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OUT PATIENT NOTES
11/6/2014
Topic
Page #
Alopecia
Amenorrhea
Anticholinergics
Aspirin
Asthma
Back Pain
Bell’s
Bioterror
Blepharitis
BPH
Constipation
COPD
COPD exacerb
Cough
Dementia
Diabetes
DISH
Dizziness
DVT
Dysmenhorrhea
Dysuria
Ear wax
Edema
Fatigue
Fibromyalgia
Fungal infections
Galactorrhea
Genitourinary
H Pylori
Hand & wrist pain
Headache
Hearing loss
Hematuria
Hepatitis C
HTN & BBs
Hypogonadism
IBS
Iliotibia band syndr
Incontinence
Insulin
Knee exam
2
22
2
20
15
10
2
2
4
2
16, 17
2
4
2
18,19
21
3
12
11
5
4
2
12
10
5
5
4
8
8
8
8
5
6, 12
8
6
8, 9
7
5
19
20
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Leg edema
2
Lipid meds
18
Mastalgia
11
Menopause
9
Osteoporosis&D&Ca 9
Otawa ankle & foot 7
Otitis externa
4
Pain
9
Parasites of body etc 21
PCOS
6
Pericarditis
12
Pharyngitis
4
Pneumonia
2,7
Preop eval
11
Probability
7
Pruritis
12
Psoriasis
6
Red eye
4
Retinal detachment 12
Rheumatoid arthritis 14
Rhinitis
4
Rosacea
12
Rx for COPD
17
Seizures
12
Sinusitis
4,5
Skin
12
Skin steroids
12
Somatization DO
7
Statin Rx
20
STDs
13
Testicular pain
5
Ulcers
14
Ulnar nerve entrapped 7
Vaccines, live
7
Vaginitis
14
Weight gain meds
7
Weight loss
14
1
George Roush. See roushmedicine.com
ALOPECIA:
Gender: Female pattern baldness: thinning on
top. Minox 2%. 1 ml BID
Male pattern baldness: receding hairline. Minox
5% 1 ml BID & finasteride 1mg.
Diffuse: a) Telogen effluvium: stress, post
partum, rapid weight loss,
b) meds (lithium, valproate), Fe, vThyroid.
Focal:
a) non-scarring: tinea capitis, syphilis, and
alopecia aereata from autoimmune conditions:
hypothyroidism, pernicious anemia
(exclamation pnt hairs, +ve pull test
Trichtilomania
b) scarring: SLE, TB, zoster, trauma
ANTI-CHOLINERGICS. (flushing, dry skin and
mucous membranes, mydriasis, altered mental status
(decreased cognition), increased heart rate)
Anti-cholinergics: Ipratropium, tiotropium, atropine,
scopalamine (anti-emetic).
Tricyclics: Amitriptyline (migraine, fibromyalgia,
depression, pruritis of systemica etiology., imipramine.
Safer ones are Nortriptyline and desipramine.
Muscle Relaxants: Cyclobenzaprine (Flexeril)
GU anti-spasmodics: oxybutynin, tolterodine (Detrol).
Benadryl, chlorpheniramine.
Antipsychogics & antiepileptics.
BELLS PALSY:
CM's: Sudden onset over hours. Facial nerve, including
forehead bilaterally. May be loss of taste in anterior 2/3 of
tongue, decreased tearing, salivation, and dysacusis
(abnormal perception of sound).
TREATABLE CAUSES
Lyme disease, syphilis, HIV, otitis media, parotid
gland tumor, Herpes Simplex: causes the majority.
Herpes Zoster is next most common (Ramsey Hunt: Cr N
5, 7 & 8: auditory canal, auditory & visual sxs.)
Uncommon: other viruses, including HIV, adeno virus,
Epstein barr, CMV, Rubella, Mumps, Influenza, and
Coxsackie.
The natural history is that the majority of
idiopathic cases improve in 3 weeks, with most resolving
completely in 6 months. Variation from this history and
associated findings suggest:
Bacterial infection of middle ear (usually obvious) Tumor
OTHER CAUSES
Diabetes/
Sarcoid/
Cholesteatoma (gradual onset)/
Sjogren's syndrome/ MS, Flu vaccine, AIDP
Work up:
*If appropriate: Lyme titer, VDRL blood glucose,
HIV ELISA.
*Imaging only if atypical presentation or failure of
resolution.
*Grade the severity of involvement at presentation and
follow up: Asymmetry at rest and, with exertion, the
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degree of extra-ocular (eye closure), forehead (wrinkling)
and mouth musculature. Grade ranges from mild (no
asymmetry at rest, eye closure with minimal effort, some
forehead and mouth movement) to severe (gross
asymmetry, inability to close eye, complete paralysis of
forehead and mouth).
*Treatment of idiopathic Bell's palsy
Predinosolone 25mg BID x 10ds within 3ds of onset
(Sullivan FM. NEJM 2007;357:1598)
*Treat for Lyme if indicated.
*Follow up at 3 weeks and at 6 months for resolution.
BONE PAIN:Osteomalacia,pagets,tumor (MM)
BIOTERROR AGENTS:
Pneumonias
Anthrax*
Yersinia (Plague). Droplet precautions.*
Franciscella tularensis (Tularemia)*
Ricin inhaled.
Mustard gas. Decontaminate.
Ventilatory paralysis
Botulism: 5 day latency, with Descending paralysis*
Sarin gas: Cholinergic crisis. Give atropine and
pralodoxime.
Cyanide poisoning. Almond odor, ENT irritation,
Metabolic acidosis. Give IV Sodium nitrite, then
sodium thiosulfate
Ricin ingested: Bleeding, Liver & kidney failure.
Viral
Marburg virus. 7-10 ds, then flu, then V, D, Abd pain,
hemorrhage. Aerosol & fomites.*
Small pox: 7 - 10 days latent period, then URI, then rash,
then pustules in same stage. Aerosol. Vaccine if < 3ds
post exposure.*
*Category 1 bioterror agents.
CHF: NYH 2 & (EF<30% or [EF 30-35 & QRS >130
milliseconds (3+ small squares)]) give eplerenone. (MI: 1
small square.)
COPD Exacerbations: Cardinal sxs: ^dyspnea,
^sputum purulence, ^sputum volume. Risk factors: Age
65+, FEV1< 50%, 3+exacerbations/yr, cardiac disease.
