease process (such as Gastroesophageal Reflux
Disease)
Vocal Quality Location – Where does your throat hurt? (Can ask patient to indicate with hand the place of
most severe pain)
Timing – When did the pain begin? Has there been a change over time? What is the relationship
of the pain with associated symptoms such as fever?
Quality – What is the severity of the pain? How would you characterize the pain? (Sharp, dull,
aching, stabbing, burning, etc)
Severity – How bad is the pain? (Consider pain scale) Are you able to swallow liquids? Solids?
Aggravating/Relieving factors – Does anything make it better? Does anything make it worse?
List medications tried for relief.
Associated symptoms – Are any other symptoms associated with the throat pain? (fevers,
rashes, mouth ulcers, cough, coryza, acid brash)
Risk Factors (child and adolescent) - Exposure to other children or adults with similar illness
(identify diagnosis)
Risk Factors (adult) – Exposure to tobacco (amount, time of exposure), Exposure to alcohol
(amount, time of exposure), Illness contacts
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Age Specific Concerns:
Infants, toddlers:
Key Question Content
Whitish patches in mouth
Sores in mouth
Lesions on hands, feet as well as in mouth
Cough, coryza
Toxic appearance
Drooling, toxic appearance
Household contact with GABHS
Further investigation if positive
Consider thrush
Consider primary herpes outbreak, herpangina
Consider coxsackie virus
Consider viral rhinosinusitis
Consider life threatening infection such as
meningitis, sepsis, pertusis, diphtheria
Consider epiglottitis
Consider GABHS
School Aged Children, Adolescents:
Key Question Content
Acute onset, lack of cough, coryza,
desquamating rash, GABHS in community
Acute onset, fever, lack of cough or coryza,
GABHS in community
Acute onset, lack of cough or coryza,
Cough, coryza
Sores in mouth
Lesions on hands, feet as well as in mouth
Toxic appearance
Drooling, toxic appearance
Household contact with GABHS
Prolonged course, adenopathy, GABHS
testing negative
History of oral-genital contact
History acid brash
History mouth breathing
Ill appearance, neck stiffness
History of prolonged illness, desquamating
rash, cherry red lips
History of non-vaccination
Prolonged illness, adenopathy, tests for
common infectious illnesses negative
Immunocompromised patient
Further investigation if positive
Consider very strongly GABHS (pre-test
probability >80%)
Consider strongly GABHS (pre-test
probability >50%)
Consider GABHS (pre-test probability
between 30 and 50%)
Consider viral rhinosinusitis (pre-test
probability < 30%)
Consider primary herpes outbreak, herpangina
Consider coxsackie virus
Consider life threatening infection
Consider epiglottitis
Consider GABHS
Consider infectious mononucleosis
Consider gonnococcal pharyngitis
Consider laryngoesophageal reflux
Consider as cause
Consider meningitis
Consider Kawasaki disease
Consider as rubeola, diphtheria, other
preventable infectious causes
Consider connective tissue disease,
hematologic disease, HIV
Consider thrush
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Young adults (patients over 15 but younger than 45):
Key Question Content
Acute onset, fever, lack of cough, coryza,
GABHS in community,
Household contact with GABHS
Cough, coryza with or without fever
Toxic appearance
Drooling, toxic appearance
Prolonged course, adenopathy, GABHS
testing negative
History of oral-genital contact
History acid brash
History mouth breathing
Ill appearance, neck stiffness
History of no or improper vaccination
History of dyspnea
Prolonged illness, +/- adenopathy, tests for
infectious illness negative
Immunocompromised patient
History of neck tenderness at thyroid
Prolonged illness, adenopathy, tests for
infectious illness negative, particular if history
of exposure to tobacco or alcohol
Further investigation if positive
Consider GABHS (pre-test probability
between 30 and 50%)
Consider GABHS
Consider viral rhinosinusitis (pre-test
probability < 30%)
Consider life threatening infection
Consider epiglottitis or peritonsillar abcess
Consider infectious mononucleosis
Consider gonnococcal pharyngitis
Consider laryngoesophageal reflux
Consider as cause
Consider meningitis, sepsis, life-threatening
soft tissue infection
Consider as rubeola, diphtheria, other
preventable infectious causes
Consider spontaneous pneumothorax
Consider connective tissue disease
Consider thrush, HIV
Consider thyroiditis
Consider hematologic illness
Older adults (patients over 45):
Key Question Content
Acute onset, fever, lack of cough, coryza,
GABHS in community,
Household contact with GABHS
Cough, coryza with or without fever
Toxic appearance
Drooling, toxic appearance
History of oral-genital contact
History acid brash
History mouth breathing
Ill appearance, neck stiffness
History of no or improper vaccination
Further investigation if positive
Consider GABHS (pre-test probability
between 30 and 50%)
Consider GABHS
Consider viral rhinosinusitis (pre-test
probability < 30%)
Consider life threatening infection
Consider epiglottitis or peritonsillar abcess
Consider gonnococcal pharyngitis
Consider laryngoesophageal reflux
Consider as cause
Consider meningitis, sepsis, life-threatening
soft tissue infection
Consider as rubeola, diphtheria, other
preventable infectious causes
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History of dyspnea
Tenderness at neck
Prolonged illness, +/- adenopathy, tests for
infectious illness negative
Immunocompromised patient
History of neck tenderness at thyroid
Prolonged illness, adenopathy, tests for
infectious illness negative, particular if history
of exposure to tobacco or alcohol
Exposure to environmental toxins
Consider spontaneous pneumothorax
Consider carotidynia,
Consider connective tissue disease
Consider thrush, HIV
Consider thyroiditis
Consider hematologic illness
Consider environmental cause
Physical:
The physical exam is targeted primarily at confirming an infectious process, identifying lifethreatening causes, and confirming clinical suspicion
Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure
General – Does the patient appear toxic? How does the patient react to his or her environment?
HEENT – Sclera and nasal turbinates for coryza, tympanic membranes for fluid, purulence,
oropharynx for purulence, lesions, Koplick spots,
Neck – Check for adenopathy, document presence or absence of rigidity,
Heart – Note rate and rhythm, presence or absence of murmurs
Lungs – Auscultate for rales, wheezes
Abdomen– n/c
Extremities – n/c
Neuro –n/c
Musculoskeletal – n/c
Diagnostic studies:
General Guidelines 1-7
Patients under 5: The evidence regarding management of febrile infants below the age of 5
who do not have a readily identifiable source of fever has been well established and will not
be reviewed here. The likelihood of a child under the age of 3 having GABHS is very small
and the clinician should look for sources other than GABHS as the source of the child’s fever
(SOR - C). Diagnostic studies are dictated by the suspicions generated by the history, the
findings on physical exam, and ultimately the clinician’s index of suspicion for GABHS or
other treatable bacterial or viral illnesses, or the suspicion of a serious bacterial infection
requiring urgent evaluation in an urgent care environment.
Patients between 5 and 15: The majority of cases of GABHS occur in this age group,
although the majority of people in this age group who have symptoms of pharyngitis do not
have GABHS. (SOR – A) Identifying and appropriately treating those patients with GABHS
infections is felt to be important because treatment of GABHS will reduce symptoms by 24
hours when compared to watchful waiting and is believed to prevent rheumatic fever. (SOR C). Testing algorithms include decision making based on symptoms, use of rapid
streptococcal antigen (Positive predictive value 86%, negative predictive value 88%, time to
result 10 minutes or less) and/or throat culture (Sensitivity 90%, specificity 99% under ideal
conditions for presence or absence of GABHS, time to result 24-48 hours).The evidence for
optimal use of rapid testing, empiric treatment, or determining the absence of clinically
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significant GABHS based on history and physical alone has not been determined but a
compilation of the literature with a proposed approach is found in Figure 1. (SOR - C).
Additional ambulatory testing for patients where GABHS is not suspected or who are
GABHS negative might include a complete blood count and/or monospot (infectious
mononucleosis, hematologic concerns) or chocolate agar culture (gonnococcal pharyngitis)
or empiric therapy (laryngoesphageal reflux). If a life threatening infection is suspected,
further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar
abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess).
Patients over 15: A number of diseases and conditions can cause symptoms of pharyngitis.
As with younger children and adolescents, identifying and appropriately treating patients
with GABHS infections is felt to be important because treatment of GABHS will reduce
symptoms by 24 hours when compared to watchful waiting and is believed to prevent
rheumatic fever. (SOR - C). ?? Because of the lower prevalence, testing algorithms are
proposed which include decision making based on symptoms, use of rapid streptococcal
and/or throat culture but they are based only on expert opinion. A proposed approach based
on existing evidence is found in Figure 2. (SOR - C). Additional ambulatory testing for
patients who are GABHS negative might include a complete blood count and/or monospot
(infectious mononucleosis, hematologic concerns), chocolate agar culture (gonnococcal
pharyngitis), or thyroid function tests (tender thyroid) or empiric therapy (laryngoesphageal
reflux).In patients with persistent symptoms, consider immunologic testing for connective
tissue diseases. In patients with persistent symptoms and exposure to tobacco and/or alcohol
referral for direct visualization might be warranted, particularly of the symptoms are
associated with voice changes, weight loss, or other worrisome signs. If a life threatening
infection is suspected, further testing in a hospital setting might include direct visualization
(epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess).
Office Based Management:
APPLICABLE TO ALL AGES
GABHS pharyngitis
Non-pharmacologic (SOR-C) – Increased fluid intake is felt to help with symptoms and will
help patient to avoid dehydration. Topical anesthetics such as Chlorasceptic spray help patient to
tolerate symptoms until infection resolves and assist with maintaining hydration. Ingestion of
fluid that is not at room temperature (either warmer or colder) is often easier for the patient.
Clean toothbrushes and other personal items after the infection has been treated.
Pharmacologic (SOR – B) – Treatment with IM penicillin is the gold standard for prevention of
non-suppurative and suppurative sequelae. Cure rates with oral regimes dosed anywhere from
every 12 to every 6 hours have been found to be equivalent. The failure rate is anywhere from 5
– 15%. Alternative antibiotics for use with those patients who reprt allergies or have treatment
failures are found in the appendix. Antipyretics likely aid in symptom relief and should be
offered to patients..
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Other viral and presumed viral causes
Non-pharmacologic (SOR-C) – Increased fluid intake and humified air are felt to help with
symptoms as have topical anesthetics such as Chlorasceptic spray. Ingestion of fluid that is not at
room temperature (either warmer or colder) is often easier for the patient.
Pharmacologic (SOR – B) – Antibiotics are known not to be effective. Decongestants, cough
suppressants, and antihistamines are felt to be harmful in children and to have significant side
effects with the potential of some symptom relief in adults. Nasal ipatropium was found to help
in adults with nasal congestion. Antipyretics likely aid in symptom relief.
Allergic rhinitis – see allergic rhinitis chapter
INFANTS, TODDLERS, YOUNG CHILDREN
Herpes gingivostomatitis
Non-pharmacologic (SOR C) - Pain associated with swallowing may limit oral intake of infants
and children, placing them at risk for dehydration. Intake should be encouraged through the use
of cold beverages, ice cream, and yogurt.
Pharmacologic (SOR – A) - Oral acyclovir (15 mg/kg/dose 5 times a day PO for 7 days,
maximum 1 g/day) started within 72 hr of onset reduces the severity and duration of the illness
Thrush:
Non pharmacologic – The condition may resolve spontaneously without treatment. The aprent
can be offered the activity of cleansing the bottle nipples or treatment of the breast of the mother
which may be effective
Pharmacologic (SOR – B) –Thrush is traditionally treated with nystatin oral suspension. For
neonates, the dose is 100,000 U (1.0 mL) given in each cheek pouch every 6 hours after feedings
for at least 7 to 10 days; for pediatric patients, the dose is 1 to 2 million U/day divided every 6
hours until resolution. Fluconazole suspension (3 mg per kg orally once daily for seven days) is
possibly more effective based on one small study (SOR – B). Gentian Violet is also effective
OLDER CHILDREN AND ADOLESCENTS
Infectious Mononucleosis
Non-pharmacologic (SOR – C) Good supportive care is the mainstay of therapy including adequate
hydration; nonsteroidal anti-inflammatory drugs or acetaminophen for fever and myalgias; and throat lozenges or
sprays, or gargling with a 2 percent lidocaine (Xylocaine) solution to relieve pharyngeal discomfort. Enforced bed
rest has been found to slow recovery and patients should be advised to increase activities as tolerated. Patients
should avoid contact sports until asymptomatic
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Pharmacologic (SOR – B) Acylclovir has been found to offer no clinical benefit.
Corticosteroids may offer some benefit to those patients who suffer from significant edema.
Antibiotics should be used for GABHS as well as suspected cellulitis from bacterial causes.
ADOLESCENTS AND ADULTS
Gonnococcal pharyngitis
Non-Pharmacologic (SOR – C) Many patients are asymptomatic. Positive cultures should be
reported and contact tracing initiated through public health mechanisms. Persons with
gonococcal pharyngitis should be counseled regarding safe sex and should be offered testing for
HIV and syphilis.
Pharmacologic (SOR – B) –Recommended first-line antibiotic is a single dose of ceftriaxone A
single dose of spectinomycin may be used (if available) in patients who cannot tolerate
cephalosporins. However, it is considered unreliable in pharyngeal infections, and so patient
should have a pharyngeal culture 3-5 days after treatment to confirm eradication All patients
should also be treated for chlamydial infection if it has not been ruled out
Gastroesophageal reflux disease:
Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down
immediately after eating (up to 3 hours). They should also be counseled that acidic foods,
alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and
should be withdrawn initially, they can be added back as symptoms permit. Reducing dietary fat
should improve symptoms as does weight loss. Medications known to cause reflux should be
withdrawn if possible. These include calcium channel agonists, alpha-adrenergic agents,
theophylline, nitrates and certain sedatives. The head of the bed should be elevated 4 – 8 inches.
Tight clothing should be avoided as should tobacco use.
Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a
proton pump inhibitor. The choice is based on previous effective and ineffective therapy and cost
to patient. (see appendix for choices and dosages) If the H2 blocker was used initially but is only
partially effective, it may be necessary to switch to a PPI. Once symptoms resolve, reduce dose
to the lowest required to maintain patient symptom free. Antacids may be added for additional
symptom relief, especially early on or when symptoms flair.
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Urgent referral to emergency department for evaluation under controlled conditions and
possible admission (SOR - B):
Suspected sepsis or other significant invasive soft tissue infection requiring IV antibiotics
Suspected Kawasaki Disease
Moderate to severe dehydration
Pneumothorax
Referral to specialist (SOR - C):
ENT - The American Academy of Otolaryngology–Head and Neck Surgery states that children
with three or more infections of the tonsils or adenoids per year, despite adequate medical
therapy, are candidates for tonsillectomy The following criteria are also used: seven documented
tonsil infections in any 1 year, five documented tonsil infections in each of 2 consecutive years,
and three documented tonsil infections in each of 3 consecutive years. Tonsil infections are
defined by three of the following criteria: fever ( > 101_F), dysphagia, cervical adenopathy,
positive GABHS culture, and tonsillar exudates. Additionally, suspected malignancy should
be urgently referred
Gastroenterology – Suspected laryngoesophageal reflux that does not respond to conservative
therapy should be referred, especially if the patient has a history of tobacco or significant alcohol
use.
Rheumatology – Suspected connective tissue cause of symptoms
Follow-up (SOR - C):
Patients with GABHS pharyngitis should be free from contagion within 24 hours of beginning
antibiotics and can increase activity as tolerated. They should be symptom free within 4 days and
should return for re-evaluation if they are not.
Patients with other viral, bacterial or fungal causes should be instructed to return for signs or
symptoms of dehydration. They otherwise should be symptom free within 2 weeks.
Patients with infectious mononucleosis should be informed that they will continue to have
symptoms for several weeks to months. They should return for signs or symptoms of
dehydration. They may return to full activity (including contact sports) when free of symptoms.
If hepatosplenomegaly was detected, ultrasound imaging and follow-up imaging may be
warranted.
Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms
within 4 weeks and resolution within 8 weeks
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Resources for patients:
Strept throat - Patient Information Handout accessed at
http://www.aafp.org/afp/20010415/1565ph.html
Things to know about infectious mononucleosis. - Patient Information Handout accessed at
http://www.aafp.org/afp/20041001/1289ph.html - October 1, 2004
Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at
http://familydoctor.org/087.xml
Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at
http://familydoctor.org/161.xml
References:
1. Laine Keahey MD Blake Bulloch MD Rose Jacobson RN Milton Tenenbein MD Amin
Kabani Diagnostic accuracy of a rapid antigen test for GABHS performed by nurses in a
pediatric ED American Journal of Emergency Medicine - Volume 20 (2)
2. Simasek M and , Blandino D, Treatment of the common cold. Am Fam
Physician2007;75:515-20, 522
3. Chapter 249. Herpes simplex in Nelsons Textbook of Pediatrics
Jeannette E. SouthPaul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at
http://www.mdconsult.com
4. Hayes C and Williamson H management of Group A Beta-Hemolytic Streptococcal
Pharyngitis Am Fam Physician 2001;63:1557-64,1565
5. Perkins A. An approach to diagnosing the acute sore throat. Am Fam Physician
1997;55:131-8,141-2.
6. Ebell M. Epstein Barr Virus Infectious Mononucleosis Am Fam Physician 2004;70:127987,1289-90
7. C.M. Discolo et al. Management of pediatric pharyngitis Pediatr Clin N Am 50 (2003)
445–458
8. Bisno A et al Practice guidelines for the diagnosis and management of GABHS Clin Inf
Dis 35 (2) Accessible by subscription at http://www.mdconsult.com
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Appendix
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Approach to pharyngitis symptoms (Ages 5-15)
History and physical suggest GABHS is likely
Signs and symptoms suggestive of GABHS
1.
2.
3.
4.
Lack of cough
History of fever
Tonsillar exudates
Swollen, tender anterior lymph nodes
None or one present
Two or three present
All four present
Symptomatic
treatment, consider
other causes, rapid
antigen test or
culture if clinical
uncertainty exists
Rapid antigen test,
treat if positive, if
negative consider
other causes, culture
if clinical
uncertainty exists or
rheumatic fever
strain prevalent
Rapid antigen test,
treat if positive if
negative consider
culture and empiric
treatment while
awaiting result. Can
offer empiric
treatment without
testing if disease
highly prevalent or
rheumatic fever
strain prevalent
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Household contact
with GABHS or
patient with
scarletinaform rash
Empiric treatment
with antibiotics
For persistent
symptoms in face of
fatigue if CBC
shows 50%
lymphocytes and
heterophile antibody
is +, consider Mono
(see following page)
Supportive care
167
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Approach to pharyngitis symptoms (Ages greater than 15)
Complaint of ―sore throat‖ and not critically ill
Finding more
suggestive of
For persistent symptoms see table
throat pain
on next page. Consider malignancy
if alcohol or tobacco exposure,
worrisome physical finding.