1) One symptom >> no antibiotic, ^ bronchodilator.
2) 2 - 3 cardinal sxs, no risk factors >> azithro,
cefuroxime, doxy, or bactrim. Plus Orl Steroids
3) 2- 3 cardinal sxs, 1+ risk factor >> moxi or amoxclavu or cipro (if at risk for pseudomonas).
Constipation: Causes: CA, or Meds (anticholinergics,
antipsychotics, opiods, Fe, Ca, verapamil, diuretics)
Rx: ½ cup of ALL Bran. Apple, grapefruit, carrot,
cabbagge,, bran muffin. Psyllium (metamucil:
3gm/capsule, 1 to 10/day). Sorbitol (30 to 150 cc),
lactulose (15-30 cc/day), or polyethylene glycol
(miralax) 1 heaping TBS in glass of water/day. MOM
2-4 TBS/Day. Senna 15mg (Exlax Maximum
strrength)/tab 1-2 tabs/d <8 days.
DEMENTIA
REVERSIBLE CAUSES OF DEMENTIA:
Metabolic: Lytes, CA, LFTs, Creat, Cu, CBC, TSH (ask
about indoor heating for CO). (Wilsons disease)
2
Deficiencies: B12 (methylmalonic acid, homocysteine)
Give thiamine.
Infections: Lyme titer, VDRL, HIV, ESR. (Whipples
disease.. fatty diarrhea, migratory arthritis, T Whipplei)
Autoimmune: ESR.
CNS: CT scan. (Normopressure hydrocephalus;
subdural)
Drugs: anti-cholinergics, NSAIDs, Alcohol, Metals.
Tumor.
Seizures and depression
Chronic Dementias:
Alzheimers: Agnosia, aphasia, apraxia, executive
functioning, abnormal clock drawing
DWLB: hallucinations /parkinsonian/ sensitivity to anticholinergics & neuroleptics
Blepharitis causes: S. Aureas, Seb Derm, or
rosacea. Use tetracycline for rosacea.
Fronto-termporal dementia: Neglect of person, behavior
to others, no insight, emotional blunting.
Multi-infarct dementia
Prion disease: rapid onset. Myoclonus, akinetic mutism,
extra and pyramidal signs, ataxia and visual changes.
Protein 13-3-3-1. EEG:Periodic Sharp Waves.
EDEMA: CAUSES OF BILATERAL LEG EDEMA
Hydrostatic: CHF, constrictive pericarditis, restrictive
CM, chronic venous insufficiency. Osmotic: Nephrotic
synd, liver failure, Na retention, pregnancy. Local:
Neoplasm (Abdominal or retroperitoneal) Bakers cyst,
cellulitis, thyroid disease. Meds: NSAIDs,
dihydropyridine CCBs, and estrogens.
months) and 4+ of 1) Post exertional fatigue, 2)
myalgias or arthralgias, 3) tender but normal
sized nodes, 4) Headache, 5) sore throat, 6)
decreased memory
Chronic fatigue syndrome, criteria: A Persistent
or relapsing fatigue not alleviated by rest (x 6+
DIZZINESS: 4types:1VERTIGO. 2PRE-SYNCOPE. 3DISEQUILIBRIUM (“off balance, wobbly”), and 4LIGHTHEADED (vague sx’s) *
Focal
neuro
Sgs
HearingV
Other
BPPV
no
no
Up & torsional nystagmus is positional, latency of 3-20s, transience (<60s),
fatiguability(1)(2). Severe but walks OK. Resolves spontaneously. Episodic
Vestibular neuritis
(labyrinthine neuritis)
no
no
Disabling,sustained, w/ imbalance, nystagmus is spontaneous, suppressed w/
visual fixation, +Head thrust test$. Constant attacks last 3-7 days & do not recur. Rx=
methyl-prednisolone:100mg/d divided, taper after 3ds; stop after 22ds.
Cochlear neuritis
no
yes
Vestibular neuronitis & chochlear neuritis (hearing loss) constant; head thrust:
inability to maintain visual fixation after rapid turning to the side of lesion.
Menieres
no
yes
Hearing loss, tinnitus, fullness in the ear. Lasts 3 hours to 2 days. Episodic
Yes(95%)
Tinnitus (63% of patients). Speaking, swallowing and ataxia are sometimes
found. No nystagmus.
Pos
Yes/No
Downbeat nystagmus is instantaneous, lasts >60sec, non-fatiguing (constant).
Less severe but falls when walking. Not suppressed with visual fixation.
Negative head thrust test.
Pos
Acoustic neuroma
Vertebroba-silar TIA or
infarct or cerebellar
hemorrhage
Yes
MRI
$
AKA “Head Impulse Test”: Patient looks straight ahead and asked to maintain same gaze while head is turned to side of the
lesion. A positive test is a saccade (abrupt rapid movement) is required to maintain straight ahead fixation.
*In addition to the entities in this table consider: (1) Postural hypotension; (2) chronic unilateral vestibular hypofunction
(rapid head turns elicits vertigo; fleeting with duration <3 secs); (3) migrainous vertigo; (4) drugs; (5) fistula.
(1) The positions can be looking up, lying down, getting up out of bed, or rolling over in bed. Resolves over months.
(2) Posterior semicircular canals, Dix-Hallpike: Sitting>Head 45d to affected side (e.g., right)>patient supine with head over
end of bed 20d down. Maintain x 30secs. Nystagmus w/ latency of 3-20 secs and last 30 secs. Sitting patient up gives
further nystagmus. Repeat maneuver leads to fatigability. Rx=either habituation exercises (reproduce dizziness, 10 sets, QID
or the Eply maneuver: Dix-Halpike > Head 90d to unaffected side >head face down>sit up off left side of bed. For horizontal
semicircular canal: Supine Head Roll: Patient supine>head turned 90d to each side. Rx=Supine head roll to effected
side>rotate head in 3 90d increments from effected ear down to supine to unaffected ear down to prone (Kim J-S. NEJM
2014;370:1138.)
ENT CONDITIONS
ADULT ACUTE PHARYNGITIS, FLU & COMMON COLD July 15, 2005
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3
Beta Hemolytic Strep: fever, exudate, anterior cervical adenopathy and no cough.