Consider connective tissue disease
Signs and symptoms suggestive of GABHS or other infectious process (No)
(Yes)
1.
2.
3.
4.
Lack of cough
History of fever
Tonsillar exudates
Swollen, tender anterior lymph nodes
None or one present
Two or three present
All four present
Probable viral or
allergic etiology.
Symptomatic
treatment, consider
other causes, rapid
antigen test or
culture if clinical
uncertainty exists
Rapid antigen test,
treat if positive, if
negative consider
other causes, culture
if clinical
uncertainty exists or
rheumatic fever
strain prevalent
Rapid antigen test,
treat if positive if
negative consider
culture and empiric
treatment while
awaiting result. Can
offer empiric
treatment without
testing if disease
highly prevalent or
rheumatic
June 30,fever
2008
strain prevalent
University of South Alabama, Department of Family Medicine
Household contact
with GABHS
Empiric treatment
with antibiotics
169
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170
Preparticipation Sports
Physical Evaluation
V70.3
Definition:
Preparticipation Sports Physical Evaluation – a targeted history and physical performed on
patients prior to participation in sports or other strenuous activity intended to detect those
patients at high-risk for activity related complications
Goals:
1. Identify conditions that predispose the participant to activity related complications
(particularly sudden death and musculoskeletal injuries)
3. Arrange for definitive care and/or appropriate follow-up studies for identified
problems.
4. Fill out preparticipation form as required by state law
5. Avoid ordering unnecessary tests on low risk patients
6. Use visit as an opportunity to address preventive services for patient
Overview:
Preparticipation physical examinations (PPE) have become the standard of care for over 6
million high school and college students in the United States prior to participation in organized
sports activities. Since 1970, the basic structure of the PPE has been developed, revised, and
implemented based primarily on the recommendations and opinions of medical experts in large
medical organizations.1 The driving force behind these exams has been a desire to prevent rare
but serious events that have occurred in athletes during sports participation. The forms used vary
from state to state. Almost all states require a PPE for all high school athletes prior to participate
in sports. These visits, in addition to fulfilling state requirements for preparticipation
examination, present the physician with an opportunity to address health maintenance issues with
patients. Although these examinations are intended to detect serious underlying pathology that
places the patient at increased risk of sudden death, they are neither sensitive nor specific.
Looking for these abnormalities has been likened to ―looking for a needle in a haystack.‖ In this
chapter, we will review in detail the PPE form used by the State of Alabama and discuss
common problems identified and how they are commonly managed. There are no universal
guidelines as to whether to give full clearance, restricted clearance or deny clearance. Ultimately
the decision is made based on clinical judgement by the physician after completing a history,
physical exam and ordering further studies (if indicated) and possibly referring the patient to a
specialist if there is uncertainty about the patient’s ability to participate safely. There is very
little evidence to support PPE for preventing sudden cardiac death and PPE does not satisfy the
basic requirements for medical screening as described by the USPSTF.1
Chief Complaint: Typically the complaint is ―Sports Physical‖ or similar.
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Vitals:
Age, gender, and past medical history should be noted prior to entering the room. If the
preparticipation history has been filled out by parents or patient, it is useful to briefly look over
this to identify areas of concern.
General approach to history:
Patients generally arrive with a PPE form given to them by the school. The history on this form
is to be filled out by the patient with the assistance of his/her parents. See appendix. Listed
below are all of the questions asked, the reason for asking the question, and how to respond to
―yes‖ answers.
1. Have you ever been hospitalized?
Have you ever had surgery?
--Both of these questions seek to identify underlying medical conditions. Some surgeries
such as a tonsillectomy may have no bearing on clearance while others such as heart
surgery or orthopedic surgery may be referred to a specialist for further evaluation
depending on the primary care physician’s level of comfort with these conditions.
2. Are you presently taking any medications or pills?
--Identifies underlying medical conditions that patient might not otherwise mention (i.e.
the patient may know that they take albuterol, but may not identify themselves as having
asthma if asked ―Do you have any medical problems?‖ Some medications such as
occasional use of allergy medicines or antacids may have little bearing on clearance,
while asthma medications, antihypertensives, diuretics and others may warrant a more
detailed history.
3. Do you have any allergies (medicine, bees or other stinging insects)?
--These could be important to note if the patient participates in outdoor sports. If patient
has a severe allergy to insect bites (anaphylaxis) it would be prudent to have an Epi-Pen
available.
4. Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Do you tire more quickly than your friends during exercise?
Have you ever had high blood pressure?
Have you ever been told that you have a heart murmur?
Have you ever had racing of your heart or skipped heartbeats?
Has anyone in your family died of heart problems or a sudden death before age
50?
--All of these questions are aimed at identifying underlying cardiac pathology. A positive
answer to any of these should prompt further cardiac work-up. See table for most
common causes of sudden death in athletes. Generally an EKG and an echocardiogram
are performed if there are any cardiac concerns. The presence of an arrhythmia (other
than sinus arrhythmia or PVC’s that go away during exercise) should prompt referral to a
cardiologist.
5. Do you have any skin problems (itching, rashes, acne)?
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6.
7.
8.
9.
--Contact dermatitis, recurrent skin infections and acne may all be identified. Generally
these are not a problem for clearance, but can be a concern that patients need to be aware
of. Contact dermatitis can be managed with topical steroidal creams for flare-ups. This
is mainly a concern because pads and protective gear can irritate skin and exacerbate
underlying skin problems.
Have you ever had a head injury?
Have you ever been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had a stinger, bumer or pinched nerve?
--Concussions are the primary concern being addressed with this question. See
Management for discussion of concussions. Seizure disorder if well controlled may not
be an absolute contraindication to participation, but most physicians would probably have
a patient see their neurologist if they are on anti-seizure medications prior to clearing
them for participation in strenuous activities. Strenuous exertion and associated
electrolyte disturbances from sweating and dehydration may lower the seizure threshold.
At the very least these patients need to stay well hydrated. Febrile seizures as an infant
are not a problem. A stinger or burner results from transient nerve compression following
an axial load to the spinal column (generally cervical). This can occur after a patient runs
or dives head first into an object. This can compromise the neural foramen transiently
and pinch the nerve. The patient experiences radicular pain along a dermatome. Any
persistent symptoms may prompt spine films and possibly neuroimaging (MRI).
Symptoms that resolved spontaneously and have not recurred are generally not
worrisome.
Have you ever had heat or muscle cramps?
Have you ever been dizzy or passed out in the heat?
--This identifies patients prone to sweating induced electrolyte disturbances, dehydration
and/or exertional hyperthermia. These patients should be encouraged to drink plenty of
water and avoid extremely high temperatures while participating. If symptoms are
persistent or severe, further investigation with serum chemistries looking for underlying
electrolyte or metabolic disturbances may be warranted.
Do you have trouble breathing or do you cough during or after activity?
--Exercise induced asthma may present as breathing difficulty or cough related to
activity. Patients who have these symptoms should undergo spirometry to look for
asthma. Patients with exercise induced asthma should use a bronchodilator prior to
participation (i.e. albuterol MDI 30 minutes before participation) or may require better
control of their asthma prior to participation.
Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye
guards, etc.)?
--This may identify problem areas specific to the patient not identified by other questions.
Generally these are not a problem for clearance unless they bring into focus serious
underlying problems not identified elsewhere in the examination. Patients may answer
yes to this question as a matter of course (shoulder pads in football, mouth guard in
boxing, etc)
10. Have you had any problems with your eyes or vision?
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Do you wear glasses or contacts or protective eye wear?
--Identifies eye problems. Vision that corrects to 20/20 in both eyes is generally not a
concern. Patients that require glasses may require corrective protective lenses for
participation in contact sports but generally poses no problem for clearance. Concern
may arise however if the patient is to participate in a contact sport and they have low
(worse than 20/40 corrected) or no vision in one eye. Eye injuries do occur in sports and
damage to a patient’s only good eye could render them blind. It is important to note and
document this concern with the patient and discuss with them the importance of eye
protection.
11. Have you had any other medical problems (infectious mononucleosis, diabetes,
etc.)?
--Identifies other problems not discussed elsewhere. Decisions regarding clearance will
be made on a disease specific basis and the experience of the physician with these
particular illnesses. Some physicians may clear a patient with diabetes, while others may
refer them to an endocrinologist, etc.
12. Have you had a medical problem or injury since your last evaluation?
--Identifies other condtions. Decisions regarding clearance will be dependent upon the
nature of the medical problem or injury.
13. Have you ever sprained/strained, dislocated, fractured, broken or had repeated
swelling or other injuries of any bones or joints
Head Back Shoulder Forearm Hand Hip Knee Ankle
Neck Chest Elbow Wrist Finger Thigh Shin Foot
--Identifies orthopedic problems. Problems with joints will mandate a targeted joint
exam for the affected joint including range of motion, strength, palpation and crepitus.
X-rays may be ordered for fractures or abnormalities on exam. If any clinical uncertainty
persists regarding joint function or stability, referral to an orthopedist or sports medicine
physician may be obtained prior to clearing patient.
14. When was your first menstrual period?
When was your last menstrual period?
What was the longest time between your periods last year?
--Identifies proper menstrual function. Female athletes who train very intensely may
become amenorrheic. The female athlete triad is eating disorder, amenorrhea, and
osteoporosis. Increasing caloric intake and decreasing intensity of training may restore
cycles. Estrogen containing oral contraceptives may prevent bone loss but has not been
shown to increase bone mass. This question may also identify pregnancy, which would
prevent clearance for strenuous activity and contact sports. Other menstrual irregularities
may not affect clearance, but warrant further investigation.
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Physical Examination:
Height: _________ Weight: _________ B/P: ______/_______ Pulse: ________
Note general appearance. Observe for evidence of excessive long-bone growth
(arachnodactyly, arm span>height, pectus excavatum) that suggest Marfan
Syndrome. Note vital signs. Height values that are extremes on a growth chart
may warrant further investigation, but generally do not pose an obstacle to
clearance. Weight extremes also may warrant discussion of eating disorders
and/or obesity, but generally pose no obstacle to clearance. Blood pressure that is
poorly controlled is a concern. Blood pressure should be well-controlled
(<140/90) prior to clearing athletes for participation. Pulse rate is often relatively
bradycardic in young, well conditioned athletes. Pulse irregularities should
prompt an EKG to assess the type of arrhythmia.
Criteria for Hypertension in Children and Adolescents
Age (Years)
Percentile for height
Blood pressure (mmHg)
Girls
6
50
111/73
Girls
6
75
112/73
Boys
6
50
114/74
Boys
6
75
115/75
Girls
12
50
123/80
Girls
12
75
124/81
Boys
12
50
123/81
Boys
12
75
125/82
Girls
17
50
129/84
Girls
17
75
130/85
Boys
17
50
136/87
Boys
17
75
138/88
Reprinted from Update on the task force report on high blood pressure in children and adolescents. Bethesda, Md.:
National Institutes of Health, 1997. Publication no. 97-3790.
Gender
Vision R 20/______ L 20/ _______ Corrected: Y N
Note vision. Vision that is worse than 20/40 corrected in one eye is a big concern. These patients
should be evaluated by an ophthalmologist.4 See recommendations below.
Cardiovascular
Palpate PMI for increased intensity and lateral displacement that suggest
hypertrophy and failure
Pulses
Palpate femoral pulses. Decreased femoral pulses suggest coarctation of aorta.
Heart
Perform auscultation with patient lying and standing. Also auscultate while
having patient strain with Valsalva maneuver. Murmurs that increase with
standing or valsalva suggest hypertrophic cardiomyopathy and warrant further
investigations. Soft murmurs (<2/6) that decrease or disappear with Valsalva are
generally innocent flow murmurs that warrant no further investigation.
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Lungs
Observe for accessory muscle use or prolonged expiration and listen for
wheezing. Exercise induced asthma will not produce manifestations on a resting
examination and requires exercise testing for diagnosis.
Skin
Evidence of molluscum contagiosum, herpes simplex infection, impetigo, tinea
corporis or scabies.
E. N. T.
Subjective hearing (finger rub)
Abdominal
Palpate for hepatic or splenic enlargement
Genitalia (males)
Assess for hernia (palpate inguinal canal with finger while patient coughs, a
palapable bulge suggests a hernia), varicocele (venous malformation of testicular
veins; will be felt as mass in testicular blood vessels), undescended testicle and
solitary testicle.
Musculoskeletal
General inspection of posture and gait. Test all of the following movements.
Follow up for abnormalities will be dependent upon findings, type of sport and
physician experience.
Neck
Shoulder
Forward flexion, extension, and lateral flexion of neck
Resisted shoulder shrug, internal and external rotation of shoulders, resisted
shoulder abduction
Elbow
Extension and flexion of elbows
Wrist
Pronation and supination, flexion, extension
Hand
Fist clench and finger spread
Back
Inspection, extension, flexion and rotation
Knee
Ankle
Foot
Having patient squat down and walk like a duck and then stand on toes will test
these joints.
Other
Any problems identified warrant a complete examination of affected joint.
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Office Based Management:
Clearance
In general, it is rare for athletes not to be cleared. In an examination of 26,247 athletes only 249
were not cleared. The range of disallowed athletes in the study ranged from 0 to 2.6%. 3
Conditions that may limit participation or require further investigation prior to clearance
Cardiovascular disease:
Patients with any cardiac abnormalities listed above should undergo EKG and echocardiogram to
evaluate for hypertrophic cardiomyopathy, conduction abnormalities (long QT). Patients with
hypertrophic cardiomyopathy or an arrhythmia should be seen by a cardiologist before clearing
the patient for participation. Mitral valve prolapse generally does not prohibit sports
participation. However, if the mitral valve prolapse is associated with repetitive arrythmias,
family history of sudden death or severe mitral regurgitation, these patients should be limited to
low intensity sports. Sinus bradycardia and occasional PVC’s (<6/minute) that resolve with
exercise are not a basis for restriction in asymptomatic patients without structural heart disease.
Musculoskeletal Injuries:
Musculoskeletal findings are the major category of abnormalities leading to restriction from
sports activities. Knee injuries are the most common followed by ankle. In knee injuries, the risk
of reinjury is high without proper rehabilitation. In order to clear a patient with a joint injury,
several criteria must be filled. There should be no joint effusion, decreased range of motion or
symptomatic ligament instability and at least 80% normal strength in the affected extremity.
Ligament laxity can be a normal finding, but symptomatic instability is pathologic and these
patients should not be cleared by a primary care physician.
Head and Cervical Spine Injury:
Concussions are the most common injuries in football. There is no clear agreement on
definitions or classifications of concussion severity, treatment or clearance guidelines. In
general, athletes with a history of concussion who have been asymptomatic for at least one week
and show no residual neurologic deficits are allowed to participate in sports. Any persistent
postconcussive symptoms (headache, dizziness, sensory changes or cognitive disturbance) are a
contraindication to contact sports even though they may take weeks to resolve. This may prevent
a sometimes fatal second impact syndrome in athletes who have a second concussion while
recovering from the first. Burners and stingers should be asymptomatic and patients free of neck
pain before returning to the sport. Recurrent stingers require cervical films before clearance.4
Convulsive disorders:
Guidelines from American Academy of Pediatrics clear young athletes with well-controlled
convulsive disorders for participation in conventional school sponsored sports. Consider
neurologic consultation for high risk sports (gymnastics, skiing, high diving). Athletes with
poorly controlled seizures should be withheld from contact or collision sports and hazardous
non-contact sports (archery, rifling, swimming, weight lifting)
University of South Alabama, Department of Family Medicine
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Exercise-induced Asthma:
Status asthmaticus is an extremely rare cause of death in athletes (4/30,000,000). This condition
should be treated appropriately (typically beta agonist prior to exercise) and patients allowed to
participate.
Heat-related Illness:
Leading causes of nontraumatic, noncardiac sports death are exertional hyperthermia, followed
by exertional rhabdomyolysis and status asthmaticus. Athletes with a history suggestive of heat
related illness are usually allowed to participate in sports, but must be cautioned about
maintaining adequate hydration and avoiding temperature extremes.
Sickle Cell Trait:
Patients with sickle cell trait should be allowed to participate without restriction. There is some
evidence that patients with sickle trait have increased risk of exertional rhabdomyolysis and
should be encouraged to drink plenty of fluids. High exertion and contact or collision sports are
generally contraindicated in patients with sickle cell disease even if appropriate hydration can be
ensured.
Solitary organs:
Whether athletes with one paired organ, especially one kidney, should be allowed to play sports
is controversial. Patients should be educated on the risks so they can make an informed decision.
A single polycystic or abnormal kidney prevents patients from participation in contact or
collision sports. Athletes with only one functional eye (worse than 20/40 corrected in one eye)
can participate only in sports that permit used of protective eyewear and do not involve projected
objects. Wrestling, boxing and martial arts are contraindicated. Athletes with a single testicle
should use a protective cup during contact sports and educated about potential for inury and loss
of fertility.4
Supplemental materials
On-line resource outlining how to do a 2-minute orthopedic exam for a sports physical.
http://www.aafp.org/afp/20000501/2696.html
References
1. Matheson et al. Preparticipation Physical Examination, 3rd ed. Minneapolis, MN:
American Academy of Family Physicians, American Academy of pediatrics, American
College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports
Medicine. McGraw-Hill: The Physician and Sportsmedicine, 2005.
2. O’Connor F. et al. Sudden death in Young Athletes: Screening for the Needle in the
Haystack. American Family Physician. Vol 57/No. 11 (June 1998)
3. Mick, T. et al. What kind of physical examination does a young athlete need before
participating in sports? Cleveland Clinic Journal of Medicine Volume 71 Number 7 July
2004 p587-597.
4. Kurowski, K. The Preparticipation Athletic Evaluation. American Family Physician.
Volume 61/No.9 May 1, 2000.
University of South Alabama, Department of Family Medicine
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178
Somatoform disorders
300.81
Definition:
Encompasses elements of somatization disorder (differentiated and undifferentiated), conversion
disorder, pain disorder, hypochondriasis, body dysmorphic syndrome, and somatoform disorder
NOS as they relate to patients in primary care settings. Specifically, refers to patients with: (1)
several (more than three) vague or exaggerated symptoms in, often, different organ systems, and
(2) a chronic course (i.e., a history of such symptoms for more than two years).
(N.B. This chapter deals with patients in the primary care setting. The strict diagnostic criteria
of the DSM-IV are frequently not useful in people with unexplained symptoms, and instead the
focus has been placed on the practical aspects of management which have been shown to
improve functional activity.)
Goals of the care process:
1. Identify patients at risk of developing a physical symptom in response to an emotional
stressor or difficult life situation
2. Identify methods to identify patients who have developed a physical symptom in
response to an emotional stressor or difficult life situation
a.
Identify symptom complexes consistent with somatization
b.
Offer a strategy for evaluating physical complaints which are not clearly related to
physical ailments but are serious in nature
c.