Infectious mono: No cough, rash, spleen, GBS, Avoid exercise, give steroids.
Mycoplasma, Chlamydia, N Gonorrhea, Pertussis, peritonsilar abscess, necrotizing gingivo stomatitis, septic
thrombophlebitis of the internal jugular vein
HIV: oral ulcers, n, v, PM truncal rash, spleen, CNS (6%)
Influenza/ HSV1/ Adeno virus/
Rhino or corona virus.
OTITIS EXTERNA (Q 60, MKSAP 13). Can be bacterial or fungal; cipro will make fungal worse.
Treatment
Fever
Lymph Nodes
Pinna & Mastoid
Cranial nerves
Steroid+anti-biotic, 4 ggts TID x 10 days(1)
no
No
non-tender
intact
Outpatient, ciprofloxacin 750 BID
yes
small or none
non-tender
intact
Rx: 1) clean ear canal, 2) antibiotic, 3) protect ear when bathing (cotton ball covered with Vaseline)
(1) Cortisporin OTIC (steroid+polymyxin & Neomycin).
Ear wax carbamide peroxide (Debrox) 10 drops BID
x4ds
SUDDEN SENSORINEURAL HEARINGLOSS:
Causes: idiopathic>50%/ tumor, CVA, MS/ Autoimmune,
Lyme, Menieres, Trauma. RX: Prednisone 60 x 4ds,
taper by 10mg Q2 ds(Rauch SD. NEJM2008;359:833)
RED EYE 20/60=sign visual loss. 20/200=blindness
>Uveitis ciliary flush, eye pain, v vision.
>Acute angle closure glaucoma: Severe pain, halo around
objects, v vision, dilated pupil.
>Zoster to nose tip: emergency referral.
>Endophthalmitis: hypopyon= pus in anterior chamber.
Suspect in immuno-suppressed.
>viral conjunctivitis is highly contagious. Hand hygiene!
>bacterial conjunctivitis.Purulent d/c. Rx for
pneumococcus. Erythro ointment. Ilotycin  ribbon
Q4hr
>Profusely purulent d/c: Gonorrhea. Systemic Abcs &
Referral.
>Chronic red eye in sexually active adult: Chlamydia.
Systemic antibiotics. Referral.
>Constitutional symptoms: consider CT disease.
>Itching,watery d/c,post URI. Allergic, viral. Artificial
tears to dilute allergen. OTC Naphcon A(Naphazolinepheniramine)1drp Q6hrx4ds. Avoid long-term use.
Chlorpheniramine (Chlortrimeton) 4 mg Q4H. Viral
conjunctivitis is highly contagious. Rx=artificial tears,
cold compresses.
RHINITIS: Allergic/ Inflammatory/
Hormonal/ Rhinitis medicamentosa/ Irritants
Rhinitis-viral:Topical:Ipratropium nasal(Atrovent nasal)
0.06% QID. Oxymetazoline(Dristan)2-3 sprays BID
PRNx3days only.
PO: pseudo-ephedrine (Sudafed 12 hr) 60 mg Q6hr.
Rhinitis-allergic: Fluticasone nasal (Flonase) 1 spray
BID; decrease to 1 spray daily when possible.
PO loratidine (Claritin) 10 mg daily. Remove carpets,
pets, bedding; keep relative humidity to less than 40%.
Rhinitis-vasomotor:Ipratroprium nasal (Atrovent nasal)
2 sprays BID OR Flonase nasal (Flonase) 1 spray BID.
ACUTE COUGH (MKSAP 13) (post nasal drip
not chronic bronchitis (no evidence for control of sx’s)
Proven effective:
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Naproxen (Aleve) 500 BID,
Ipratropium nasal spray (Atrovent) .03%-.06%, 2
sprays/nostril BID to QID (Contraindications: narrow
angle glaucoma, BPH, or myasthenia gravis).
(Oxymetazoline (DristanQ12 hr) 2-3 sprys /nostril bid
PRNx3 days. Not in MKSAP but for nosebleeds.)
Proven ineffective: Non-sedating anti-histamines, nasal
steroids, zinc lozenges, echinacea.
ACUTE COUGH: Guafenesin (Robitussin)
CHRONIC COUGH.
1. Post nasal drip: Sedating anti-histamine
(+naproxen,drixoral), then fluticasone .06%, 2-4 puffs
BID) then ipratroprium .06%, 2 sprays, QID, Distran, 2
sprays BID.
2. Asthma: see page 15
3. Treat GERD: PPI (Pantoprazole (Protonix) 40 mg
QDx3 mo + prokinetic(metoclopramide) 10-15 mg qid 30
minutes pre meals.
4. ACEI: Starts in 1-2 wks (up to 6 months). Stops in 1-4
days (up to 1 month).
5. Pertussis causes cough in 25% with length >2wks.
Culture, direct fluorescent Ab test, PCR of nasopharynx.
Azithro x 5ds
6. Non-asthmatic eosinophilic bronchitis: fluticasone.
^ sputum eos; -ve methacholine challenge
7. non-tuberculous mycobacteria (MAC).
Immunocompetent: elderly women, fatigue, mailaise,
SOB. Tree-in-bud CT. Obtain sputum culture. Rx=INH
(or clarithro or azithro), rifamipin, ethambutol.
8. Dont miss: malignancy, TB or CHF
SINUSITIS. Remember: Chronic sinusitis could be
Wegeners or in a young adult, it could be cystic
fibrosis.
Acute sinusitis, indications for anti-biotic (any of these):
(1)Temp 102+ + [purulent nasal discharge or facial pain]
or (2) duration longer than 7 days, or (3)worsening sxs
after initial improvement. Anti-biotic choice:
1) no comorbidities: amoxicillin-clavulanate (Augmentin)
875/125 BID.
2) comorbidities: Double this dose.
Otherwise give loratidine (Claritin) (5 BID or 10 AD),
phenylephrine (Sudafed) spray q4hr x 3 days, analgesics,
systemic or topical decongestants, ipratropium, and
inhaled corticosteroids. Complications: meningitis,
4
central vein thrmbosis.
For diagnosis of sinusitis in average risk patients,
imaging is rarely necessary.