Offer a diagnostic testing strategy which optimizes use of health care resources
3. Initiate treatment using strategies known to be effective
4. Monitor for improvement in function and well-being
5. Continue surveillance for concomitant conditions that are of a serious nature but may be
overlooked because of patients previous history of somatization
6. Avoid iatrogenic harm
Rules of Thumb:
Age
Frequency of
somatic
symptoms
Frequency of
multiple
symptoms over
two years
1-10
11- 25
25-40
40-65
>65
Common
Common
Common
Common
Common
Rare
Uncommon
Uncommon
Uncommon
Uncommon
Most common
symptom
Abdominal pain
Headache
Headache
Nausea
Chest pain
Fatigue
Joint pain
Arm/leg pain
Headache
Bloating
Arm/leg pain
Headache
Bloating
Abdominal pain
Bloating
Palpitations
Overview:
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Many people manifest non-physical illness as somatic complaints. Commonly expressed
symptoms such as headache, nausea, chest pain or fatigue, are often stress related and in some
office settings as many as 80% patients present with complaints that have no physical findings
which correlate with symptoms. If a physician spends his or her energy looking for disease
where none exists, what results is wasted money, wasted time, and increased frustration 1 Patients
who seek care for somatic complaints in a pathologic manner constitute a group which, if
considered a single disease, would have a prevalence of 1.2 million Americans potentially
afflicted in the general population with as many as 22% of patients in an office waiting room
afflicted, including 5% children at the physicians office and a larger number of adolescents. 2 - 4.
The care of these patients can cost as much as 9 times as that of caring for patients who are
unaffected. Despite using excessive healthcare dollars, these patients report higher levels of
disability and suffering than their peer group.5 Physicians do not find care of these patients
rewarding, either. They report increased frustration and a decreased sense of job satisfaction
when engaged in the care of a disproportionate number of patients reporting multiple
unexplained symptoms.1,6,8
There is a paucity of evidence-based recommendations regarding the identification, evaluation,
and management of these patients. In part, this is because many people, either prior to seeking
physician input or after interpretation by a professional, have the awareness to realize that their
symptoms are not related to a serious illness. Logistically, it is difficult to design and investigate
interventions targeted at patients lacking this insight. These recommendations are based on
anecdotal evidence, limited small studies, and expert opinion. In addition, patients who interpret
stressful situations with physical symptoms are not immune to serious illness. This in no way
should preclude adequate investigation of worrisome symptoms particularly if they are relatively
new or incompletely evaluated by the previous care provider.
Chief Complaint:
Typically suspicion will be aroused by multiple symptoms, recurrent visits for the same or
similar symptoms, or the shear amount of clinical information gathered over time with the dearth
of diagnoses made. Additionally complaints regarding food sensitivity, chronic fatigue, or
fibromyalgia should trigger concern
Vitals:
Initial and subsequent visits: At a minimum age, gender, weight/height (BMI) should be
obtained. In addition, based on the patient’s complaint, pulse, temperature, blood pressure,
respiratory rate and/or pulse oximetry reading should be noted. Time permitting, through chart
review the provider should review the last 6 months worth of visits and any consultation,
diagnostic results, or other available data prior to going into the room as well.
History of Present Illness (New complaint):
Patient should be allowed to voice symptoms in an open-ended manner, encouraging a
description of symptomatology and a discussion of patient fears and concerns. Clarifying
questions should lead patient to characterize the complaint in the standard manner (timing,
location, radiation, quality, severity, precipitants, and relievers of pain, as well as any associated
University of South Alabama, Department of Family Medicine
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symptoms) but care should be avoided not to lead the patient into a description that fits a known
diagnosis. Clues include: amplification of common symptoms such as chest pains associated
with premature atrial contractions, knowledge that the patient is from a family in stress,
knowledge that the patient stands to benefit from secondary gain associated with the illness, and
a patient self report of dissociative type symptoms. The clinician should always bear in mind that
serious illness can co-exist with somatization. (SOR - C) 1,7
Common Symptomatic Organ
System
Gastrointestinal symptoms
Pain symptoms
Cardiopulmonary symptoms
Pseudoneurologic symptoms
Reproductive organ symptoms
Syndromes
Common Symptoms Reported
Vomiting
Abdominal pain
Nausea
Bloating and excessive gas
Diarrhea
Food intolerances
Diffuse pain (i.e., "I hurt all over.")
Pain in extremities
Back pain
Joint pain
Pain during urination
Headaches
Shortness of breath at rest
Palpitations
Chest pain
Dizziness
Amnesia
Difficulty swallowing
Loss of voice
Deafness
Double or blurred vision
Blindness
Fainting
Difficulty walking
Seizures (pseudoseizures)
Muscle weakness
Difficulty urinating
Burning sensations in sexual organs
Dyspareunia
Painful menstruation
Irregular menstrual cycles
Excessive menstrual bleeding
Vomiting throughout pregnancy
Vague "food allergies"
Atypical chest pain
Temporomandibular joint syndrome
"Hypoglycemia"
Chronic fatigue syndrome
Fibromyalgia
Vague "vitamin deficiency"
Premenstrual syndrome
Multiple chemical sensitivity
University of South Alabama, Department of Family Medicine
Commonly Ignored Red Flags
Requiring Further Clarification
Symptoms: Risk factors for
pancreatic cancer, weight loss,
Signs: Murphy’s sign,
Symptoms: Risk factors for cancer,
weight loss, fevers,
Signs: Diminished strengths,
physiologic deficits, Speech deficits
Symptoms: Risk factors for heart
failure, weight loss, fevers
Signs: Abnormal cardiac or
pulmonary exam
Symptoms: Risk factors for cancer,
weight loss, fevers,
Signs: Diplopia, Diminished
strengths, physiologic deficits,
Speech deficits
Symptoms: Risk factors for sexually
acquired infection, weight loss,
fevers
Signs: Abnormal GU exam
Symptoms: Risk factors for cancer,
weight loss, fevers
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Inquire About Risk Factors for Somatization:
Consider when suggested by 1) A history of unexplained symptoms 2) Previous unrevealing
work-up of serious symptoms 3) a sense by the treating physicians that the symptoms are not
reflective of a physical ailment 4) Multiple symptoms seemingly unrelated or 5) presence of risk
factor (SOR - C) 1
Risk Factor
Key Signs or Symptoms
Disorder of mood (depression)
Disorder of affect (anxiety)
Obsesive-compulsive disorder
Fatigue, aches and pains,
palpitations, dizziness and nausea.
Chest pain, palpitations
Amplification of bodily
―imperfections‖
Organic Illness of Which to be
Mindful
Thyroid disorder
Thyroid disorder
Anorexia and/or bulemia
Addiction
Substance abuse
Problems with work
Survivor of sexual abuse
Pelvic pain, dyspyrunia
Pregnancy, infection
Follow organized diagnostic process for suspected somatoform symptoms (SOR - C): 1
Stage of Diagnosis
Evaluate for organic
medical conditions.
Process
Obtain excellent history and
physical
Review previous visits and
studies
Order limited but appropriate
studies
Offer interpretation of
symptoms
Stage of Diagnosis
Process
University of South Alabama, Department of Family Medicine
Strategy
Focus on complaint, use open ended technique, ask
clarifying questions
Perform physical exam of affected area, no matter
how unlikely the complaint is to be manifested in
a physical finding
Explain findings and likely interpretation to patient
Attention to previous evaluations
Avoid repetition where possible
Reassure patient of the likely benign nature of the
illness
Focus on simple, inexpensive tests first
Avoid repetition
Schedule follow-up to discuss results
Offer reassurance
Offer explanation for symptoms
Have patient repeat interpretation back to you prior
to leaving
Offer intervention to allow improvement
Avoid expression ―It’s all in your head‖
Strategy
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Evaluate for psychiatric
conditions associated
with somatic complaints
(depression, anxiety
disorders, substance
abuse/dependence).
Screen for Depression
Screen for Anxiety disorder
Screen for substance abuse
Pursue a positive
diagnosis of
somatization.
Empathize with the patient
Discuss diagnosis
Schedule follow-up
University of South Alabama, Department of Family Medicine
Asking (1) "Over the past two weeks, have you ever
felt down, depressed, or hopeless?" and (2) "Have
you felt little interest or pleasure in doing things?"
may be as effective as any instrument as an initial
screen
Child: Consider screening instrument such as
Reynolds Child Depression Scale or Children's
Depression Inventory
Adolescent: The Center for Epidemiologic Studies
Depression Scale for Children and Beck
Depression Inventory are inexpensive and have
been shown to be effective
Adult: Beck Depression Inventory Scales is
commonly used
Post-partum: Edinburgh Postnatal Depression
Scale
Elderly: "Do you often feel sad or depressed?" may
be as effective as any scale
Children: Pediatric Symptom Checklist may be
useful
Adolescents and Adults: A validated web-based
anxiety screened is available at http://mdao.vcc.com/wb%2Ddat/
A version of the CAGE questionnaire (Cut down on
drinking, Annoyance with criticisms about
drinking, Guilt about drinking, and using alcohol
as an Eye opener.) can be used and modified for
use for any drug and any age group. A positive
answer should be pursued
Avoid ―It’s all in your head‖
Acknowledge severity of illness
Offer possibility of improvement
Offer to maintain relationship and work with patient
over time
Discuss meaning of diagnostic label
Regular, brief office visits key to successful
management
Therapeutic goal is to limit unscheduled phone calls
and emergency department visits
Frequency dictated by severity of condition and
may need to be altered over time
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Return visits:
General Principles:
Targeted history to demonstrate attention to detail and identify medical/surgical
conditions
o Agreeing on the diagnostic process
o Identify potential red flags in symptom complex, if none focus on function
o Monitor changes in function over time
Physical examination focused on symptoms
Laboratory and imaging studies should be selected based on the history and physical
examination.
Focus therapy on function
o Treat concomitant mental health disorder
o Offer suggestions to improve lifestyle
o Avoid overmedicalization
o Avoid causing harm
History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. ―How have
your symptoms interfered with your everyday life?‖ Ask open-ended questions
Physical:
The physical exam is targeted at area of complaint. Do not underemphasize the power of the
―therapeutic touch‖
If satisfied that symptoms are not due to physical cause, focus on function (SOR - C) 7
BATHE Technique:
Question Intent
Background
Affect
Trouble
Handle
Empathy
Sample Question
"What is going on in your life?"
"How do you feel about it?"
"What troubles you the most about that situation?"
"What helps you handle that?"
"This is a tough situation to be in. Anybody would feel
(down, stressed, etc.). Your reaction makes sense to
me...‖
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184
General Treatment Guidelines (SOR - C): 7,8
Monitor and comply with age appropriate health maintenance protocols. Attention to new
complaints with particular attention to worrisome symptoms that are consistent with life
threatening illnesses
Therapeutic Goal
Treatment
Treatment of concomitant
depression
SSRI, TCA
Treatment of concomitant
anxiety
SSRI, newer agents
Treatment of illness beliefs
Offer explanation of symptoms
to patient
Psychotherapy
Brief group therapy
Family intervention
General lifestyle
Increase physical activity
Change leisure focus
Avoid overmedicalization
of the symptoms
Limit number of physicians,
schedule frequent follow-up
Prescribe benign symptom based
remedies
Prescribe leisure activity
Avoid causing harm
Notes
Start low and go slow
Anticipate side-effects
Treatment does not affect underlying disorder
Start low and go slow
Anticipate side-effects
Treatment does not affect underlying disorder
Avoid long-term benzodiazepine use
Reassures patients of likely benign nature and
effect of time
Have patient repeat interpretation back to you
prior to leaving to assure understanding
Reduces intensity and improves function in
some patients
Challenges illness beliefs
May be helpful
Many patients express concern regarding
stigma
Helpful with toxic family situation
Enhances sense of well-being
Creates focus on healthy behavior
Should strive for 20 minutes daily and increase
as tolerated
Encourage pleasurable activities outdoors and
with groups
Limiting ―doctor shopping‖ can take focus off
of medical model
Avoid ―follow-up prn‖, schedule visits to give
patient permission to visit regardless of
symptoms
Minimize chronic symptoms, focus on function
Use BATHE technique
Hot and cold packs
Bandages and poultices
Lotions and salves
Inexpensive nutritional supplements
Inexpensive alternative medicine
Discuss success or failure at follow-up
Problem solve with patient
Don’t disregard symptoms
Avoid ―It’s all in your head‖
Pursue diagnosis despite
evidence that there is no physical
cause
Avoid excessive diagnostic testing
Avoid expensive or potentially harmful
treatments
Avoid referrals to ―get patient out of office‖
Avoid excessive attention to symptom
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185
Problem solving (SOR – C): 7, 8
Problem
Example
Fear of uncontrolled visits
Open ended question might
extend visit until next day
Unrealistic goals
Desire for complete resolution of
symptoms
Symptom substitution
Fatigue substitute for chest pain
after institution of PPI therapy
Presence or development of
co-morbid conditions
Chronic disease manifests over
time or development of illness
such as cancer
Desire for diagnostic
studies
Request for MRI for cephalgia
Desire for opiate analgesia
Trial of oxycodone from friend
was effective
Excessive phone contacts
Calling after hours to discuss
symptoms
Frequent ED visits
Multiple ambulance rides for
chest pain
University of South Alabama, Department of Family Medicine
Potential solution
Set out with agenda to inquire about function
from outset
Use verbal cues to limit time (I’ll wash up and
do your exam now)
Address patients emotions up front
Be aware of your own emotions
Sit and make eye contact
Prepare for the ―Oh-by-the-way‖
Indicate that visit is over and set plan for next
visit
Focus on improving function rather than cure
Accept new symptom
Limited work-up of new symptom
Focus on function
Follow accepted screening guidelines
Work towards cure where possible but
continue focus on function
Monitor progression of disease using objective
measures
Focus on normal exam
Can allow testing to occur over time for patient
well-being
Negotiate least invasive test
Focus on benign treatments
Focus on side effects of opiates
Focus on possibility of addiction
If opiates are used, move quickly to long acting
and limit short acting
Focus on physician needs (I need my sleep; I
need to take care of others as well)
Schedule more frequent visits
Limit number of calls
Encourage list making
Communicate with staff to avoid iaotrogenic
illness
Have record available to ED staff
Shorten visit interval
Encourage list making
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186
Suggested for further reading:
Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care
physician. 2d ed. Westport, Conn.: Praeger, 1993.
Barsky AJ. A 37-year-old man with multiple somatic complaints. JAMA 1997;278:673-9.
Resources for patients:
When you have chronic unexplained medical problems
http://www.aafp.org/afp/20000301/1431ph.html
Chronic pain: How to get relief
http://familydoctor.org/551.xml
Fibromyalgia: What is it and how to manage it
http://familydoctor.org/070.xml
Stress: How to cope better with life’s changes
http://familydoctor.org/167.xml
References:
1. Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: part I. Practical diagnosis.
Am Fam Physician 2000;61:1073-8.
2. Allen L, Gara M, Escobar J, Waitzkin H, Silver R. Somatization A debilitating syndrome
in primary care. Psychosomatics 2001; 42:63-67
3. Kreipe RE The biopsychosocial approach to adolescents with somatoform disorders.
Adolesc Med Clin 2006; 17(1): 1-24
4. Silber TJ, Pao M. Somatization disorders in children and adolescents. Pediatr Rev
2003;24(8): 255– 64.
5. Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB. Somatization in
the community: relationship to disability and use of services. Am J Public Health
1987;77:837-40.
6. Lin EH, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J, et al. Frustrating patients:
physician and patient perspectives among distressed high users of medical services. J Gen
Intern Med 1991;6:241-6.
7. Servan-Schreiber D, Tabas G, Kolb R. Somatizing patients: Part II. Practical
Management. Am Fam Physician 2000;61:1423-8,1431-2
8. Lutton ME. Sticking the landing: how to create a clean end to a medical visit. Fam Pract
Manag. 2004 Jul-Aug;11(7):51-3.
9. Rief W, Heitmuller AM, Reisberg K, Ruddel H Why reassurance fails in patients with
unexplained symptoms—Anexperimental investigation of remembered probabilities.
PLoS Med 3(8): e269. DOI: 10.1371/journal.pmed.0030269
University of South Alabama, Department of Family Medicine
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187
Tobacco Dependence:
Primary and Secondary Prevention of
Tobacco Related Illnesses
Rules of thumb:
Age
% daily smokers
Evidence supports
screening for
smoking
(USPHSTF)
0-13
13-18
18-65
>65
<1%
8%
23%
9%
No
Yes
Yes
Unclear if
previously negative
Primary
preventive
measures
Identification of
patients at risk
Provide information
regarding harmful
effects
Encourage
abstinence
Ask
Advise
Assess
Assist
Arrange
Justification
Tobacco use in
some communities
as high as 15% in
3rd grade
15% of 8th graders
and 31% of 12th
graders report recent
smoking
Ask
Advise
Assess
Assist
Arrange
For recalcitrant
smokers: Relevance,
risk, rewards,
roadblocks,
repetition
Risk of smoking
initiation plateaus at
age 22, 70% of
current tobacco
users want to quit
Ask
Advise
Assess
Assist
Arrange
For recalcitrant
smokers: Relevance,
risk, rewards,
roadblocks,
repetition
Pulmonary benefits
detectable in 3
months, cardiac
benefits in 1 year
Goals of the primary and secondary prevention process:
1. Identify patients at risk of beginning tobacco use and offer information and guidance
regarding harmful effects of tobacco.
2. Identify patients who have begun tobacco use on a regular basis but who are not yet
addicted and offer information and guidance regarding harmful effects of tobacco.
3. Identify patients who have used tobacco on a regular basis and who are addicted and
assess willingness to quit, offer assistance, and arrange follow-up and support.
4. Monitor for continued abstinence, assist patient when relapse detected.
Overview:
Cigarette smoking remains the leading preventable cause of death in the United States,
accounting for approximately 1 of every 5 deaths (438,000 people) each year. Tobacco use starts
early with an estimated 3 percent of male middle school students using smokeless tobacco. The
health care system has difficulty competing with the marketing budget for the tobacco industry.
In 2005, cigarette companies spent $13.4 billion, or more than $40 million per day, on
advertising and promotional expenses. This amounted to more than $50 for every person in the
United States, or $320 for each adult smoker. Tobacco industry advertising and promotional
expenditures more than doubled since 1998. Specific products are targeted towards members of
University of South Alabama, Department of Family Medicine
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188
racial/minority communities and specific age groups. As an example, Marlboro is the cigarette
brand preferred by 49 percent of smokers aged 12 to 17 years, followed by Newport (24 percent)
and Camel (10 percent). These are the brands most heavily advertised in the United States. In
addition, there is a bit of regional variation in smoking. The highest state estimates for cigarette
smoking among men were in Kentucky (29.3 percent), Mississippi (29.1 percent), and Alabama
(29 percent); the lowest estimates were in Utah (11.7 percent), California (18.5 percent), and
Idaho (19.2 percent). When broken down by educational status, adults with a General Education
Development (GED) diploma or 9–11 years of education have the highest rate of smoking (34
percent). Smoking rates are lowest for adults with an undergraduate college degree (11.7
percent) or a graduate college degree (8 percent).
The Surgeon General has identified tobacco use and dependence as a chronic condition
which often requires repeated interventions but can be effectively treated. Effective treatment
relies upon the stages of change model, where people who must make a behavior change move
from having no interest in making the change (―precontemplation‖), to interest
(―contemplation‖), to making plans (―preparation‖), to actually doing something (―action‖).
Taking advantage of this, even patients unwilling to try to quit tobacco use should be provided a
brief intervention designed to increase their motivation to quit. To do so, consistent
identification, documentation, and treatment of every tobacco user seen in a health care setting is
essential. The clinician should become comfortable with brief tobacco dependence treatment
and should offer it to every patient who uses tobacco. There is a dose-response, and therefore
multiple attempts in various settings should be used. In addition to counseling, numerous
effective pharmacotherapies for smoking cessation now exist (see appendix). Except in the
presence of contraindications, these should be used with all patients attempting to quit smoking.
The first-line pharmacotherapies should be used initially but the two second-line
pharmacotherapies have been identified as efficacious and may be considered by clinicians if
first-line pharmacotherapies are not effective. Remember that relapse rates are high. About 60%
will relapse in 3 months and 75% in 6 months, so ongoing monitoring and support is essential.
Because it is estimated that 70% of the tobacco users will visit a physicians office at least once in
a calendar year, it is important that the clinician become comfortable with assisting the patient to
become abstinent of tobacco. Following is the approach recommended by the US Surgeon
General.
Preventive approach in younger children:
Preventive Strategy
Line of Inquiry
Initially and periodically
Inquire about pre-smoking
Inquire about exposure to environmental smoke, document on chart.
environment
Inquire about patient
Begin at age 10–12. Inquire about all forms of tobacco.
tobacco use
Periodically (typically at well child check). See below if tobacco use initiated
Review environment
Anticipate tobacco use
Inquire about poor school performance, low aspirations, alcohol and other drug
use, school absences, and anticipated dropping out.
Explore the teen’s knowledge of short-term risks of smoking (such as cough and
Assess patients ability to
shortness of breath) and chewing tobacco (such as gingivitis and bad breath).
resist pressure
Clarify misperceptions
Reinforce and rehearse refusal skills.
Positively identify abstinence as goal.
Reward abstinence
Encourage parents of at risk children to establish reward.
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Preventive approach in teens and older:
Action
Initially and periodically:
Line of Inquiry
Or
Implement an office-wide system that
ensures that tobacco-use status is
obtained and recorded for every
patient at every office visit.
―Many people use tobacco, do you?‖
Include in collected vital signs data.
And, if so
Place tobacco-use status stickers on
patient chart.
―Do you use tobacco?‖
Ask about smoking and
tobacco use (if no, inquire
periodically; if not started
by 22, unlikely to begin)
Operationalization
―How much do you use and how often?‖
(quantify)
Indicate smoking status using computer
reminder systems.
At every visit if identified as a user and, at a minimum annually, in context of “wellness” exam:
Be clear. (―I think it is important for
you to quit smoking now, and I will help
you.‖)
Advise tobacco users to
quit
Speak strongly. (―As your clinician, I
need you to know that quitting smoking
is the most important thing you can do
to protect your current and future
health.‖)
Personalize your advice. (―You’ve
already had one heart attack.‖) Mention
the impact of smoking on children or
others in the household. (―You know
your children need you.‖)
Assess at every visit and optimally 3
times a year.
Assess willingness to quit
―Are you ready to discuss quitting?‖
If no, offer brief information and repeat
at next visit. If yes, offer assistance.
University of South Alabama, Department of Family Medicine
Record conversation and patients
response in medical record. Use
information at next visit to further
argument for quitting.
Record conversation and patients
response in medical record. Use
information at next visit to further
argument for quitting.
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If user remains in pre-contemplative phase incorporate portions of this in every visit:
Discussion
Topic
Line of Inquiry
Explore why quitting is personally relevant, being as specific as possible.
Relevance
Move discussion to patient’s disease status or risk, family or social situation (e.g., having children
in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior
quitting experience, personal barriers to cessation).
Explore potential negative consequences of tobacco use. Suggest and highlight those that seem
most relevant to the patient. Emphasize that smoking low-tar/low-nicotine cigarettes or use of
other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks.
Examples of risks are:
Risks
Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence,
infertility, and increased serum carbon monoxide.
Long-term risks: Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx,
esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis
and emphysema), long-term disability, and need for extended care.
Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of
smoking in children of tobacco users; increased risk for low birth weight, Sudden Infant Death
Syndrome, asthma, middle ear disease, and respiratory infections in children of smokers.
Ask the patient to identify potential benefits of stopping tobacco use. Suggest and highlight those
that seem most relevant to the patient.
Rewards
Roadblocks
Repetition
Examples of rewards:
Improved health.
Food will taste better.
Improved sense of smell.
Save money.
Feel better about yourself.
Home, car, clothing, breath will smell better.
Can stop worrying about quitting.
Set a good example for children.
Have healthier babies and children.
Not worry about exposing others to smoke.
Feel better physically.
Perform better in physical activities.
Reduced wrinkling/aging of skin.
Ask the patient to identify barriers or impediments to quitting and note elements of treatment
(problem solving, pharmacotherapy) that could address barriers.
Typical barriers might include:
Withdrawal symptoms.
Fear of failure.
Weight gain.
Lack of support.
Depression.
Enjoyment of tobacco.
Repeat elements every time an unmotivated patient visits the clinic setting. Tobacco users who
have failed in previous quit attempts should be told that most people make repeated quit attempts
before they are successful.
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When user expresses willingness to move to action (contemplative, preparation phase):
Assist
patient with
a quit plan
Arrange
follow-up
and support
Review previous quit attempts—
what helped, what led to
relapse.
Anticipate challenges,
particularly during the critical
first few weeks, including
nicotine withdrawal.
Offer advice on successful
quitting.
Total abstinence.
Alcohol is associated with
relapse.
Others smoking in household
pose a problem.
When arranging follow-up
Identify if intensive support will
be necessary.
Number of quit attempts
Intensity of tobacco use
Period of time of use
At follow-up visit
Congratulate success.
Review benefits accrued.
If tobacco use has occurred,
review circumstances and elicit
recommitment to total
abstinence.
Remind patient that a lapse can
be used as a learning
experience.
Consider multimedia resources for modeling behaviors.
Have patient set a quit date, ideally within 2 weeks.
Have patient inform friends, family, and coworkers of plans
to quit, and ask for support.
Have patient remove cigarettes from home, car, and
workplace and avoid smoking in these places.
Contact patient to remind to quit.
Offer access to community resources.
Initiate class, assign buddies.
Offer pharmacologic assistance (see appendix).
Make referral to intensive support if necessary and available
to patient.
Timing—Follow-up contact should occur soon after the quit
date, preferably during the first week. A second follow-up
contact is recommended within the first month. Schedule
further follow-up contacts as indicated.
Actions during follow-up contact
Identify problems already encountered and anticipate
challenges in the immediate future.
Assess pharmacotherapy use and problems.
Encourage use of support.
Consider use or referral to more intensive treatment.
At every follow-up regularly for the first 6 months and periodically for at least five years,
ex-smokers should be assessed for smoking status and counseled to avert relapse:
Line of Inquiry
Inquire about support
Inquire about withdrawal symptoms
Inquire about weight gain
Flagging motivation, feel deprived
Action if Positive
If limited support, refer to community resources.
If symptoms, consider changing pharmacologic treatment.
Encourage physical activity.
Reassure that it is temporary.
Emphasize healthful choices.
Consider pharmacotherapy known to delay weight gain.
Refer to intensive program.
Reassure these are common feelings.
Recommend reward activities.
Query about use.
Reinforce abstinence.
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Components of an intensive intervention:
Assessment
Program
clinicians
Program intensity
Program format
Type of
counseling and
behavioral
therapies
Assessments should ensure that tobacco users are willing to make a quit attempt using an
intensive treatment program. Other assessments can provide information useful in
counseling (e.g., stress level, presence of comorbidity).
Multiple types of clinicians are effective and should be used. One counseling strategy
would be to have a medical/health care clinician deliver messages about health risks and
benefits and deliver pharmacotherapy, and nonmedical clinicians deliver additional
psychosocial or behavioral interventions.
Because of evidence of a strong dose-response relationship, the intensity of the program
should be:
Session length—longer than 10 minutes.
Number of sessions—4 or more sessions.
Total contact time—longer than 30 minutes.
Either individual or group counseling may be used. Proactive telephone counseling also is
effective. Use of adjuvant self-help material is optional. Followup assessment intervention
procedures should be used.
Counseling and behavioral therapies should involve practical counseling (problem
solving/skills training) and intra-treatment and extra-treatment social support.
Every smoker should be encouraged to use pharmacotherapies endorsed in the guideline,
except in the presence of special circumstances. Special consideration should be given
before using pharmacotherapy with selected populations (e.g., pregnancy, adolescents).
Pharmacotherapy
The clinician should explain how these medications increase smoking cessation success
and reduce withdrawal symptoms. The first-line pharmacotherapy agents include:
bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch.
Intensive intervention programs may be used with all tobacco users willing to participate in
Population
such efforts.
Counseling to Prevent Tobacco Use and Tobacco-Caused Disease
U.S. Preventive Services Task Force (USPSTF)
This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on
counseling to prevent tobacco use and tobacco-caused disease and the supporting scientific evidence, and updates
the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition.
PHARMACOTHERAPY:
The use of pharmacotherapy is a key part of a multicomponent approach to assisting patients
with their tobacco dependence. The following tables address the clinical use of
pharmacotherapies for tobacco dependence and some of the more common questions and
concerns regarding pharmacotherapy.
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Clinical guidelines for prescribing pharmacotherapy for smoking cessation:
Who should receive
pharmacotherapy for smoking
cessation?
What are the first-line
pharmacotherapies
recommended?
What factors should a clinician
consider when choosing among
the five first-line
pharmacotherapies?
Are pharmacotherapeutic
treatments appropriate for lighter
smokers (e.g., 10-15
cigarettes/day)?
What second-line
pharmacotherapies are
recommended?
When should second-line agents
be used for treating tobacco
dependence?
Which pharmacotherapies should
be considered with patients
particularly concerned about
weight gain?
Are there pharmacotherapies that
should be especially considered
in patients with a history of
depression?
Should nicotine replacement
therapies be avoided in patients
with a history of cardiovascular
disease?
May tobacco dependence
pharmacotherapies be used longterm (e.g., 6 months or more)?
May pharmacotherapies ever be
combined?
All smokers trying to quit, except in the presence of special circumstances.
Special consideration should be given before using pharmacotherapy with
selected populations: those with medical contraindications, those smoking
fewer than 10 cigarettes/day, pregnant/breastfeeding women, and adolescent
smokers.
All six of the FDA-approved pharmacotherapies for smoking cessation are
recommended, including varenicline (Chantix), bupropion SR, nicotine gum,
nicotine inhaler, nicotine nasal spray, and the nicotine patch.
Because of the lack of sufficient data to rank-order these six medications,
choice of a specific first-line pharmacotherapy must be guided by factors
such as clinician familiarity with the medications, contraindications for
selected patients, patient preference, previous patient experience with a
specific pharmacotherapy (positive or negative), and patient characteristics
(e.g., history of depression, concerns about weight gain).
If pharmacotherapy is used with lighter smokers, clinicians should consider
reducing the dose of first-line nicotine replacement therapy (NRT)
pharmacotherapies. No adjustments are necessary when using varenicline or
bupropion SR.
Clonidine and nortriptyline.
Consider prescribing second-line agents for patients unable to use first-line
medications because of contraindications or for patients for whom first-line
medications are not helpful. Monitor patients for the known side effects of
second-line agents.
Bupropion SR and nicotine replacement therapies, in particular nicotine gum,
have been shown to delay, but not prevent, weight gain.
Bupropion SR and nortriptyline appear to be effective with this population.
No. The nicotine patch in particular is safe and has been shown not to cause
adverse cardiovascular effects.
Yes. This approach may be helpful with smokers who report persistent
withdrawal symptoms during the course of pharmacotherapy or who desire
long-term therapy. A minority of individuals who successfully quit smoking
use ad libitum NRT medications (gum, nasal spray, inhaler) long term. The
use of these medications long term does not present a known health risk.
Additionally, the FDA has approved the use of bupropion SR for a long-term
maintenance indication. However, varenicline is not indicated for use
beyond 24 weeks.
Yes. There is evidence that combining the nicotine patch with either nicotine
gum or nicotine nasal spray increases long-term abstinence rates over those
produced by a single form of NRT.
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Suggestions for the clinical use of pharmacotherapies for smoking cessation:
First-line Pharmacotherapies (Approved for use for smoking cessation by the FDA)
Precautions/
Pharmacotherapy ContraSide Effects
Dosage
Duration
Availability
indications
150 mg QAM
History of
7-12 weeks
for 3 days, then
Generic
Insomnia
seizure
maintenance
150 mg BID
(prescription
Bupropion SR
up to 6
History of
Dry mouth
(Start 1-2 wks
only)
months
eating disorder
before quitting)
1-24 cigs/day-2
Mouth soreness mg gum (up to
24 pieces/day)
Up to 12
Generic
Dyspepsia
Nicotine Gum
weeks (+?)
(OTC only)
25+ cigs/day-4
Nausea
mg gum (up to
24 pieces/day)
Local irritation
Nicotrol Inhaler
6-16
Up to 6
of mouth and
(prescription
Nicotine Inhaler
cartridges/day months (+?)
throat
only)
1st cigarette
<30min in AM:
4 mg PO Q1-2
hr x 6 wks, Q
2-4 hr x 3 wks,
Mouth soreness Q 4-8 hr x 3
wks; use >8
Dyspepsia
pieces/day
12 weeks (+?) Generic
Nicotine Lozenge
during initial
Nausea
6wks
1st cigarette
>30min in AM:
Same schedule,
using 2 mg
dose
Nicotrol NS
3-6 months
Nicotine Nasal
Nasal irritation 8-80 doses/day
(prescription
(+?)
Spray
only)
21 mg/24 hrs x
4 weeks
then
Local skin
14 mg/24 hrs x
reaction
8 weeks (+?) Generic
Nicotine Patch
2 weeks
Insomnia
then
7 mg/24 hrs x
2 weeks
Nausea (30%) Days 1-3:
12 wks
0.5 mg QD
Chantix weekly
Preexisting
Agitation
Days 4-7:
An additional
dose packs and
behavioral
0.5 mg BID
12 wks may
Varenicline
continuing
disorders
Depression
Remainder of be prescribed
monthly packs
Suicidal
12 wks: 1 mg to maintain
ideation
BID
abstinence
University of South Alabama, Department of Family Medicine
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Cost/day
$1.99
$2.06 for
10, 2-mg
pieces
$2.35 for
10, 4-mg
pieces
$10.57 for
10
cartridges
$4.44 for 8
pieces
$37.58 for
20 doses
$2.57
$4.46
195
Second-line Pharmacotherapies (Not approved for use for smoking cessation by the FDA)
Pharmacotherapy Precautions/
ContraSide Effects
Dosage
Duration
Availability
Cost/day
indications
Oral generic
Dry mouth
Clonidine
$0.50
Rebound
hypertension Drowsiness
0.2-2.4 mg/day
3-10 weeks
Transdermal
(as BP allows)
Dizziness
Postural
Catapres-TTS
hypotension
(prescription
$3.07
Sedation
only)
Nortriptyline
Nortriptyline
Sedation
Risk of
HCI-generic
$0.43 for
75-100 mg/day 12 weeks
arrhythmias
(prescription
75 mg
Dry mouth
only)
a. The information contained within this table is not comprehensive. Please see package insert for additional
information.
b. Prices based on least expensive option at Drugstore.com March 2008.
c. OTC = Over the Counter.
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Proposed smoking cessation algorithm from Okuyemi et al.
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197
Summary of Recommendations:
The USPSTF strongly recommends that clinicians screen all adults for tobacco use and
provide tobacco cessation interventions for those who use tobacco products.
Rating: Level A recommendation.
Rationale: The USPSTF found good evidence that brief smoking cessation interventions,
including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy
delivered in primary care settings, are effective in increasing the proportion of smokers who
successfully quit smoking and remain abstinent after 1 year. Although most smoking cessation
trials do not provide direct evidence of health benefits, the USPSTF found good evidence that
smoking cessation lowers the risk for heart disease, stroke, and lung disease. The USPSTF
concluded that there is good indirect evidence that even small increases in the quit rates from
tobacco cessation counseling would produce important health benefits, and that the benefits of
counseling interventions substantially outweigh any potential harms.
The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco
use and provide augmented pregnancy-tailored counseling to those who smoke.
Rating: Level A recommendation.
Rationale: The USPSTF found good evidence that extended or augmented smoking cessation
counseling (5-15 minutes) using messages and self-help materials tailored for pregnant smokers,
compared with brief generic counseling interventions alone, substantially increases abstinence
rates during pregnancy, and leads to increased birth weights. Although relapse rates are high in
the post-partum period, the USPSTF concluded that reducing smoking during pregnancy is likely
to have substantial health benefits for both the baby and the expectant mother. The USPSTF
concluded that the benefits of smoking cessation counseling outweigh any potential harms.
The USPSTF concludes that the evidence is insufficient to recommend for or against
routine screening for tobacco use or interventions to prevent and treat tobacco use and
dependence among children or adolescents.
Rating: Level I recommendation.
Rationale: The USPSTF found limited evidence that screening and counseling children and
adolescents in the primary care setting are effective in either preventing initiation or promoting
cessation of tobacco use. As a result, the USPSTF could not determine the balance of benefits
and harms of tobacco prevention or cessation interventions in the clinical setting for children or
adolescents.
Resources for patients:
University of South Alabama, Department of Family Medicine
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198
Smoking, steps to help you break the habit
http://familydoctor.org/161.xml
ACS: Guide to quitting smoking
http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp
Online smoking cessation support
http://www.dartmouth.edu/~nobacco/LFSF/smokersmain.htm
Smoking cessation and abstinence resource for teens
http://www.mededu.miami.edu/Tobacco/main
References used for preparation of this chapter that also offer additional resources:
Okuyemi KS, Nollen NL, Ashluwalia JS. Interventions To Facilitate Smoking Cessation. Am
Fam Physician 2006;74:262-71, 276.