FUNGAL INFECTIONS:
Cutaneous candidiasis: clotrimazol cream (lotrimin)
15, 30 or 45 gm tube. apply BID
Tinea versicolor: Ditto
Tinea pedis, cruris, corporis: ditto
Tinea versicolor: Ditto
Vaginal candidiasis: clotrimazole-vaginal: 2% cream
applicator. QHS x 3ds.
Onychomycosis: terbinafine 250 mg x 12 wks for
toes, x 6 wks for fingers.
BPH: Rx:1) alpha 1 antagonist, tamulosin .4mg (Flomax),
2) 5 alpha reductase inhibitors, finasteride 5mg (Propecia,
Proscar) 5 mg, or dutasteride (Avodart) 0.5mg (more
potent… v prostate ca: NEJM 2010;362:1192). Both types
are equally effective in reducing rate of progression. The
2 together are more effective than 1 alone.
DX OF DYSURIA: UTI, bacterial vaginosis,
trichomonas, STDs, interstitial cystitis
Interstitial cystitis = symptoms with a negative U/A.
Rx=pentosan polysulfate sodium (Elmiron) (100 mg TID
with water 1 hour before or 2 hours after meals),
amitriptyline (25, 50, 75 mg) and hydroxyzine (Vistaril)
50, 100 QID.
HEMATURIA. Causes of red urine: Hgb, porphyrin,
myoglobin, beets, INH, phenazopyridine
Ddx: Bladder Cancer/Cystitis/Renal Cell Ca/Glomerulonephritis/Renal Stones/ BPH/AVM.
TESTICULAR PAIN OR MASSES:
Non-acute: ALWAYS AN ULTRASOUND.
Varicocele (varicose veins of testes). Dull ache, increased
with standing. Bag of worms around spermatocord,
Transilluminates. R/O renal cell ca OR IVC obstruction
if unilateral. Surgery if sxs. Check semen Q2y.
Hydroceole. Gradual onset. Fluid. Transilluminates.
Drain & instill sclerosing agent.
Testicular CA. Painless, non-tender, firm. Doesnt
transilluminate.
Epididymitis: solid mass separate from testicl: 2nd to TB
Epididymal cysts: cysts are separate from the testis.
Azithromycin 1gm or DOXY 100bid x 7ds
URINARY INCONTINENCE
Reversible causes:
1) Meds: Anticholinergics (TCAs, cyclobenzaprine,
ipratrium, tiotropium, sedatives, sedatives,
antihypertensives (diuretics, CCBs), alcohol)
2) UTI, atrophic urethritis, excess urination,
2) restricted mobility, stool impaction, Ca.
Urge incontinence: Behavioral. Do timed voids.
Kegel exercises, tolteradine (Detrol) 2 mg bid ($4 med)
OR Tolteradine XR 4mg qd (May cause cognitive
problems), Not in gastric retention, glaucoma, or vHR.
Stress incontinence: Kegel exercises.
Meds: Duloxetine (Cymbalta) 20 or30 mg BID.
Causes of increased uterine bleeding:
Structural: Polyps, hyperplasia, ca, fibroids, AVM
Pregnancy related: Pregnancy, ectopic, spontaneous abrtn
Ovarian: PCOs, ovarian cyst, ovarian tumor
Hypothyroidism
Hematologic: von Willebrands, thrombocytopenia,
liver disease, hematologic malignancies
GERD:
Ddx: CAD, Cancer, achalasia, DES, non-ulcer dyspepsia,
PUD, infectious esophagitis (HIV>> candida, CMV,
herpes), eosinophilic esophagitis, pill esophagitis.
Red flags for an EGD: no response to a PPI for 2 months.
Breath test or stool antigen for H. Pylori:no PPI for 2 wks.
PPI predisoposes to B12 def & C diff
Galactorrhrea: r/o Ca or infection (unilateral, bloody, pus)
Causes: Pregnancy (BHCG), hypothyroidism (TSH),
renal failure (Cr), prolactinoma (prolactin), Meds
(Antipsychotics, TCAs, SSRIs, opioids, metoclopramide
(Reglan), chest wall pathology.
Rx: Cabergoline 0.5 mg tabs, ½ to 2 tabs/ day.
SAs: HA, dizziness, psychosis or aggression (rare),
valvulopathy (rare).
Pregnancy: B
Acute testicular pain
1) Testicular torsion: 15-30 yo, acute very severe pain,
difficulty walking, abd pain, n, v. Exam: Severe pain.
Bell clapper abnormality. With elevation of testis, pain
worsens or gives no relief. Lab: US. Immediate surgery.
2) Epididymitis. Includes systemic symptoms. May have
hydrocele. Improvement of pain with elevation of testis.
U.S. if question.
Rx: < 35 y.o. treat as if for chlamydia and gonorrhea.
ceftriaxone 125 im or cefixime (Suprax) 400mg PO.
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Criteria for Hep C Rx:
1) 18+ years old
2) Detectable HCT RNA
3) Live Bx with chronic hepatitis and fibrosis
4) Compensated liver disease: Bili <1.5 gm/dL,
INR < 1.5, albumin 3+ gm/dL Platelets 75,000+
5) No evidence of ascites or hepatic encephalopathy
6) Hgb > 13 in men and > 12 in women, PMNs
>1,500, Creatinine <1.5
7) Adherent
New Rx for Hep C: Peg interferon, ribavirin, protease
inhibitor (telepevir or baceprevir)
Hypogonadism in adult male
Sx’s: Decreased libido, hot flashes, infertility. PE:
Gynecomastia, decreased body hair and muscle mass.
Diagnosis: 8AM total testosterone. If obese or aged
(increased T binding), T will be spuriously low.
Measure free T by a specialty lab. Free T is usually
calculated from Total T, SHBG, and albumin.
If T is low, repeat and measure LH and FSH.
Loss of libido is most specific symptom.
Erectile dysfunction, weakness, and muscle mass
loss occurs when T is less than 200.
Administering T increases the PSA by 0.5 mg/dL
Types/causes:
Secondary Hypogonadism: LH and/or FSH are
normal or low.
Chronic disease: Liver failure, kidney failure,
COPD, HIV.
Hormonal: Increased prolactin, DM, Obesity,
treatment with steroids or opiods.
Infiltrative: Sarcoid, hemochromatosis, eosiinophilic
granuloma.
Primary hypogonadism: LH and/or FSH are
high:
1) Congenital: Klinefelter, cryptorchidism.
2) Direct insult: Mumps, antineoplastic.
3) Metabolic: liver failure, kidney failure, steroids,
keto-conazole (In high doses, ketoconazole can
suppress adrenals.)
4) Autoimmune
5) HIV
Treatment:
*The role of testosterone replacement in men age
60+ is uncertain.
*Screen for prostate ca in men age 50+ or in blacks.
*Measure Hgb at baseline, at 3 months, then yearly.
*Measure T at 3 months and then Q 6-12 months.
*Treat underlying disease.
*Transdermal gel: Androgel 1%, 50 -100 mg to
shoulder and either upper arms or abdomen QAM.
*Transdermal patch.
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*Testosterone enthanate injections (least expensive):
150 to 200 mg every other week. Can be selfadministered.
Polycystic Ovary Syndrome (PCOS)
Criteria, Rotterdam criteria (2003): Clinical
or laboratory hyperandrogenism, oligo- or anovulatory function, PCOs on imaging.
NIH criteria replaces the last with excluding
Tumor, pregnancy, hypothyroidism,
hyperprolactinemia, Cushings, and CAH.
Mechanism: ^ LH/FSH >> blocks conversion
of androgens to estradiol >> blocks negative
feedback of androgens on LH release from
hypothalamus >> vicious cycle. Also, the
^LH/FSH >> v insulin response.
Labs: Pregnancy test. DHEA, total and free T,
androstenedione, prolactin, tsh, fbs, lipids, LH,
FSH. HS salivary cortisol to r/o Cushings.
Treatment:
No pregnancy desired
*Improving menstrual regularity and reducing
androgenicity: Loestrin (estradiol 30
mcg/norethindrone acetate 1.5 mg)
*Spironolactone 50 – 200 mg/day
(contraceptive required because of feminization
of male babies.)
Anti-androgen: *Eflornithine topical BID.
Induction of ovulation:
Clomiphene (Clomid) 50 mg/day x 5 days. May
repeat after 30 days.
Metformin: May improve response to
Clomiphene. May promote weight loss and
menstrual regularity.
Psoriasis: DDx: Eczema, lichen planus
simplex, tinea, seborrheic dermatitis, mycosis
fungoides. Oncholysis from psoriasis vs
onychomycosis.
Treatment: Relative absorption: Genitalia 42.
Mandible 13. Forehead 6. Scalp 4. Forearm 1. Palm 0.8.
Sole 0.14.
Potency: Ointments (80% oil; occlusive, best total
absorption) > Creams (50% oil) > Lotion. (OCL)
I. Clobetasol 0.05%. III Betamethasone 0.05%.
V. Triamcinolone 0.1%. VI. Triamcinolone 0.025%. VII.
1% hydrocortisone (OK for eyelids & groin).
Pituitary-Adrenal Axis suppression occurs in 3 weeks
with high potency and/or high absorption.
Vitamin D analog=calcipotriol or triene (Dovonex)
0.005%, 60 or 120 gm (cream or ointment).
Retinoid=tazarotene 0.1% cream or gel. No more than
6
20% of BSA. 30 or 60 gm. Pregnancy test.
Tacrolimus ointment 0.1% (Protopic).
Pneumonia CURB65: confusion, urea >20 mg/dL. RR
>30, BP <90/60, age>65.
Rx: No comorbities or prior antibiotics: azithro 500 x1,
then 250/day x 5 days. or doxy 100 bid. For other
categories, you can use a respiratory quinolone.
Levofloxin (Levoquin 500/d) or moxifloxacin (Avelox
400/d)
Dysprareunia or Vaginal dryness: Vaginal
tablets or rings (Estring 2 mg per 90 days,
monitor endometrial ca) have no systemic
effects, unlike vaginal estrogen creams.
Mild cognitive impairment: MMSE scoere = 2425.
Ottawa ankle rules for imaging: 1) inability to
bear weight or 2) tenderness on medial or lateral
malleolus.
Ottawa foot rules for imaging: tenderness at
base of 5th metatarsal or Navicular bone.
Ilio-tibial band syndrome has worse pain
walking up or down steps.
Morton’s neuroma occurs between 3rd & 4th
toes.
Somatization disorder: 1) 2 GI sx’s, 2) 4 pain
sx’s, 3) pseudoneurologic sx’s, 4) sexual sx’s.
Ulner nerve entrapment: Elbow pain with
flexion of the arm.
Estrogen use in a smoker causes DVT or PE.
Use progresterone contraceptive.
IUDs have the lowest failure rate and cost.
HPV DNA testing for cervical ca is not
recommendced.
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Odds of disease = OR/(1-OR)
Positive Likelihood ratio, test +ve =
Sens/(1-Spec).
Negative likelihood ratio: test –ve: 1-Sens/Spec
For post test odds of disease:
Test +ve: (OR/(1-OR)) * (Sens/(1-Spec))
For post test odds of disease:
Test –ve: (OR/(1-OR)) * ((1-Sens)/Spec).
For disease probability: OR/(1+OR).
Live attenuated vaccines are Varicella Zoster
(chckn pox), Herpes Zoster (shingles), MMR.
All glaucoma meds can cause systemic effects,
including syncope (e.g., timolol).
Shoulder exam:
AC impingement: Neer Test (pronate arm in
front of body and raise overhead.
Supraspinatus impingement: Hawkins test:
elbow forward at 90 degrees with forearm at 90
degrees and internally rotate. Empty can test.
Infraspinatus: elbow at side bent at 90 degrees
and rotate externally against resistance.
Subscapularis: hand over back at about T8 and
attempt to “lift off” against examiner.
Meds causing weight gain: seizure meds:
valproate, carbamazepine. Anti-psychotics:
quetipiane, clozapine, risperidone. SSRIs:
paroxetine. TCAs, antidiabetics, and steroids.
Depression: PHQ9: up to 27. Score of 10+ =
depression.
Afib or DVT prophylaxis (not for heart valves):
Xa inhibitors: apixaban (Eliquis) BID;
rivaroxaban (Xarelto; once/day). Thrombin
inhibitor: dabigatran (Pradaxa).
7
PAIN: hand, wrist, HA, IBS, chronic pain, fibromyalgia, back pain.
Hand & wrist pain
Entity
Symptoms
Sign
RX
1st carpo-metacarpal degenerative
arthritis (pain at base of thumb)
women 30 to 60 y.o.