U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Related
Diseases: Recommendation Statement. November 2003. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm
CDC National Center For Chronic Disease Prevention and Health Promotion Tobacco
Information and Prevention Source. http://www.cdc.gov/tobacco/data.htm
U.S. Public Health Service Treating Tobacco Use and Dependence. Summary, June 2000.
http://www.surgeongeneral.gov/tobacco/smokesum.htm
American Academy of Pediatrics. Tobacco’s Toll: Implications for the Pediatrician. Pediatrics
2001. 107 (4), 794-798, accessed at
http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b107/4/794
Additional Reading:
Rustin T. Assessing Nicotine Dependence. Am Fam Phys 2000 62(3) 585-590, accessed at
http://www.aafp.org/afp/20000801/579.html
Appendixes from U.S. Public Health Service Treating Tobacco Use and Dependence. Summary,
June 2000.
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Upper Respiratory Infection
465.9
Definition
Upper respiratory infection or ―common cold‖ is a self-limited illness usually lasting less than
two weeks. Associated symptoms include cough, rhinorrhea and low grade fever.
Goals:
1.
2.
3.
4.
Determine whether symptoms of serious illness are present.
Determine whether complicating factors exist.
Determine whether symptoms or illnesses other than then URI are present.
Provide patient education about the prevention and treatment of URI.
Overview
URI is the most frequent acute illness in the United States. It is the leading cause of morbidity
and doctor visits with a total economic burden close to $40 billion per year. School-age children
average 5 –7 episodes per year, adults 2 – 3 per year. Viruses are the pathogens most frequently
associated with URI. Transmission is by direct contact, aerosols and fomites.
Chief complaint:
Typically the complaint is ―I have a cold‖.
General approach to history
The history is focused on assessing symptoms and determining the presence of serious illness,
complicating factors or illness other than viral URI.
Age – Note the patient’s age. Seriousness of symptoms is often dependent on the patient’s age.
Temperature – Have you had a fever? Where was the temperature taken? (Orally, rectally,
axillary)
Symptoms of serious illness
Symptoms of respiratory distress – retractions, dyspnea, rapid breathing
Decrease in activity – inconsolable, excessive sleeping, refusal to eat
Ask about vomiting and urination
See table below for age related symptoms
University of South Alabama, Department of Family Medicine
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Symptoms of Serious Illness by age group
< 3 months
3 months – 3 years
4 years - adult
Respiratory distress
Respiratory distress
Respiratory distress
- grunting
- retractions
- retractions
- retractions
- cyanosis
- cyanosis
- cyanosis
- marked dyspnea
- moderate to severe
- stridor with croup
- rapid respirations
dyspnea
symptoms not relieved
- shallow respirations
- rapid respiratory rate
by conservative
- difficulty swallowing
- shallow respirations
measures
- choking
- difficulty swallowing
- stridor with croup
- choking
symptoms not relieved
- drooling
by conservative
- dysphonia
measures
- feeling that throat is
closing
Responsiveness, activity
Responsiveness, activity
Responsiveness, activity
- flaccid
- unresponsive
- altered mental status
- lethargic
- decreased level of
- decreased level of
- difficult to awake or
consciousness
consciousness
keep awake
- difficult to awaken or
- markedly decreased
- weak cry, weak suck
keep awake
activity
- inconsolable
- markedly decreased
- refusing to eat
- poor feeding
activity
- very lethargic
- very lethargic
- excessive sleepiness
- excessive sleepiness
- difficult to awaken or
- inconsolable
keep awake
- weak suck, weak cry
- unresponsive
(infants)
- poor feeding
Dehydration, vomiting
Dehydration, vomiting
Dehydration, vomiting
- > 8 hrs without wet
- no urine >8 hrs if <1yr
- no urine >12 hrs
diapers
- no urine >12 hrs if
>1yr
Meningeal signs
Meningeal signs
- stiff neck
- stiff neck
- persistent vomitting
- persistent vomiting
- severe headache
Other
Other
Other
- petechial or purpuric
- petechial or purpuric
- increased urinaton
rash
rash
with decreased intake
- petechial or purpuric
rash
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Symptoms of illness other than viral URI
Lower respiratory tract infection – barky cough, fever >72 hrs, wheezing)
Sinusitis – nasal discharge > 2 weeks, facial pain
Pharyngitis – sorethroat, fever with exposure to strep. Pharyngitis
Epiglotitis – hoarsness, stridor, drooling
Influenza – cough, fever, myalgia
Illnesses to be Differentiated from URI
Diagnosis
Strep. Pharyngitis
Otitis media
Sinusitis
Pneumonia / Bronchitis
Epiglottitis
Symptoms
- sudden onset of sore throat
- exudative tonsils
- fever
- hoarseness
- otalgia
- otorrhea
- hearing loss
- ear popping or fullness
- dizziness
- URI symptoms > 7 days
- 2 or more of the following
present > 7 days after onset:
- sinus tenderness
- facial pain
- fever > 102
- past history of
sinusitis
- tooth pain
- ear pressure
- known anatomical
nasal blockage
- deep cough
- deep mucous
- fever
- pleuritic chest pain
- wheezing
- rhonchi
- mild dyspnea
- chest tightness
- hoarseness
- severe sore throat
- severe dysphagia
- stridor
- drooling
Caution
Severe dysphagia, drooling
If person has asthma, lung
disease or is a smoker
Needs immediate evaluation
Continued…
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Illnesses to be Differentiated from URI (continued)
Diagnosis
Mononucleosis
Influenza
Allergic Rhinitis
Asthma
Pertussis
Symptoms
- severe sore throat
- many enlarged lymph
nodes
- fatigue
- prolonged fever
- fever
- myalgia
- headache
- sore throat
- cough, chest tightness
- EENT pruritis
- watery rhinorrhea
- sneezing
- seasonal changes
- FHx of allergies
- sensitivities to specific
allergens
- atopy
- cough
- wheezing
- dyspnea
- chest tightness
- bronchitis
Caution
If symptoms severe, treat
for mono.
May be at risk for
pneumonia
Patients may not know they
have asthma. Viral URI
may be a trigger. Excessive
use of inhaler may indicate
that further evaluation is
needed.
- prodrome typical of URI
for several days
- severe cough follows
prodromal period
- (children) whoop after
paroxysm of severe cough
- (adolescents/adults) cough
without whoop but with
gagging or vomiting.
- culture or DFA positive
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Are complicating factors present?
Elderly or newborn
Pregnancy
Immunocompromised
Chronic illnesses (ie. Asthma, COPD, sickle cell disease, renal failure)
Physical Exam
The physical exam is primarily to identify signs of serious illness or illnesses other than URI.
Vitals – Note patient’s age, temperature, change in weight by reviewing chart prior to entering
the room.
General – Observe responsiveness. Is the child consoleable?
HEENT – Observe the conjunctiva for erythema. Inspect the tempanic membranes (erythema,
drainage, effusion). Inspect the nasal passages for congestion and discharge. Inspect the
posterior pharynx (erythema, exudates, tonsillar hypertrophy).
Neck - Assess suppleness and note any lymphadenopathy
Lungs – Observe breathing effort (respiratory rate, grunting, retractions, dyspnea), cyanosis and
drooling. Auscultate for wheezing or stridor.
Heart – heart rate, capillary refill
Abdomen – n/c
Extremities - n/c
Diagnostic Studies
No diagnostic studies are needed in absence of signs and symptoms of serious illness or illnesses
other than URI.
Management
Prevention – Hand washing is the most effective way to prevent the spread of URI.
There is no medical literature to support Echinacea in the prevention of URI.
Non-pharmacologic – Maintain adequate rest, nutrition and hydration.
Warm humidified air (vaporizer) may decrease nasal stuffiness and loosen nasal discharge.
Salt water gargles sooth sore throats. (homemade: ¼ tsp salt dissolved in 8oz water).
Pharmacologic – Because colds are viral infections, antibiotics will not cure or shorten their
course. Antibiotics are only effective in the treatment of bacterial infections. Unnecessary use
of antibiotics can lead to development of antibiotic-resistant bacterial strains.
Do not use aspirin containing products in children under age 21.
Zinc gluconate (not acetate) may decrease the duration of URI if taken within the first 24hrs of
symptoms. It has no effect on the severity of symptoms.
There are no consistent studies to advocate the use of vitamins C and E in the therapy of URI.
Cough and cold preparations do not change the course or duration of URI, they only help to
lessen symptoms.
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Cough – antitussives (dextromethorphan, codeine, Tessalon), expectorants (guaifenesin)
Nasal congestion – decongestants (pseudoephedrine/phenylephrine)
Sneezing/rhinorrhea – antihistamines (dyphenhydramine, loratadine)
Sore throat – lozenges, Chloraseptic spray
Fever, muscle aches – acetaminophen or ibuprofen
The Food and Drug Administration (FDA) has recommended that over- the-counter cough
and cold medicines not be used in infants and children < 2 y.o.
Suggested for further reading
Chapter 26. ―Upper Respiratory Infections‖ in Current Diagnosis & Treatment in Family
Medicine. Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis. Lange Medical
Books/McGraw-Hill publishing. 2004.
Ressel, Genevieve., Practice Guidelines. Principles of Appropriate antibiotic use: Part II.
Nonspecific Upper Respiratory Infection. Am Fam Physician. 2001 Aug 1; 64(3). Accessed
online at http://www.aafp.org/afp/20010801/practice.html August 1, 2001.
Del Mar, Chris and Paul Glasziou. Upper Respiratory Infection. Am Fam Physician. 2002 Dec 1
66(11). Accessed online at http://www.aafp.org/afp/980800ap/dick.html December 1, 2002.
References
Viral Upper Respiratory Infection in Adults and Children. Institute for Clinical Systems
Improvement. Ninth Edition. May 2004.
University of South Alabama, Department of Family Medicine
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205
Urinary Tract Infection
599.0
Acute cystitis 595.0
Pyelonephritis 590.80
Definition:
A urinary tract infection is infection of the lower urinary system (cystitis) or upper urinary
system (pyelonephritis). The term ―UTI‖ is often used in reference to cystitis/stricty lower
urinary tract infection. This will be the focus of this chapter.
Overview:
UTIs are categorized as complicated or uncomplicated based on certain criteria, this then dictates
management of the infection. Both will be discussed in more detail in this chapter.
Characteristics of both types are listed below:
Uncomplicated UTI
Normal genitourinary tract
Unobstructed
No recent instrumentation
Symptoms confined to lower genitourinary tract
Adult Female
Acute cystitis in well controlled diabetic female having no complications of DM
Complicated UTI
EVERYTHING not listed above
Including, but not limited to:
o Male
o Age (children, elderly)
o Pregnancy
o Abnormality of urinary tract (functional or anatomical)
o Urolithiasis
o Indwelling catheters or recent catheterization
o Recent surgery involving GU tract
o Diabetes mellitus
o Renal insufficiency
o Immunosuppression
o Nosocomial infection
o Recent antibiotic use
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Uncomplicated UTI
Uncomplicated UTI is one of the most common diagnoses in the USA. 10% of women per year
will experience a UTI, and 60% of women experience at least 1 episode during their lifetime.
The peak incidence is in sexually active women between the ages of 18 and 24 years old. In this
population 75-90% of infections are related to sexual intercourse with the frequency of infection
directly correlating to frequency of intercourse. There has also been shown a correlation with
spermicide use for birth control and UTIs. The frequency of spermicide use has been shown to
correlate with infection frequency independent of intercourse frequency. Postmenopausal
women experiencing acute cystitis likely had frequent infections when younger, however a
complicated UTI must be ruled out in this population.
Repeated epidemiologic studies have shown there is no evidence that any of the following
behaviors create increased or decreased risk for development of acute cystitis. These include
oral contraceptive use, condom use, post-coital voiding, type of underwear, personal hygiene
after voiding or bowel movement, or bath vs. shower.
The natural history of uncomplicated urinary tract infections has been shown through multiple
placebo controlled trials. Spontaneous clinical and microbiologic resolution occurs in about half
of patients by 3 days – 6 weeks. Untreated acute uncomplicated UTIs do not have any long-term
sequellae. However, they cause significant life disruption, therefore leading patients to seek
medical care for faster resolution of the infection and relief of symptoms.
Approach to Patient
History
This is the most important part of diagnosing an acute uncomplicated UTI. The following
elements in the history have been shown to have a 90% positive predictive value in diagnosing
acute cystitis: dysuria, urinary frequency, urinary urgency, new onset, absence of vaginal
diacharge. Other common findings in the history may include suprapubic pain, hematuria, new
urinary incontinence.
Physical Exam
This is usually unremarkable. The patient may have some suprapubic tenderness to palpation in
the abdominal exam. Look for fever or CVA tenderness as these would indicate likely
pyelonephritis. Also, if any vaginal complaints, a pelvic exam should be included in the exam.
Laboratory Studies
These studies should be used to reinforce a clinical diagnosis. Laboratory studies have failed to
predict clinical outcomes in uncomplicated UTIs.
Urinalysis dipstick – may have positive either nitrite, leukocyte esterase, or both; may
have protein or blood present
*The sensitivity and specificity of the urine dipstick varies somewhat with the setting and
population, as does its recommended interpretation. Women with classic urinary tract
infection (UTI) symptoms have a high pretest probability of infection, and use of the
dipstick adds little to the diagnosis. In women with nonspecific urogenital symptoms,
positive or negative dipstick results may require a backup urine culture depending on the
University of South Alabama, Department of Family Medicine
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207
clinical situation. In low-risk patients with a low pretest probability of UTI, the urine
dipstick alone is useful to exclude infection if both nitrites and leukocyte esterase are
negative. [Strength of recommendations: C, all recommendations based on meta-analyses
of cohort studies not addressing patient-oriented outcomes]1
Urinalysis microscopic – this evaluation for the presence of WBCs or bacteria is not
needed or recommended.
Urine culture – routine culture in uncomplicated UTI is not needed or recommended, it is
negative in 10-20% of cases. Culture is appropriate and recommended with initial
treatment failure, early recurrence, pyelonephritis, or an atypical presentation. In these
cases, the infection would then qualify as complicated UTI.
Management
Studies have shown that women having experienced previous UTIs are >90% accurate in selfdiagnosis of a UTI. These plus other studies have led to recommendations and guidelines that
empiric antibiotic therapy can and should be initiated in cases of acute uncomplicated cystitis.
This can even be implemented by phone triage in patients that have experienced previous UTIs.
Symptom resolution occurs in 6 hours in over 50% of patients and by 48 hours in greater than
90% of patients. Empiric antibiotic choice should be guided by local resistance patterns and
patient allergy, however general guidelines are published.
Infectious Diseases Society of America current guidelines for empiric antibiotic therapy:
Drug
Dose
Frequency
Duration**
TMP/SMX
160/800mg
BID
3 days
Trimethoprim
160mg
BID
3 days
Fluroquinolones
varies
varies
3 days
Fosfomycin
3 grams
QD
1 day
Other
Nitrofurantoin
100mg
BID
7 days
**Note: postmenopausal women with no other complicating factors should have 7 days of
therapy.
First Line
Alternatives
Bacteria associated with uncomplicated UTIs:
• Escherichia coli (Gram neg bacilli)
– 75-95%; 80-85%
• Staphylococcus saprophyticus (Gram pos cocci)
– 5-10%
• Other Enterobacteriaceae (Klebsiella, Proteus) (Gram neg bacilli)
– occasional
• Group B streptococcus (Gram pos cocci)
– pregnant, diabetic
• Proteus mirabilis (Gram neg anaerobe)
– postmenopausal
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―Diagnosis and Management of Uncomplicated Urinary Tract Infections‖ SUSAN A. MEHNERT-KAY, M.D.,
American Family Physician August 1, 2005 ◆ Volume 72, Number 3
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating
References
A three-day course of trimethoprim-sulfamethoxazole (TMP/SMX;
Bactrim, Septra) is recommended as empiric therapy of uncomplicated
urinary tract infections (UTIs) in women, in areas where the rate of
resistance Escherichia coli are less than 20 percent.
C
24
Fluoroquinolones are not recommended as first-line treatment of
uncomplicated UTIs in order to preserve their effectiveness for
complicated UTIs.
C
24
Use of beta-lactam antibiotics is not recommended for the routine
treatment of uncomplicated UTIs because of limited effectiveness.
C
24
For treatment of uncomplicated urinary tract infections in older women,
consider short or longer (three to 10 days) courses of antibiotics.
B
25
Clinical recommendation
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For more
information about the SORT evidence rating system, see page 363 or http://www.aafp.org/afpsort.xml.
University of South Alabama, Department of Family Medicine
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209
―Diagnosis and Management of Uncomplicated Urinary Tract Infections‖ SUSAN A. MEHNERT-KAY, M.D.,
American Family Physician August 1, 2005 ◆ Volume 72, Number 3
Non-Pharmocologic Management
• Cranberry Juice: A recent Cochrane review showed insufficient evidence to
recommend cranberry juice to treat/manage UTIs.
• Increase Fluid Intake: there is no evidence of benefit, and speculations of negative
effect due to decreased antimicrobial concentrations.
Prevention
• Modifiable behavior
– i.e. discontinue spermicide use
• Antimicrobial prophylaxis (95-100% efficacy)
– Long-term low dose – continuous daily or every-other-day (at bedtime); 6 mos or
1-2 years
– Postcoital
– First line – nitrofurantoin or TMP/SMX
– Fluroquinolones – RESERVED – first line intolerable or resistant organisms
while using first line
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210
•
Nonantimicrobial strategies
– Cranberry or lingonberry juice or products (20-30% efficacy)
• Cochrane Database – some evidence may decrease incidence over 12
month period in recurrent UTIs
• Efficacy in other groups unclear
• Dose and method of administration (juice, tablets, capsules) unclear
– Topical estrogen in postmenopausal women (0-30% efficacy)
– Probiotics (investigational)
– Vaccination (investigational)
Complicated UTI
Complicated UTIs areeverything that does not qualify as an uncomplicated UTI. This can be
based on age, gender, urinary tract abnormalities, of co-morbid disease states. See the list of
characteristics/risk factors below. Usually these are ascending infections moving up the urinary
tract. The exceptions are hematogenous spread seen in IV drug abusers where skin flora such as
Staph aureus is the most common pathogen. Other hematogenous spread is found in military
infections such as TB. Drug resistance is very common, and indwelling catheters significantly
increase the risk of multi-organism infection, thus necessitating urine culture with sensitivities.
Overall a wider variety of organisms are seen. E. Coli is still often the initiating infection, but
involvement of other gram negative and (to a greater extent than uncomplicated infections) gram
positive organisms are often seen. Fungal infections, especially Candida species, are also
commonly seen. When Pseudomonas aeruginosa is involved it creates a biofilm that lends a
survival advantage and high antibiotic resistance.
Complicated UTIs require prolonged therapy (longer than uncomplicated UTI) and are at greater
risk of complication.