Crepitus. Watsons test: rest hand palm up
fingers & thumb extended; downward pressure
causes pain
Splinting& NSAIDS,
possibly inject steroids
DeQuervains tenosynovitis: radial
styloid proximal to anatomic snuff box.
Post pregnancy,
repetitive hand work
Grasp thumb under fingers and passively deviate
the wrist to ulnar side>> pain over radial styloid.
Splinting & NSAIDS.
Steroid injections.
Carpal tunnel (JAMA 2000;283:310.)
Best signs: Katz Hand diagram(1),
thenar abduction, hypoalgesia.(2)
Tingling or pain of
palmar digits 1-4,
thenar eminence,
dorsal finger tips1-4.
Phalens:One minute of wrist flexion.
S&S:68&73
Carpal pressure x 30 secs: S&S:64&83%.
Tinnel: S&S 50 & 77%.
Square wrist sign and closed fist sign.
Nerve conduction studies are used to confirm.
Splinting & NSAIDs.
Steroid injections.
Steroid PO.(1)
If no effect, then refer to
surgeon.
(1) Katz classic: 2 of digits 1, 2 & 3 but no palmar or dorsal sxs. Probable: Palm symptoms allowed unless confined to
ulnar aspect. (2) Co-morbidities: Fracture 13%, RA etc 6.5%, Menopause 6.4%, DM 6.1%, OA 5.3%, hypothyroid 1.4%.
Other: amyloid, acromegaly.
HEADACHE
DANGER SIGNS FOR HEADACHE (MKSAP 13
1. Migraine. Without aura: 5 attacks: 1) 4-72 hours. 2)
and JAMA 2006;296;1274).
2+ of mod-severe/ unilateral/throbbing/decreased
Abrupt onset, Thunder clap HA.
activity. 3) 1+ of N&V/ phono and photophobia.
Worse with valsalva, cough, or exertion.
With Aura: Two Attacks: 1 ) 1+ of all reversible:
Wakes at night.
sensory/ visual/ speech/brainstem, motor, retinal. 2)
New, worsening, or sudden onset headache
2+ of unilateral sensory or visual/onset>5min/duration
New headache in elderly on or patient on anti-coagulant
5-60min/HA within 60 min/ No other disorder. Image
or anti-platelet medication, such as aspirin,
only if abnormal neuro exam. Triggers are chocolate,
dipyridamole, clopidogrel, or NSAID.
caffeine withdrawal, red wine, cheese, MSG and fatty
Systemic symptoms.
foods. Image only if abnl neuro.ASA &
Neurologic symptoms.
metoclopramide
TA tenderness or jaw claudication
Migraine Prophylaxis: Metoprolol 50-100 BID,
Infection, HIV, rash, pregnancy, head trauma.
Atenolol 100/d ©, amitriptyline 20-50 HS ©,
Hearing Loss, sensori-neural type:(NEJM 2008):
topiramate 25/day then increase by 25-50 mg q week to
Ddx: Ear impaction or URI. Testing: Weber 512Hz or
100 BID (D)
Humming. Telphone, Tinne test, hair crackling. Causes:
1. Idiopathic (majority); 2. Tumor, CVA, MS. 3. Less
2. Cluster: Autonomics including Horners: Rx:
common: Menieres, autoimmune, trauma, Lyme dis,
Acute: O2 inhalation 7L/min. Subcu sumatriptain.
Prophylaxis: Verapamil, lithium, prednisone PO,
peri-lymphatic fistula. Rx (must start in 2 wks):
valproate.
Prednisone 60 x 4ds; taper over 12 days (10mg/2 days).
3. Hemicrania: Autonomics. Rx = Indomethacin.
H Pylori Rx for 2 weeks: prevpac 1bidx14 ds
4. Tension
Total $36:
5. Trigeminal neuralgia
Amoxicilin 500 mg 2 TT BID (2 gm BID) ($8)
6. Medication overuse: >15ds/mo x 3mos.
Metronidazole 500 mg 1T BID (1 gm BID) ($8)
DONT MISS DIAGNOSES: CO poisoning.
Prilosec 20 mg 1T BID ($20)
Vascular: TA (S&S 91+ when there are 3 of these 5:
HYPERTENSION
age50+, localized new HA, TA tenderness, jaw
Overall, beta blockers are less effective than
claudication or ^ESR>50 (99% sensitive). The gold
other BP meds for preventing CVA (Lancet
standard is biopsy. One can see fever, malaise,
2005;366:1545).
peripheral synovitis, hematuria(1/3), bruits of axilla,
brachial, carotid arteries), SAH, Subdural hematoma,
<120/75 if proteinuria
CVA (intra-parenchymal hemorrhage or ischemia),
IBS: Criteria: 1) The pain is for at least 3 days/month
carotid artery dissection, vasculitis, aneurysm,
with onset of any symptom for at least 6 months. 2) Pain
AVM.
is associated with a) a decrease in pain with defecation,
Mass lesions: tumor, normo pressure hydro-cephalus,
b) a change in stool frequency, and/or c) a change in
idiopathic intracranial hypertension (pseudo-tumor
stool appearance. With 2 of 3 of these the +PV=98%.
cerebri)(HA increased with cough or lying down, visual
th
RX: v caffeine.Diarrhea predominant: ?
chngs, tinnitus, 6 n palsy, papilledema).
Lactose intolerance.
Infections: Encephalitis, Meningitis
1) Trial of Lactose free diet. D/C caffeine
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8
2) Rifaximin 200 TID x 3 ds
3)BRAT diet:Banana, Rice, Applesauce, Toast
4) Loperamide (Immodium) 2 mg after each
unformed stool to a max of 8x daily, PRN
5) Amitriptyline 10, 25, 50, or 100 HS.
6) Dicyclomine 20-40 mg QID (anticholinergic, dizziness in 40%)
6) Alosteron (risk for ischemic colitis: 1/700)
(5) Clonidine 0.1 mg bid improves diarrhea
predominant (Camilleri, 2003).
Constipation predominant: (JAMA
2006;295:925.)
See “constipation” above. Hydration.
Exercise.
Docusate sodium (Colace) is contraindicated
in CHF 50 mg tabs, 1 to 4 times/day.
>Do NOT use Senna (May cause melanosis
coli and changes in GI motility.)
>Hyoscyamine or Tegaserod (Zelnorm)
(Tegaserod is evidenced based).
Pain predominant: Use tricyclics.
Motion sickness: diphenydramine; meclizine
(antivert) 25-50 mg 1 hr prior. Warnings:
drowsiness; BPH; glaucoma; pud; elderly.
Menopause: HOT FLASHES: Gabapentin
100, 300 tabs, 300-600 TID; as good or better
than Paroxetine 12.5mg or 25mg (JAMA
2006;395:2063).
Vaginal dryness: Vaginal moisturizers (e.g..,
Me Again or Replens Q 2 to 3 days (not just
before intercourse. Premarin (estrogen) cream
(but not in breast cancer) 0.5gm conjugated
estrogen daily x 3 weeks then 2x/wk (no
increase in serum estrone or estradiol).
Vaginal progesterone Prochieve 4% 45 mg.
KY long lasting
Astroglide is used just before intercourse.
Osteoporosis: Dexa scan for women age 65+ or hi risk
women age 60+, men age 70+. For FRAX risk of >20%
or hip fx risk >3%, treat.
RX: (NEJM 2005;353:595).
*Calcium Carbonate (TUMS) 2 tabs tid=1200 mg
elemental Ca / day plus Cholecalciferol 1,000 IU/day.
If on a PPI, give calcium citrate or Citracal Maximum
Caplet has 315 mg Ca + 250 IU Vit D. Take 4/day.
For supplement, give 600 mg of vitamin D under age 71,
and 800 mg for age 71+.
Osteoporosis
*Alendronate (Fosomax) 35 to 70 mg/week )(35 mg
tabs) or 5 to 10 mg/day (5mg tabs) OR
*Risedronate (Actonel) 30 mg/week (30 mg tabs) or 5
mg/day (5 mg tabs). Give for 5 years then 1 year off.
Zoledronic acid 5 mg iv/year
Contraindicated for Cr Clearance <35. Take  hour
before eating; remain upright for  hour.
Calcium will block absorption of fquinolones and T4.
Vitamin D deficiency: 50,000 units (Decara—1
capsule)/week x 8 weeks, then 1,000 units/day.
Lowers risk for falls!!
ONYCHOMYCOSIS: Terbinafine HCL (not Lamisil
as this is very expensive): 250 mg/d x 6 weeks for
fingernals and 12 weeks for toenails.. Itraconazole and
fluconazole are very expensive.
PAIN: Screen for h/o personal or family history of
substance abuse, major psychopathology,
MEDICATIONS:
TRAMADOL LOWERS THE SEIZURE
THRESHHOLD AND INTERACTS WITH SSRIs
and Amitriptyline.
*Do not use indomethacin or piroxicam in the elderly.
Rather use ibuprofen, 200 mg tabs, 1-2 tabs Q4hr prn.
*Do not use meperidine (cumulates and causes seizures
or delirum.)
*Reduce dosage in elderly, renal disease, hepatic
disease.
*Constipation is a nearly universal side effect of opioids.
Fecal impaction may present with diarrhea, urinary
retention or delirium.
Neuropathic pain: gabapentin (300 QD x1, BID x 1,
TID; can increase to 1200 TID. Dosage forms: 300, 600
mg. On cessation, this has to be tapered over 1 week),
carbamazepine, phenytoin, or tricyclics. NSAIDs: All
are $ unless otherwise specified.
Proprionic acids IF ONE CLASS DOESNT WORK,
TRY ANOTHER CLASS.
Ibuprofen(Advil, Motrin): OTC(200mgtabs):200-800mg
QID (max/day=3200mg). Scrip:300,400,600,800
Naproxen (Aleve): 500 BID. OTC: 200 mg tabs, Q 6 hrs.
Acetic acids:
Indomethacin 25 or 50mg TID or QID. (Avoid in
elderly)
Etodolac (Lodyne) 400 mg TID OR Nabumetone
(Relafen) 500mg-2000mgQD $$$ SAFER NSAIDs
Ketorolac (Toradol) must be given for 5 days
maximum.
Piroxicam 20 mg QD to 20mg BID. (Not in
elderly>>^GI bleed.)
Urine tox screen does not detect methadone.
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9
Begin the new opioid at 2/3 the equianalgesic dose
Oral rescue doses are 10% of the total daily opioid dose
Lower the starting opioid dose by 25-50% in elderly
Daily bowel regimen with stimulant laxatives
Fentanyl is not recommended for opioid naive patients.
12 hr delay in onset; 14 - 24 hr residual effect once
removed.
MSIR (15,30mg): 10-30 mg Q4H.
MS CONTIN(15,30,60,100,200mg): 30mg Q12Hr or
Q8Hr.
Hydromorphone (Dilaudid) 7.5 mg Q 4 hr.
Oxycodone (Percodan) 30mg Q6hr
Propoxyphene (Darvon) 200mg Q4hr
Methadone 20 mg Q 6 hr :avoid in 1st degree AV blck
Fentanyl patch: 50 mcg/hour: 1 patch Q72 hours.
These interact with CYP3A4 metabolized meds such as
azoles and diltiazem.
Fibromyalgia:
*Do not use NSAIDs no better than placebo in RCTs.
*Exercise training. Acetaminophen. SSRIs.
*1) Amytriptyline (50, 100 HS tabs=25,50,75,100),
Cyclobenzaprine (5 or 10 mg tab tid). In patients with
intense fatigue, use duloxetine (Cymbalta) 30 or 60 tabs
QAM. For insomnia, use pregabalin (Lyrica) 50 or 100
mg tab HS.
*Combo of fluoxetine in AM and amytriptyline in
evening is more effecting than either alone.
*-BACK PAIN: (JAMA 1992;268:760.)
Broad differential diagnosis: 1) mechanical low back
pain: spasm, disc herniation, spinal stenosis,
degenerative disk disease, spondolysthesis. 2) Nonmechanical spinal conditions: Neoplasia, infection. 3)
Non-spinal (visceral disease): renal, aneurysm, GI,
shingles.
Sciatica=pain in dermatome, especially below the knee.
95% of herniations are L4-5 or L5-S1 (L5-Big & S1Little toe, respectively). S&S of sciatica for herniation
is 95% and 88%.
X strt leg: 95% spec for herniation.