Risk Factors / Characteristics:
Indwelling catheters
Obstruction
Male gender
Age
Diabetes mellitus
Renal insufficiency
Immunosuppression
Urolithiasis
Surgery
Voiding dysfunction
Valves
Reflux
Pregnancy
Nosocomial
Nursing home patients
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Complications:
Urosepsis
More likely in immunocompromised, but ALL complicated UTIs carry this risk
More commonly seen with Gram negative organisms, which carry a greater risk of
fatality as they cause profound hemodynamic changes, multiple organ failure, and death
Renal failure
May be acute or chronic, permanent or self-limited
Greater risk with pre-existing renal insufficiency and obstruction
Approach to Patient:
At-risk populations need expedited evaluation and treatment to limit short and long-term
morbidity and mortality. The first step in this is correctly identifying these patients. Your
suspicion should start with the above risk factors and characteristics.
Several basic principles will aid in managing these patients:
1. Accurate H&P
2. Urine culture is MANDATORY
3. CBC, chemistries
4. Imaging study – CT scan preferred
5. Minimize any obstruction identified
6. Aggressive use of antibiotics
a. Broad-spectrum for gram-negatives and positives
b. Empiric and/or prophylactic yeast coverage, esp. in catheter and diabetic patients
c. Use C&S information and adjust accordingly
d. Older agents should remain as first line to minimize antimicrobial resistance
e. Consider combination therapy for additive and synergistic effects
Overview of UTI in children
Children are considered complicated UTI. They are more prevalent in females. By the age of 6
years old, 7% of females will have a UTI where only 2% of males. Newborns can have UTI
with this accounting for 7% of diagnosed infections in febrile newborns. As with adults, they are
usually ascending infections, except in infants <12 weeks old hematogenous infection is more
common. E. coli accounts for 60-80% of UTIs in children, with other organisms including
Proteus, Klebsiella, Enterococcus, and coagulase negative staphylococci. Evidence of risk
factors is very limited. Two studies have shown an association with constipation, encopresis,
bladder instability, and infrequent voiding, but this did not hold true for febrile children less than
2yo. Bathing and back-to-front wiping have not been shown to be risk factors.
Symptoms of UTI in older children are the same as seen in adults. In infants symptoms include
fever, irritability, jaundice, vomiting, and failure to thrive. Urine odor is not predictive of
infection. Other conditions may mimic a UTI in children such as acute urethritis or
vulvovaginitis caused by various irritants (bubble baths, soaps, self-exploration, pinworms).
Clinical Signs and Symptoms of UTI in Children:
Newborns
Jaundice
Infants/preschoolers
Diarrhea
School age children
Vomiting
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Sepsis
Failure to thrive
Vomiting
Fever
Failure to thrive
Vomiting
Abdominal or flank pain
New urinary incontinence
Dysuria (preschoolers)
Urgency (preschoolers)
Fever
Strong-smelling urine
Abdominal or flank pain
New urinary incontinence
Dysuria
Urgency
Frequency
In evaluating UTIs in children, urine culture and sensitivities are required in all cases prior to
initiating antibiotics. A urine dipstick can rule out UTI if it is negative, but can not rule in
infection if positive due to high false positive rates. Blood cultures are unnecessary in most
cases.
Imaging
Imaging in pediatric UTIs can be a confusing topic. Below are the Clinical Practice Guidelines
published by the American Academy of Pediatrics:
Infants and young children 2 months to 2 years of age with UTI who do not demonstrate
the expected clinical response within 2 days of antimicrobial therapy should undergo
ultrasonography promptly, and either voiding cystourethrography (VCUG) or
radionuclide cystography (RNC) should be performed at the earliest convenient time.
Infants and young children who have the expected response to antimicrobials should have a
sonogram and either VCUG or RNC performed at the earliest convenient time (strength of
evidence: fair).
UTI in young children serve as a marker for abnormalities of the urinary tract. Imaging of the
urinary tract is recommended in every febrile infant or young child with a first UTI to identify
those with abnormalities that predispose to renal damage. Imaging should consist of urinary tract
ultrasonography to detect dilatation secondary to obstruction and a study to detect VUR.
Ultrasonography Urinary tract ultrasonography consists of examination of the kidneys to
identify hydronephrosis and examination of the bladder to identify dilatation of the distal ureters,
hypertrophy of the bladder wall, and the presence of ureteroceles. Previously, excretory
urography (commonly called intravenous pyelography) was used to reveal these abnormalities,
but now ultrasonography shows them more safely, less invasively, and often less expensively.
Ultrasonography does have limitations, however. A normal ultrasound does not exclude VUR.
Ultrasonography may show signs of acute renal inflammation and established renal scars, but it is
not as sensitive as other renal imaging techniques.
Usually the timing of the ultrasound is not crucial, but when the rate of clinical improvement is
slower than anticipated during treatment, ultrasonography should be performed promptly to look
for a cause such as obstruction or abscess.
VUR The most common abnormality detected in imaging studies is VUR. The rate of VUR
among children younger than 1 year of age with UTI exceeds 50%. VUR is not an all-or-none
phenomenon; grades of severity are recognized, designated I to V in the International Study
Classification (International Reflux Study Committee, 1981), based on the extent of the reflux
and associated dilatation of the ureter and pelvis. The grading of VUR is important because the
natural history differs by grade, as does the risk of renal damage. Patients with high-grade VUR
Page 213
are 4 to 6 times more likely to have scarring than those with low-grade VUR and 8 to 10 times
more likely than those without VUR.
VCUG; RNC Either traditional contrast VCUG or RNC is recommended for detecting reflux.
Although children may have pyelonephritis without reflux, the child with reflux is at increased
risk of pyelonephritis and of scarring from UTI. With VCUG and RNC, a voiding phase is
important because some reflux occurs only during voiding. If the predicted bladder capacity is
not reached, the study may underestimate the presence or degree of reflux.
VCUG with fluoroscopy characterizes reflux better than does RNC. In addition, RNC does not
show urethral or bladder abnormalities; for this reason, boys, whose urethra must be examined
for posterior urethral valves, or girls, who have symptoms of voiding dysfunction when not
infected, should have a standard fluoroscopic contrast VCUG as part of their initial studies. RNC
has a lower radiation dose and therefore may be preferred in follow-up examinations of children
with reflux. However, the introduction of low-dose radiographic equipment has narrowed the gap
in radiation between the VCUG and RNC.
There is no benefit in delaying performance of these studies as long as the child is free of
infection and bladder irritability is absent. While waiting for reflux study results, the child should
be receiving an antimicrobial, either as part of the initial treatment or as posttreatment
prophylaxis.
Radionuclide Renal Scans Renal cortical scintigraphy (with 99 m Tc-DMSA or 99 m Tcglucoheptonate) and enhanced computed tomography are very sensitive means of identifying
acute changes from pyelonephritis or renal scarring. However, the role of these imaging
modalities in the clinical management of the child with UTI still is unclear.
Recommendation 11
PEDIATRICS Vol. 103 No. 4 April 1999, pp. 843-852
AMERICAN ACADEMY OF PEDIATRICS:
Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile
Infants and Young Children
Committee on Quality Improvement, Subcommittee on Urinary Tract Infection
Pharmacologic Therapy
TABLE 2
Empiric Oral Antibiotic Therapy for UTI in Children
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Antibiotic
Daily dosage
Amoxicillin
20 to 40 mg per kg in three doses*
Cefixime (Suprax)
8 mg per kg in two doses
Cefpodoxime (Vantin)
10 mg per kg in two doses
Cefprozil (Cefzil)
30 mg per kg in two doses
Cephalexin (Keflex)
50 to 100 mg per kg in four doses
Loracarbef (Lorabid)
15 to 30 mg per kg in two doses
Sulfisoxazole (Gantrisin)
120 to 150 mg per kg in four doses
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
6 to 12 mg per kg/30 to 60 mg per kg
in two doses
UTI = urinary tract infection.
*-Amoxicillin is the first choice for infants younger than two months.
Adapted with permission from Committee on Quality Improvement, Subcommittee on Urinary Tract Infection.
Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants
and young children [published corrections appear in Pediatrics 2000;105:141, 1999;103:1052, and
1999;104:118]. Pediatrics 1999;103:848.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating
References
Urine culture should be obtained for diagnosis of UTI in children if
there is high clinical suspicion, cloudy urine, or positive urine dipstick.
C
13-16
Routine imaging studies (e.g., ultrasonography, VCUG, renal scans)
do not appear to improve outcomes in children with a first
uncomplicated UTI, but the evidence is weak.
B
24, 26, 27
Oral antibiotics should be used (when tolerated) instead of parenteral
antibiotics to manage UTI in children.
A
35, 36
One-day courses of antibiotics should not be used to manage UTI in
children.
A
37
Consider that short courses of antibiotics (two to five days) may be as
effective as longer courses (seven to 14 days).
B
37-39
Prophylactic antibiotics may be used to reduce the risk of recurrent
UTI.
B
42, 43
UTI = urinary tract infection; VCUG = voiding cystourethrography.
A = consistent, good quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For more
information about the SORT evidence rating system, see page 2416 or http://www.aafp.org/afpsort.xml.
References:
1. Brian S. Alper, M.D., M.S.P.H., AND Sarah H. Curry, M.D. ―Urinary Tract Infection in
Children.‖ American Family Physician. Volume 72, Number 12. December 15, 2005.
Page 215
2. Susan A. Mehnert-Kay, M.D. ―Diagnosis and Management of Uncomplicated Urinary
Tract Infections.‖ American Family Physician. Volume 72, Number 3, August 1, 2005.
3. Urinary Tract Infection. DynaMed accessed through USA Biomedical Library online.
4. American Academy Of Pediatrics ―Practice Parameter: The Diagnosis, Treatment, and
Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children.‖
Committee on Quality Improvement, Subcommittee on Urinary Tract Infection Pediatrics
Vol. 103 No. 4 April 1999, pp. 843-852.
5. University of Michigan Health System. Guidelines for Care of Urinary Tract Infection.
Ann Arbor (MI): University of Michigan Health System; 2005 May.
Page 216
Pharmacotherapy
Understanding Pregnancy Categories1,2
Category A: controlled studies in women fail to demonstrate a risk to fetus in the first trimester (and there
is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote.
Category B: either animal-reproduction studies have not demonstrated a fetal risk but there are no
controlled studies in pregnant women or animal-reproduction studies have shown an adverse event (other
than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and
there is no evidence of risk in later trimesters)
Category C: either studies in animals have revealed adverse effects on the fetus (teratogenic or
embryocidal or other) and there are no controlled studies in women or studies in women and animals are
not available. Drugs should be given only if potential benefit justifies the potential risk to the fetus.
Category D: there is positive evidence of human fetal risk, but the benefits from use in pregnant women
may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious
disease for which safer drugs cannot be used or are ineffective.)
Category X: studies in animals or human beings have demonstrated fetal abnormalities or there is evidence
of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women
clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become
pregnant.
Principles of Drug Interactions (CYP 450 system, p-glycoprotein, and protein binding):3,4,5
CYP 450 system:
o CYP 450 system is a phase I metabolism system
o >200 P450 enzymes exist in nature; six enzymes are responsible for 90% of all metabolic activity
of P450 enzymes:
 1A2, 3A4, 2C9, 2C19, 2D6, 2E1
 2A6, 2B6, 2C8: minor but clinically relevant enzymes
 Enzymes are located on smooth endoplasmic reticulum of hepatocytes and luminal
epithelium of small intestine
Associated with NADPH CYP450 reductase, which donates or is source of
electrons needed for oxidation
Major reactions involved in phase I metabolism
o N-dealkylation
o O-dealkylation
o Aliphatic hydroxylation
o Aromatic hydroxylation
o N-oxidation
o S-oxidation
o Deamination
o Hydrolysis reactions
 Drugs can inhibit or induce these enzymes
Inhibition:
o Drugs can be metabolized at a common enzyme and compete or share
metabolic sites within the ER in the liver and get
o Drugs with higher affinity for the enzyme will inhibit another drug
from binding thus decreasing its metabolism; this will result in
increased levels of any drug dependent on that enzyme
o Inhibition is immediate in effect; enzyme returns to normal function
once offending agent is removed
Induction:
Page 217
o
o
o

o
2D6:








o
3A4:




Drugs can increase synthesis of P450 proteins and increase number of
sites available for metabolism
May lead to decreases in amount of parent drug administered and
increases in amounts of metabolites produced
An inducer may decrease levels of coadministered drug and result in
loss of efficacy
Polymorphisms:
Poor metabolizers: slower metabolism or less able to biotransform a compound
at a specific site compared to rest of population
Ultraextensive metabolizers: require more drug than expected to achieve
therapeutic effect because their enzymes rapidly and extensively metabolize
compounds
Extensive metabolizers: average metabolizers; may be ―converted‖ to PMs by
P450 inhibitors
o not genetically determined to metabolize poorly, but they mimic
genetic PMs
Hydroxylates, demethylates, dealkylates compounds through oxidative metabolism
Polymorphic enzyme; EMs, PMs, and UEMs will experience differences in metabolism
of drugs primarily metabolized by 2D6
E.g.; PMs will have a delayed metabolism and accumulate the parent drug which
could increase risk of side effects
Low -capacity, high- affinity enzyme; makes up only 1.5% of total CYP450 content in
liver
Found primarily in liver; also in brain, prostate, bone marrow and heart
Potent Inhibitors:
Fluoxetine, bupropion, norfluoxetine, paroxetine, cimetidine, metoclopramide,
quindine, ritonavir
Other inhibitors:
Antidepressants: Amitriptyline, fluvoxamine, desipramine, imipramine,
sertraline, venlafaxine
Antipsychotics: Chlorpromazine, clozapine, fluphenazine, haloperidol,
perphenazine, risperidone, thioridazine
Others: amiodarone, chlorpheniramine, celecoxib, clomipramine,
diphenhydramine, doxorubicin, lansoprazole, loratadine, methadone,
methylphenidate, pimozide, terbinafine, ticlodipine, valproic acid, yohimbine
Inducers: unclear whether 2D6 is inducible
Substrates:
TCAs
SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline
Other antidepressants: trazodone, venlafaxine, nefazodone, mirtazapine
Antipsychotics: chlorpromazine, clozapine, fluphenazine, haloperidol,
perphenazine, quetiapine, risperidone, thioridazine, aripiprazole, atomoxetine
Analgesics: codeine, hydrocodone, lidocaine, methadone, oxycodone, tramadol
Cardiovascular drugs: carvedilol, diltiazem, flecainide, metoprolol, nifedipine,
nisoldipine, propafenone, propanolol, timolol
High capacity/low affinity enzyme
Potent Inhibitors:
Norfluoxetine, nefazodone, ciprofloxacin, norfloxacin, quinupristin/dalfopristin,
itraconazole, ketoconazole, clarithromycin, erythromycin, telithromycin,
efavirenz, indinavir, ritonavir, diltiazem, grapefruit juice
Potent Inducers:
Carbamazepine, Phenobarbital, phenytoin, rifabutin, rifampin, ritonavir
Substrates (drug classes)
Page 218
Antidepressants: TCAs, SSRIs, mirtazapine, nefazadone, trazodone, venlafaxine
Antipsychotics: aripiprazole, chlorpromazine, clozapine, haloperidol,
perphenazine, quetiapine, risperidone, ziprasidone
Sedative-hypnotics:
o Benzos: clonazepam, diazepam, alprazolam, midazolam
o Zolpidem, zopiclone,
o Buspirone, donepezil, galantamine
Analgesics: codeine, fentanyl, hydrocodone, meperidine, methadone,
propoxyphene, tramadol
Antiarrythmics: Amiodarone, lidocaine, propafenone, quinidine
Antibiotics: ciprofloxacin, rifabutin, rifampin
Antiepileptics: carbamazepine, valproic acid, zonisamide
Antihistamines: chlorpheniramine, ebastine, loratadine, terfenadine
Antimalarials: choloquine, halofantrine, primaquine
Antineoplastics: cyclophosphamide, docetaxel, doxorubicin, etoposide,
paclitaxel, tamoxifen, vinblastine, vincristine, vinorelbine, etc.
Antiparkinsonian drugs: bromocriptine, pergolide, ropinirole, selegiline
Antiprogesterone drugs: mifepristone, etc
Antirejection agents: cyclosporine, sirolimus, tacrolimus
Beta-blockers: metoprolol, propanolol, timolol
o
1A2:







o
2C9:





o
2C19:

Found exclusively in the liver
10-15% of P450 activity in liver
Low affinity/high capacity
Potent inhibitors:
Ciprofloxacine, enoxacin, lomefloxacin, norfloxacin, fluvoxamine, flutamide,
propafenone
Other inhibitors: cimetidine, grapefruit juice, lidocaine, oral contraceptives, ranitidine,
rifampin, ropinirole, ticlodipine, verapamil
Inducers: caffeine, carbamazepine, esomeprazole, lansoprazole, omeprazole, rifampin,
ritonavir
Foods: broccoli, brussel sprouts, cabbage, cauliflower, charbroiled foods
Chronic smoking
Substrates:
Imipramine, mirtazapine, clozapine, caffeine, cyclobenzaprine, flutamide,
provatriptan, melatonin, ropinirole, theophylline, zolmitriptan
Located in kidney, testes, adrenal gland, prostate, ovary, duodenum; 18% of P450 content
in liver
Potent Inhibitors:
Fluconazole, ritonavir, sulfaphenazole
Other inhibitors:
SSRIs, amiodarone, cimetidine, clopidogrel, efavirenz, fluvastatin, isoniazid,
ranitidine, valproic acid
Inducers: carbamazepine, cyclophosphamide, ethanol, Phenobarbital, phenytoin,
rifabutin, rifampin, ritonavir, valproic acid
Substrates:
Irbesartan, losartan, valsartan
Fluoxetine, sertraline
Glipizide, glimepiride, glyburide, tolbutamide
NSAIDs
Fluvastatin, phenytoin, tamoxifen, S-warfarin, zafirlukast, torsemide
Responsible for 20% of P450 activity along with 2C9 in liver
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


Potent Inhibitors
Fluoxetine, fluvoxamine, norfluoxetine, paroxetine
Esomeprazole, omeprazole, ritonavir, ticlodipine
Other Inhibitors:
Amitriptyline, cimetidine, efavirenz, fluconazole, indomethacin, lansoprazole,
oral contraceptives, ranitidine, topiramate
Inducers
Carbamazepine, Phenobarbital, phenytoin, prednisone, rifabutin, rifampin,
ritonavir, valproic acid
Substrates
Antidepressants: TCAs, SSRIs, venlafaxine
PPIs
Alprazolam, diazepam, indomethacin, phenytoin, propanolol, tolbutamide
P-glycoprotein
o Membrane-based glycoproteins that transport substances such as steroids, cytokines, and
glucuronate and sulfate conjugates
o Present on villi in jejunum (the primary site of absorption of oral drugs), colon, gonads, renal
proximal tubules, placenta, and biliary system; and in capillary endothelial cells of blood brain
barrier
o Transport hydrophobic substances across cells in the gut, into bile and urine and out of gonads and
brain
o Drugs can be P-glycoprotein substrates, inhibitors, and/or inducers
o if p-glycoprotein function is inhibited or induced, absorption of drug substrates is altered
 p-glycoprotein inhibitors increase drug levels of substrates
 p-glycoprotein inducers decrease drug levels of substrates
Nonsubstrates
Amantadine
Chlorpheniramine
Citalopram
Clozapine
Fentanyl
Fluconazole
Flunitrazepam
Fluoxetine
Haloperidol
Itraconazole
Ketoconazole
Lidocaine
Methotrexate
Midazolam
Sumatriptan
Yohimbine
Substrates
Aldosterone
Amitriptyline
Amoxicillin
Carbamazepine
Chloroquine
CImetidine
Ciprofloxacin
Colchicine
Corticosteroids
Cyclosporine
Digitoxine
Digoxin
Diltiazem
Docetaxel
L-Dopa
Doxorubicin
Enoxacin
Erythromycin
Estradiol
Fexofenadine
Indinavir
Irinotecan
Lansoprazole
Loperamide
Losartan
Lovastatin
Mibefradil
Morphine
Inhibitors
Amiodarone
Amitriptyline
Atorvastatin
Bromocriptine
Chloroquine
Chlorpromazine
Clarithromycin
Cyclosporine
Cyproheptadine
Desipramine
Diltiazem
Erythromycin
Felodipine
Fentanyl
Fluphenazine
Garlic
Grapefruit juice
Green tea (catechins)
Haloperidol
Hydrocortisone
Hydroxyzine
Imipramine
Iraconazole
Ketoconazole
Lansoprazole
Lidocaine
Lovastatin
Maprotiline
Inducers
Dexamethasone
Doxorubicin
Nefazadone (chronic)
Phenobarbital
Prazosin
Rifampin
Ritonavir (chronic)
St. John’s wort
Trazodone
Venlafaxine ?
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Nelfinavir
Nortriptylne
Ondansetron
Phenytoin
Quetiapine
Quinidine
Ranitidine
Rifampin
Ritonavir
SAquinavir
Tacrolimus
Talinolol
Teniposide
Terfenadine
Vinblastine
Vincristine
Methadone
Mibefradil
Nefazadone (acute)
Nelfinavir
Ofloxacin
Orange Juice
Pantoprazole
Phenothiazines
Pimozide
Piperine
Probenecid
Progesterone
Propafenone
Propanolol
Quinidineng
Ritonavir (initial)
Saquinavir
Simvastatin
Spironolactone
Tamoxifen
Terfenadine
Trifluoperazine
Valspodar
Verapamil
Vinblastine
Vitamin E
Protein binding
o Plasma protein binding plays a role in pharmacokinetics, pharmacodynamics and drug interactions
o drug concentrations in plasma represent drug that is bound to plasma protein plus unbound drug
 unbound drug is the pharmacologically active moiety
o any factor that alters protein binding becomes clinically important when a drug is highly protein
bound
o fu value: represents fraction of unbound drug
 fu <0.1 or 10%= highly protein bound
o Albumin:
 Number of protein binding sites exceeds number of drug molecules available for binding
in most cases
 When plasma concentrations for drugs bound to albumin >25-50 mg/L, albumin binding
sites can become saturated; fraction of drug that is free will change with plasma
concentration
 E.g.; salicylates and valproic acid can saturate plasma protein binding sites
 These drugs exhibit concentration-dependent plasma protein binding
o Low plasma protein concentrations decrease plasma concentration of bound drug; however,
unbound drug is usually not affected
o Acidic drugs bind primarily to albumin (e.g.; phenytoin and most of anti-epileptic drugs)
o Basic drugs bind to globulin (e.g; lidocaine, quinidine
o Alpha1-acid glycoprotein (AAG) is an acute phase reactive protein
 Can be significantly decreased and increased under certain clinical conditions
 AAG concentrations are difficult to assay in clinical settings
o Binding affinity:
 Binding affinity of plasma protein for a drug can alter fraction of drug that is free
 Ex: uremic patients exhibit plasma proteins that have less affinity for phenytoin than
proteins present in nonuremic patients
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o fu values for plasma protein binding
Drug
fu value
Drug
fu value
Amitriptyline
0.04
Phenobarbital
0.5
Carbamazepine
0.2
Phenytoin
0.10
Cyclosporine
<0.1
Procainamide
0.84
Digoxin
0.70
Propanolol
0.06
Gabapentin
0.97
Quindine
0.20
Lidocaine
0.30
Salicyclic acid
0.16
Lithium
1.0
Valproic acid
0.15
Methotrexate
0.5
Vancomycin
0.9
Nafcillin
0.10
warfarin
0.03
o If a drug is displaced from plasma proteins it would increase the unbound drug concentration and
increase the drug effects and could potentially produce toxicity
o An increase in unbound drug in body produces % increase in pharmacologically active unbound
drug at the site of action
o When amount of unbound drug increases, rate of elimination will increase
o When drug interactions associated with protein binding have been studied, it has been shown that
the displacing drug is also an inhibitor of clearance
 The change in clearance of the unbound drug is the relevant mechanism explaining the
interaction
o Drugs can exhibit high or low protein binding; binding to plasma proteins can affect drug
concentrations
o Binding of drugs to plasma proteins is capacity-limited
o Unbound drug concentration is determined by dosing rate and clearance; therefore increases in
dosing rate will cause corresponding changes in unbound concentration
Dosage Adjustments in Renal Disease:6
Renal Excretion:
o Depends on both glomerular filtration and renal tubular secretion and absorption
 Glomerular elimination also depends on molecular size and protein binding of drug
 When glomerular filtration is impaired by renal disease, the clearance of drugs that are
primarily eliminated by this mechanism will be decreased and plasma half-life of the
drugs will be prolonged
o Secretion of drugs can also be affected by renal disease
 Drugs dependent on renal tubular secretion will be excreted more slowly as creatinine
clearance decreases
Drugs are adjusted based on estimated creatinine clearance
o CrCl= (140 – age) x ideal body weight in kg/72 x serum creatinine mg/dL x 0.85 (women)
o For men, ideal body weight= 50.0kg + 2.3kg/in over 5 ft tall
o For women, ideal body weight= 45.5kg + 2.3kg/in over 5 ft tall
Loading dose should be considered when half-life of a drug is long in patients with impaired renal function
o Loading dose given to renally impaired patient is same as initial dose given to patient with normal
renal function if the extracellular fluid volume is normal in patient with impaired renal function
o Loading dose calculation:
 Loading Dose= Vd (L/kg) x Wt (kg) x Cp (mg/L)
 Vd= volume of distribution; Wt= patient’s ideal body weight; Cp= desired plasma drug
level
o Patients with edema or ascites may require larger loading doses; those who are dehydrated or
debilitated should receive smaller initial doses
o To adjust maintenance dose in renally impaired patients, the intervals between individual doses
can be lengthened and the dose can be kept normal
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
o
o
Increasing the dosing interval is useful for drugs with wide therapeutic ranges and long
half-lives in patients with renal insufficiency
Can also reduce the size of individual doses and keep the interval the same
 Decreasing the dose reduces differences between peak and trough plasma concentrations
 Important for drugs with narrow therapeutic ranges and short half-lives in patients with
renal insufficiency
Combination of interval prolongation and dose-size reduction is often effective and convenient
Black Box Warnings:7
-
Black Box Warnings appear in package inserts for certain drugs that have potential to cause serious adverse
effects in patients
These warnings mean that studies have indicated a drug carries significant risk of potentially serious or lifethreatening adverse effects
Strongest warning FDA requires
5HT3 antagonists (Alosetron): ischemic colitis, serious complications of constipation; prescribing program
implemented
Protease Inhibitors:
o Abacavir: lactic acidosis and severe hepatomegaly with steatosis, hypersensitivity reactions,
hepatitis B exacerbations
o Entecavir: lactic acidosis and severe hepatomegaly with steatosis, hepatitis B exacerbations
o Ritonavir: Coadministration with certain nonsedating antihistamines, sedative hypnotics,
antiarrhythmics, ergot alkaloids may cause serious adverse reactions
o Indinavir
o Saquinavir: different forms are not bioequivalent
TNF- inhibitors (adalimumab, infliximab, etanercept): Tuberculosis, invasive fungal infections, other
opportunistic infections may occur; test for tuberculosis before initiating therapy
o Infliximab: Hepatosplenic T-cell lymphomas
Aminoglycosides: Nephrotoxicity, ototoxicity, monitor renal and eighth cranial nerve function at initiation
Antiarrythmics
o Amiodarone: life-threatening arrhythmias; potentially fatal toxicities (arrhythmias, pulmonary,
liver), high-risk patients
o Flecainide: have not been shown to enhance survival in nonlife-threatening ventricular
arrhythmias and may increase mortality, ventricular proarrhythmic effects in patients with atrial
flutter
o Procainamide: have not been shown to enhance survival in nonlife-threatening ventricular
arrhythmias and may increase mortality, blood dyscrasias
o Propafenone: have not been shown to enhance survival in nonlife-threatening ventricular
arrhythmias and may increase mortality
o Quinidine: have not been shown to enhance survival in nonlife-threatening ventricular arrhythmias
and may increase mortality; may increase mortality is atrial fibrillation/flutter
ACE inhibitors: can cause injury or death to the fetus in the second and third trimesters
Angiotensin II receptor blockers: can cause injury or death to the fetus in the second and third trimesters
Amphotericin B: only use for the treatment of progressive and potentially life-threatening fungal infections
Amphetamines: high potential for abuse
Antipsychotic agents
o Clozapine: agranulosytosis, seizures, myocarditis, orthostatic hypotension, collapse, respiratory
arrest, cardiac arrest, elderly patients with dementia-related psychosis are at an increased risk of
death
Antidepressants: increased risk of suicidal thinking and behavior in children, adolescents, and young adults
at the beginning of therapy
Beta-blockers: may cause an increase in ischemic symptoms after abrupt cessation of therapy
Azathioprine: increased risk of neoplasia; possible hematologic toxicities
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Carbamazepine: aplastic anemia and agranulocytosis; transient or persistent decrease in platelets or WBCs
NSAIDs
o Celecoxib: increased risk for CV thrombotic events, MI, and stroke; do not use for perioperative
pain after a CABG; increased risk of GI bleed, ulceration, and perforation of stomach or intestines
Cyclosporin – should be managed by facilities properly equipped and staffed for immunosuppressive
therapy; can cause systemic hypertension and nephrotoxicity; Sandimmune cannot be interchanged with
Neoral and Gengraf
o Sandimmune: administer with adrenal corticosteroids but not with other immunosuppressive
agents; increased susceptibility to infection and lymphoma; absorption is erratic, so monitor drug
levels and possible organ rejection
o Neoral and Gengraf: increased susceptibility to infection, lymphoma and other neoplasia; monitor
drug concentration levels; psoriasis patients previously on PUVA or other immunosuppressants
have an increased risk for skin malignancies
Corticosteroids
NNRTIs
o Efavirenz
o Nevirapine: Severe hepatotoxicity (especially in the first 18 weeks), severe skin rashes
(hypersensistivity, Stevens-Johnson syndrome, toxic epidermal necrolysis); monitor patient
closely during the first 18 weeks (fist 6 weeks are most important)
NRTI
o Emtricitabine: lactic acidosis and severe hepatomegaly with steatosis; not indicted for hepatitis B;
exacerbations of hepatitis B have been reported after discontinuing this drug
o Tenofovir: lactic acidosis and severe hepatomegaly with steatosis; not indicted for hepatitis B;
exacerbations of hepatitis B have been reported after discontinuing this drug
o Lamivudine: lactic acidosis and severe hepatomegaly with steatosis; HIV and hepatitis B doses are
different, so make sure patient is getting the correct dosage; exacerbations of hepatitis B have
occurred after discontinueing the medication
o Stavudine: lactic acidosis and severe hepatomegaly with steatosis; pancreatitis
o Zidovudine: hematologic toxicity (neutropenia and severe anemia), myopathy, lactic acidosis and
severe hepatomegaly with steatosis
Low Molecular weight heparins: spinal/epidural hematomas may occur in patients who have
epidural/spinal anesthesia or spinal puncture, which can result in paralysis; risk is increased with indwelling
epidural catheters or with other anticoagulant use; monitor for neurologic impairment
Estrogens: endometrial cancer, stroke, DVT, should not be used to prevent CV disease or dementia
Gold compounds: physician she familiarize themselves with signs and symptoms of toxicity and warn
patients about toxicity; review lab work before each gold injection
Hydroxycloroquine:
o Physicians should completely familiarize themselves with the complete contents of the package
insert before prescribing HCQ
Interferon 
o Can cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and
infectious disorders
o Monitor patients closely with periodic clinical and laboratory evalutations
o Patients with persistently severe or worsening symptoms of these conditions should be withdrawn
from therapy
Iron-containing products:
o Accidental overdose is leading cause of fatal poisoning in children younger than 6 years of age;
keep products out of reach of children
Isotretinoin:
o Must not be used by women and adolescents who are pregnant or who may become pregnant; high
risk of birth defects
o Special prescribing requirements: approved for marketing only under special restricted distribution
program approved by FDA due to its teratogeniticty and to minimize fetal exposure; can only be
prescribed by physicians registered with iPLEDGE program, only registered pharmacies can
dispense the drug, patients must also be registered with the program
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Isoniazid:
o Hepatitis: risk increases with daily consumption of alcohol
o Carefully monitor patients and interview at monthly intervals
o Patients >35yo: monthly symptom reviews, AST/ALT prior to starting therapy and periodically
throughout treatment
Azole antifungals:
o Ketoconazole
 Hepatotoxicity
 Drug interactions:
Terfenadine- contraindicated; rare cases of serious cardiovascular adverse events
including death, ventricular tachycardia and torsades de pointes
Astemizole- contraindicated; ketoconazole inhibits metabolism of astemizole
resuling in elevated levels of its active metabolite which may prolong QT
intervals
Cisapride: contraindicated; serious cardiovascular adverse events including
ventricular tachycardia, ventricular fibrillation and torsades de pointes have
occurred with coadministration
o Itraconazole
 CHF: discontinue of signs or symptoms of CHF develop; do not administer to patients
with evidence of ventricular dysfunction such as CHF or history of CHF
 Coadministration of cisapride, pimozide, quinidine or dofetilide is contraindicated; may
inrease concentrations of these drugs and cause serious cardiovascular adverse events
Leflunomide:
o Pregnancy must be excluded before start of treatment; contraindicated in pregnant women or
women of childbearing potential who are not using reliable contraception
o Pregnancy must be avoided during leflunomide treatment or prior to completion of drug
elimination procedure after treatment
lithium:
o lithium toxicity is closely related to serum lithium levels and can occur at doses close to
therapeutic levels
o facilities for prompt and accurate serum lithium determinations should be available before
initiating therapy
loop diuretics:
o potent diuretics; excess amounts can lead to profound diuresis with water and electrolyte
depletion; careful medical supervision is required and dosage must be individualized
Metformin:
o Lactic acidosis: rare but serious metabolic complication that can occur due to accumulation of
metformin
o Do not use in patients who have conditions associated with hypoxemia, dehydration or sepsis; do
not use in patients with significant renal impairment
o Monitor for signs and symptoms of lactic acidosis including decreased blood pH, electrolyte
disturbances with increased anion gap, increased lactate/pyruvate ratio, and elevated blood lactate
levels (5mmol/L or more)
o Monitor renal function closely and temporarily discontinue prior to any intravascular radiocontrast
study and for any surgical procedure
Mercaptopurine:
o Potent drug and should not be used unless a diagnosis of acute lymphatic leukemia has been
adequately established and responsible physician is knowledgeable in assessing response to
chemotherapy
Methotrexate:
o Deaths: use only in life-threatening neoplastic diseases or in patients with psoriasis or rheumatoid
arthritis with severe, disabling disease that is not adequately responsive to other forms of therapy
o Bone marrow suppression: may occur with resultant anemia, leucopenia, or thrombocytopenia
 Severe, sometimes fatal, bone marrow suppression, aplastic anemia, and GI toxicity has
occurred
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o
Monitor:
 CBC with differential and platelet counts, liver function tests
 Periodic liver biopsies
 Patients with renal dysfunction, pleural effusions, ascites are at increased risk for
impaired elimination and should be monitored more frequently
o Liver: hepatotoxicity, fibrosis, cirrhosis after prolonged use
o Methotrexate-induced lung disease:
 Potentially dangerous lesions may occur at any time during therapy at doses as low as
7.5mg/week
 Monitor for pulmonary symptoms (dry, nonproductive cough)
o Pregnancy: fatal death and/or congenital anomalies have occurred; do not use in women of
childbearing potential unless benefits outweigh risks
 Contraindicated in pregnant women with RA or psoriasis
o Renal use: use extreme caution in patients with renal dysfunction and use at reduced dosages;
renal dysfunction will prolong elimination
o GI: diarrhea and ulcerative stomatitis require interruption of therapy; hemorrhagic enteritis and
death from intestinal perforation may occur
o Diluents: do not use formulations and diluents containing preservatives for intrathecal or
experimental high dose MTX therapy
o Malignant lymphomas: may occur in patients receiving low-dose MTX and may regress following
withdrawal of drug
o Tumor lysis syndrome: may induce tumor lysis syndrome in patients with rapidly growing tumors
o Skin reactions: severe, occasionally fatal, skin reactions may occur following single or multiple
doses of MTX
o Potentially fatal opportunistic infections: especially Pneumocystis carinii
o Radiotherapy: given concomitantly with radiotherapy may increase risk of soft tissue necrosis and
osteonecrosis
o Severe reactions: because of possibility of severe toxic reaction which can be fatal, fully inform
patients of the risks involved and assure constant supervision
Metronidazole:
o Shown to be carcinogenic in mice and rats; unnecessary use of drug should be avoided and
reserved for conditions for which it is indicated
Midazolam:
o Syrup has been associated with respiratory depression and respiratory arrest, especially when used
for sedation in noncritical care settings
o Continuously monitor respiratory and cardiac function
Misoprostol:
o Can cause abortion, premature birth or birth defects when administered to pregnant women
o Women of child-bearing potential should not be prescribed this drug for reducing risk of NSAIDinduced ulcer unless patient is at high risk of complications from gastric ulcers or at high risk of
developing gastric ulcers; prescribe to patient if:
 Negative serum pregnancy test 2 weeks prior to beginning therapy
 Capable of complying with effective contraception measures
 Received both oral and written warnings of hazards of this drug, risk of possible
contraception failure, and danger to other women of childbearing potential should the
drug be taken by mistake
 Will begin misoprostol only on second or third day of next normal menstrual period
Mycophenolate:
o increased susceptibility to infection and possible development of lymphoma
o Female users of childbearing potential must use contraception; increased risk of miscarriage and
congenital malformations
Naltrexone:
o Hepatotoxicity: when given in excessive doses, can cause heptocellular injury
o Contraindicated in acute hepatitis or liver failure
Nitroprusside:
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o
Not suitable for direct injection after reconstitution; must be diluted further in 5% Dextrose
injection before infusion
o Can cause precipitous decreases in blood pressure; can lead to irreversible ischemic injuries or
death in patients not properly monitored; monitor blood pressure continuously
o Causes rise in cyanide ion to potentially lethal levels if used at rates >2mcg/kg/min
 Usual dose rate is 0.5 to 10mcg/kg/min and should not last longer than 10 minutes
o Monitor acid-base balance and venous oxygen concentration which may indicate cyanide toxicity
Opioid Analgesics:
o Fentanyl transmucosal: indicated only for management of breakthrough cancer pain in patients
with malignancies already receiving and tolerant of opioid therapy for underlying persistent cancer
pain
 Contraindicated in management of acute or postoperative pain
 Do not use in opioid nontolerant patients due to life-threatening hypoventilation
o Fentanyl transdermal system: schedule II substance and has high potential for abuse and fatal
overdose due to respiratory depression
 Indicated for management of persistent, moderate to severe chronic pain that requires
continuous, around-the-clock opiod administration for an extended period of time, and
cannot be managed by other means such as nonsteroidal analgesics, opioid combination
products or IR opioids
 Should only be used in patients already tolerant to opioid therapy of comparable potency
due to risk of respiratory depression in nontolerant patients
 Only intended for transdermal use on intact skin
o Hydromorphone
 High potency injection: highly concentrated solution intended for use in opioid tolerant
patients
 Extended-release capsules: indicated for management of persistent moderate to severe
chronic pain in opioid tolerant patients
Use in patients already receiving opioid therapy, have demonstrated tolerance,
and require minimum total daily dose of opiate medication equivalent to oral
hydromorphone 12mg.
o Methadone:
 Should be dispensed only by hospitals, community pharmacies, and maintenance
programs approved by FDA and designated state authorities
 Used to treat narcotic addiction in detoxification or maintenance programs
 Cardiac conduction effects: inhibits cardiac potassium channels and prolongs QT interval
o Morphine:
 Avinza: modified-release formulation intended for once-daily dosing
 Astromorph PF, Duramorph, Infumorph: because of risk of severe adverse effects when
epidural or intrathecal route of administration is employed, patients must be monitored in
fully equipped and staffed environment for at least 24 hours after initial dose
 Infumorph: not recommended for single-dose IV, IM or SC administration because of
very large amount of morphine in ampul and risk of overdose
o Oxycodone:
 CR is a schedule II substance with abuse potential similar to morphine
 Indicated for management of moderate to severe pain when continuous, around-the-clock
analgesic is needed for an extended period of time
 Not intended for as needed use; to be used only in opioid tolerant patients
o Propoxyphene:
 Do not prescribe for patients who are suicidal or addiction-prone
 Prescribe with caution for patients taking tranquilizers or antidepressants
 Tell patients not to exceed recommended dose and to limit alcohol intake
 Excessive doses of propoxyphene either alone or in combination with other CNS
depressants including alcohol are major cause of drug-related deaths
Oral contraceptives:
o Smoking: cigarette smoking increases risk of serious cardiovascular side effects from OCs
o Risk increases with age (>35yo) and heavy smoking (at least 15 cigarettes a day)
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Penicillamine:
o Physicians should be thoroughly familiar with drug’s toxicity, special dosage considerations, and
therapeutic benefits
o Never use casually
Pentazocine combinations:
o Potentially lethal reaction including pulmonary emboli, vascular occlusion, ulceration and
abscesses, withdrawal symptoms in narcotic dependent patients if used by injection or in
combination with other substances
o Talwin Nx is intended for oral use only
Phenytoin:
o Administer slowly; do not exceed 50mg/minute IV in adults
o Do not exceed 1 to 3 mg/kg/min in neonates
Thiazolidinediones (pioglitazone, rosiglitazone)
o Cause or exacerbate CHF in some patients
o Observe for signs and symptoms of heart failure including excessive, rapid weight gain, dyspnea,
and/or edema
o Do not use in patients with established NYHA class III or IV heart failure
Pramlintide acetate injection:
o Increased risk of insulin-induced severe hypoglycemia, especially in type 1 diabetes
Polymixin B:
o Nephrotoxicity: monitor for albuminuria, cellular casts, azotemia; monitor for decreased urine
output or increased BUN
o Neurotoxicity: monitor for signs and symptoms of irritability, weakness, drowsiness, ataxia,
perioral parathesia, numbness of extremities, blurred vision
o Concurrent therapy with other neurotoxic or nephrotoxic drugs
o Neuromuscular blockade
o Use in pregnancy: safety has not been established
Progestins:
o Should not be used for prevention of cardiovascular disease
o Should be prescribed at lowest effective doses and for shortest duration
Promethazine:
o Do not use in children <2yo because of potential for fatal respiratory depression
Quetiapine:
o Increased mortality in elderly patients with dementia-related psychosis
o Extended-release form is not approved for treatment of elderly patients
o Suicidality in children and adolescents (immediate-release form)
Ribavirin:
o Ineffective as monotherapy for chronic hepatitis C infection and should not be used alone for this
indication
o Hemolytic anemia; may worsen cardiac disease and lead to MI
 Do not use in patients with history of significant or unstable cardiac disease
o Teratogenic and/or embryocidal effects
Rituximab injection:
o Fatal infusion reactions
 Deaths within 24 hours; monitor for signs and symptoms of hypoxia, pulmonary
infiltrates, acute respiratory distress syndrome, MI, ventricular fibrillation or cardiogenic
shock
o Tumor lysis syndrome
 Acute renal failure requiring dialysis following treatment of non-Hodgkin lymphoma
o Severe mucocutaneous reactions
Salicylates:
o Reye’s syndrome in children and teenagers with chickenpox or flu virus
Long-acting beta- 2 agonist: salmeterol/formoterol
o May increase risk of asthma-related death
Sirolimus:
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o
o
Increased susceptibility to infection and possible development of lymphoma
Liver transplantation
 Excess mortality, graft loss, and hepatic artery thrombosis (HAT)
 When used in combination with tacrolimus
 Use not recommended in liver transplant patients
o Lung transplantation
 Bronchial anastomotic dehiscence
 Not recommended for use in these patients
Tacrolimus:
o Increased susceptibility to infection and possible development of lymphoma may result from
immunosuppression
Streptomycin injection:
o Risk of neurotoxic reactions in patients with impaired renal function or prerenal azotemia
 Disturbances of vestibular and cochlear function, optic nerve dysfunction, peripheral
neuritis, arachnoiditis, encephalopathy
o Monitor renal function; peak serum concentrations should not exceed 20-25mcg/mL
o Avoid use of concurrent nephrotoxic drugs
Succinylcholine injection:
o Acute rhabdomyolysis with hyperkalemia followed by ventricular death in children
o Reserve for emergency intubation or immediate securing of airway is necessary
Tamoxifen:
o For women with ductal carcinoma in situ (DCIS) and women at high risk of breast cancer
 Can cause uterine malignancies, stroke, pulmonary embolism
Thyroid hormones:
o Do not use thyroid hormones either alone or in combination with other therapeutic agents for the
treatment of obesity or for weight loss
o In euthyroid patients, doses within range of daily hormonal requirements are ineffective for weight
reduction
o Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly
when given in association with sympathomimetic amines such as those used for their anorectic
effects
Trastuzumab:
o Cardiomyopathy: can result in left ventricular dysfunction and CHF
o Infusion reactions and pulmonary toxicity: symptoms can occur within 24 hours; monitor for
dyspnea or significant hypotension
Urokinase injection:
o Risk of potentially serious hemorrhage
o Use in hospitals where recommended diagnostic and monitoring techniques are available
Valganciclovir/ganciclovir:
o Granulocytopenia, anemia, thrombocytopenia; carcinogenic, teratogenic and caused
aspermatogenesis in animal studies
Valproic acid:
o Hepatotoxicity: children <2yo are at increased risk; monitor for symptoms such as anorexia, facial
edema, lethargy, malaise, vomiting and weakness
o Teratogenicity: information sheet describing teratogenic potential should be given to patients
o Pancreatitis: monitor for symptoms of abdominal pain, nausea, vomiting, and/or anorexia
Warfarin
o Bleeding risk; can cause major or fatal bleeding
o Regular monitoring of INR is recommended; report signs/symptoms of bleeding immediately
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Dangerous Abbreviations:8,9
Dangerous Term
O.D. for once daily
q.o.d. for every other day
q.d. for once daily
q.n. for every night
q hs for once daily at bedtime, each
day
TIW for three times a week
U for unit
O.J. for orange juice
µg (microgram)
sq or sub q for subcutaneous
IU for International units
AU for each year
ss for sliding scale or half
(Apothecary system)
Chemical symbols
cc
Lettered abbreviations for drug
names
Examples: MS or MS04 for
morphine sulfate
DPH, ASA, APAP, AZT, CPZ, etc.
Apothecary symbols/terms
per os for by mouth
D/C for discharge
T/d for one per day
/ use for with, and, or per
Roman numerals
> and <
Drug name and dosage not separated
by a space
Trailing zeros (after a decimal point
 1.0)
Naked decimal point (no number
before the decimal point  .5)
HS written for half strength
AU, AS, AD written for both ears,
left ear, right ear
Reason for Danger
Interpreted as right eye
Interpreted as ―every once a day‖ or
read as q.i.d or q.d.
Read as q.i.d.
Read as every hour
Read as every hour
Appropriate Term
Write out ―once daily‖
Write out ―every other day‖
Write out ―once daily‖
Write out ―every night,‖ ―HS,‖ or
nightly
Use ―HS‖ or ―at bedtime‖
Interpreted as T/W (Tuesday and
Wednesday), twice a week, or TID
Read as 0, 4, 6, or cc
Read as OD or OS
Misread as mg when written
The q could be read as every; may
be misread as SL (sublingual) if
written poorly
Misread as IV; the I could be
misread as a 1; could be read as 10
Read as OU
Read as 55
Write out ―three times a week‖
Not understood or misunderstood
Write out the full name of the
chemical
Write ―mL‖
Write out generic or brand names or
use facility’s protocol procedure
Read as U for unit
Not understood or misunderstood
Not understood or misunderstood
OS read as left eye
Interpreted as discontinue
Read as TID
Read as a 1
Not understood or misinterpreted
Not understood or the meaning is
reversed
Last letter (such as an l) could be
misread as part of the dose (140 mg
instead of 40 mg)
Decimal point may be missed,
causing a tenfold overdose
Decimal point may be missed,
causing a tenfold overdose
Interpreted as HS meaning ―hour of
sleep‖
Misinterpreted as OU, OS, OD (both
eyes, left eye, right eye)
Write out ―unit‖
Write out ―orange juice‖
Write ―mcg‖
Write out ―subcut‖
Write out ―units‖ or ―international
units‖ with a lowercase i
Write out ―each year‖
Write out ―sliding scale‖ or ―1/2‖
Use the metric system
Write ―by mouth,‖ ―orally,‖ or ―PO‖
Write out ―discharge‖
Write out ―once daily‖
Write out ―and’‖ ―with,‖ or ―per‖
Use Arabic numerals
Write or ―greater than‖ or ―less
than‖
Leave a space between the drug
name, dose, and unit
Omit the zero after the decimal point
Add a zero before the decimal point
Write out ―half strength‖
Write out instructions clearly
Page 230
Narrow Therapeutic Index Drugs:10
Definition: Drugs where increasing the dose only slightly may cause a large increase in serum drug levels and
clinical effect and could also cause a toxic effect. A small decrease in the dose may cause plasma
levels to drop, resulting in a loss of therapeutic effect. The clinical implication of recognizing and
monitoring these medications is to avoid possible toxicities (with supratherapeutic levels) and
ineffectiveness (with subtherapeutic levels).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Aminoglycoside Antibiotics
Warfarin, heparin
Aspirin
Carbamazepine
Conjugated estrogens
Cyclosporine
Digoxin
Esterified Estrogens
Hypoglycemic agents
Levothyroxine sodium
Lithium
Phenytoin
Procainamide
Quinidine sulfate/gluconate
Theophylline
Tricyclic antidepressants
Valproic Acid
Page 231
Therapeutic drug level monitoring11
TABLE KEY: RIA – Monoclonal radioimmunoassay; FPIA – Fluorescence polarization immunoassay; HPLC –
High-performance liquid chromatography
Drug
Goal Levels
Timing of Level
Frequency of Level
Aminoglycosides Gentamicin, Tobramycin: Peak level: 1 hour after
Some institutions wait until after
Conventional dosing –
maintenance dose is given
steady state is reached (after 3-4
Peak: 5-8 mg/L, Trough:
to avoid distribution phase
doses) but this is not necessary
<2 mg/L. ―Once daily‖
Trough level: within ½
dosing – Peak: 20 mg/L,
hour before next
Trough: undetectable
maintenance dose is given
Amikacin: Conventional
dosing – Peak: 20-30
mg/L, Trough: < 10 mg/L.
―Once daily‖ dosing –
Peak: 60 mg/L, Trough:
undetectable.
Carbamazepine
Plasma Concentration: 4Take samples at the same
Obtain plasma samples within the
12 mg/L (some physicians time of the day each time a
first few weeks of therapy to
prefer 4-8 mg/L because
sample is drawn to compare compare level with clinical
toxicity can develop)
serum levels (example –
response and periodically
always in the morning
thereafter
before dose is given)
Digoxin
Concentrations: 0.8-2
Trough level: Once steady
Within 24 hours of loading dose
µg/L
state reached: draw level
to confirm relationship between
just before next dose given; dose and response; routine levels
any sample time can be
once steady state has been
used that is 4 hours after an reached (7-14 days after
IV dose or 6 hours after an
maintenance regimen is initiated
oral dose
or changed and 15-20 days in end
stage renal disease);
Ethosuximide
Plasma Concentrations:
Long t1/2 so not critical;
Monitor after patient has reached
40-100 mg/L
trough levels preferred
steady state (7-14 days in
children, longer in adults)
Cyclosporine
Serum/Plasma (µg/L):
Troughs are most
RIA: 5-125
commonly used (draw
FPIA polyclonal: 150-400 directly before next dose is
FPIA monoclonal: 50-125 given)
HPLC: 50-125
Whole Blood (µg/L):
RIA: 150-400
FPIA polyclonal: 200-800
FPIA monoclonal: 150400
HPLC: 150-400
Tacrolimus
Therapeutic
Wait 24-36 hours after
Concentration: 5-20
initiating or altering dose
ng/mL
and draw a trough level
(right before next dose is
given)
Sirolimus
Therapeutic
Wait 1 week and draw a
Concentration: 5-15
blood sample to look at
ng/mL
trough levels (draw directly
before next dose is given)
University of South Alabama, Department of Family Medicine
June 30, 2008
232
Lidocaine
Therapeutic Plasma
Concentrations: 1-5 mg/L
Lithium
Therapeutic Range: 0.60.8 mEq/L
Methotrexate
Therapeutic Plasma
Concentration: variable
Phenobarbital
Therapeutic
Concentrations: 15-40
mg/L
Phenytoin
Therapeutic Plasma
Concentrations: 10-20
mg/L
Procainamide
Therapeutic Plasma
Concentrations: 4-8 mg/L
Theophylline
Therapeutic Plasma
Concentration: 5-20 mg/L
Tricyclic
Antidepressants
Therapeutic Range
(µg/L):
Amitriptyline: 120-250
Desipramine: 100-250
Just before the first a.m.
dose of lithium; at least 12
hours after the last evening
dose
Checking leucovorin
regimen: 24-48 hours after
leucovorin initiation to see
if another dose is needed
Not critical; can be taken
anytime, but troughs are
recommended for
consistency (draw level
directly before next dose is
given); when IV, draw at
least one hour after end of
infusion
Oral extended absorption:
time of sample isn’t critical,
but troughs are preferred
IV form: measure troughs;
avoid taking a sample 1-2
hours after infusion is over
Immediate release: Trough
levels preferred
Sustained Release:
Sample times less
important, but trough
preferred (draw sample
directly before next dose is
given)
Nonsustained Release or
liquid: Troughs (draw
sample directly before next
dose is given)
Sustained Release: Time
less crutial, troughs
recommended
12 hours after a dose, which
is usually in the morning
(Peaks – unpredictable
Troughs – hard because
University of South Alabama, Department of Family Medicine
Do not monitor until 4-8 hours
after initiating therapy; not used
to adjust therapy; used to relate
clinical impressions with plasma
levels
Steady state occurs in 3-5 days;
draw levels when needed to
adjust dose
Check levels when infusing to
make adjustments, when patients
are taking multiple doses, and
when testing leucovorin regimen
2-3 weeks after initiation or
dosage change
Tests plasma levels before
reaching steady state to monitor
for low and high concentrations,
but adjust cautiously based on
these levels;
Varies with disease
Need rapid therapeutic
concentrations, monitor 2-3 days
after initiation and get a second
level in another 3-5 days; if level
hasn’t changed in 3-5 days,
monitor weekly
Stable patient on long-term
therapy, monitor every 3-12
months
Within the first 24-48 hours and
when patient’s clinical status
changes
Begin 24 hours after initiation or
change
At the beginning of therapy:
Without signs of toxicity, wait 1
week after initiation; after
adjusting based on levels,
June 30, 2008
233
Imipramine: 180-350
Nortriptyline: 50-150
dosed at bedtime)
Valproic Acid
Therapeutic Plasma
Concentration: 50-100
mg/L
Troughs (draw sample
directly before next dose is
given)
Vancomycin
Therapeutic Plasma
Concentartion:
Peak: < 40-50 mg/L
Trough: ~ 10 ± 5 mg/L
Troughs, but can monitor
peaks as well; troughs
should be obtained within 1
hour before the next dose;
if peaks are measured, draw
levels 1-2 hours after end of
infusion
monitor signs and symptoms; test
if suspect noncompliance or side
effects caused by concentration
2-4 days following initiation,
change in regimen, addition of
other antiepileptic drugs; measure
when seizure control changes or
suspect toxicity
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Williams, and Wilkins; 2005. xxvi p.
2. Billups NF, Billups SM, editors. American Drug Index. 47 th ed. St. Louis: Facts and Comparisons; 2002.
1022 p.
3. Cozza KL, Armstrong SC, Oesterheld JR. Drug Interaction Principles for Medical Practice: Cyctochrome
P450s, UGTs, P-glycoproteins. 2nd ed. Washington, DC: American Psychiatric Publishing, Inc; 2003.
4. Katzung BG, editor. Basic and Clinical Pharmacology. 7 th ed. Stanford, CT: Appleton & Lange; 1998.
47-48 p.
5. Winter ME. Basic Clinical Pharmacokinetics. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2004.
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12th ed. Warminster (PA): Neil M Davis Associates; 2005. 6-7 p.
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10. Brown CH. Overview of Drug Interactions. U.S. Pharmacist [Internet]; [cited 2008 Jul 1]. Available
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