Pain on sitting=disc disease;
Pain on bending forward=compression fracture.
Spinal stenosis: increase with standing or pain leaning
backward.
*Back pain only (no sciatica) + age < 50 w/o
systemic illness>>conservative Rx>>not
improved>>w/u.
Cauda equina syndrome includes:
Incontinence of bladder and/or bowel.
Dysfunction of bladder and bowel.. e.g., dysuria or
straining at urination
Saddle anesthesia
Loss of rectal sphincter tone
Loss of anal wink: Scratch the anal skin causes
reflexive closure of the anus.
Loss of bulbo cavernosus reflex: squeezing the penis or
clitoris causes anal wink
Increased post void residual
*Back pain AND [age 50+ or sytemic sxs or
IVDU] >> ESR. If 2+ risk factors or ^ESR>>x-ray.
*Sciatica w/o cauda equina sxs >> Conservative
RX for 4 weeks. If worse or no change>>MRI or CT.
*Bilateral sciatica or cauda equina syndrome urgent
MRI.
*Low back pain that is better on sitting and is
tolerable w/o neurologic sxs >> Conservative Rx.
*Low back pain that is worse on sitting, intolerable,
or has neurologic sxs >> MRI.
*Spinal stenosis Dx: pain radiating below buttock
(fairly sensitive), decreased pain with sitting (fairly
sensitive), increased pain with lumbar extension (fairly
specific), positive Rhomberg (poor sensitivity, but high
specificity). Rx: NSAIDs, PT to reduce lordosis, back
care pamphlet, walk to the point of pain, aquatherapy.
Imaging is CT. If this confirms the diagnosis, then refer
for laminectomy.
Pain Med: For back pain with or without sciatica,
NSAIDs should be minimized and Tylenol used where
possible. No NSAID is more effective than another.
(NSAIDs are statistically but not clinically more
effective than acetominophen
Red flags:
On history:
Pain onset age <20 or >50.
Pain unrelieved after 6 weeks.
Night time pain (unrelenting), Trauma
Neurologic signs
Cauda equina syndrome
Constitutional symptoms: Weight loss, anorexia, marked
fatigue.
History of cancer
Recent infection.
Immunosuppressed state
IVDA Hx
On physical exam:
Pacing and restless
Fever
Point tenderness
Neurologic deficit
Cauda equina syndrome
Positive straight leg raise
Severe intractable pain
Progressive neurologic deficit
Cauda equine syndrome
Indications for surgery:
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10
Waddell's signs include:
Over reaction to stimuli.
Superficial diffuse tenderness.
Axial loading leads to pain.
Rotating the trunk at the hips leads to pain.
Straight leg raise on sitting is negative but positive on
lying.
Pain not corresponding to nerve distribution.
Intra-nasal calcitonin relieves compression fracture (?)
PMMA injection for compression fracture.
Pelvic pain diagnoses:
*Ruptured corpus luteum occurs before menses and has
red fluid on culdocentesis.
*Ruptured ectopic pregnancy would have an elevated
or marginally elevated beta HCG and positive
ultrasound. This can exist even with apparent
menstruation and positive stool for guiac (see Q 130,
MKSAP 12).
*Ruptured endometrioma has history of chronic
dysmenorrhea, negative pregnancy test, and chocolate
brown fluid on culdocentesis.
*Ruptured graafian follicle is very rare.
*PID with Fitz-Hugh-Curtis has RUQ tenderness and
fever.
OPIOD USE: Criteria are 1) specific diagnosis. 2) No
H/O drug or alcohol abuse. 3)Negative urine tox
screen. 4) Disabling pain. 5) Good adherence history.
6) Medical failure of other medicine.
Mastalgia: Danazol 100 BID x 4-6mos. (dvt risk)
Fluid retention & bloating: spironolactone 100/d.
Overall sxs: fluoxetine: 20-60/d.
Dysmenohrrnea: B1 (thiamine) has RCT evidence.
Heat to lower extremities. NSAIDs (naproxen (Aleve)
500 BID). OCPs, Depomedroxyprogesterone acetate
(DMPA) causes hypo or a-menorrhea in 50%. (Mg,
B6, Vit E and N3 FAs may work but RCTs are
lacking.)
Other causes of secondary dysmenorrhea are PID, IUD,
uterine leiomyoma, and endometrial polyps.
PREOP EVAL:
FOR APPARENTLY HEALTHY PERSON: ASK
THESE QUESTIONS: Are you over 60? How many
stairs DOE? How do you feel? Any serious illness? Do
you get more SOB than others your age? Any coughing
or wheezing? Any exertional CP? Have you taken any
medicines, pills, herbs, or excess Etoh in last 3 months?
Any allergies? Prior ab-reaction to anesthesia in you or
in relatives? Any anesthesia looking risk? Last LMP?
Get vital signs. Is the patient undergoing major surgery?
If any of the above is abnormal, do H&P,
For major surgery, get Hgb. For patient on diuretic or
hypertensive, get lytes+. For age > 50 or for major
surgery, get Creatinine. For age >60 or pulmonary
disease, get CXR. Get EKG for men & women age
>40 & >50 respectively, CAD equivalent, CAD risk
factors, diuretic use, or Major surgery. Pregnancy test.
Cardiac Risk:
Very high risk patient requires delay of surgery and
modification of risk. 4 conditions: 1) Recent MI, UA,
recent PCI. 2) Serious arrythmias, 3) Decompensated
CHF 4) Severe valvular heart disease.
SURGICAL RISK:
High: Major vascular surgery (aorta, PVD, valvular) or
prolonged surgery with large fluid or blood shifts or loss/
Intermediate: CEA, ENT, intra-peritoneal or thoracic,
orthopedic, or prostate./
Low: endoscopic, superficial, cataract, breast surgery.
PATIENT RISK:
The following are considered minor predictors when
occurring alone: age, low functional status, irregular
rhythm, stroke history, and uncontrolled hypertension.
By themselves they do not predict operative risk.
Assign Goldman risk factors: Mnemonic device: HI4Cs:
Hi Risk surgery, Insulin for DM, CAD, CHF, CVA
or TIA, Creat>2mg/dL.
Secondary Dysmenorrhea: Endometriosis:
dysmenorrhea, dyspareunia, worsening pain as menses
progresses, abnormal bleeding and infertility. PE: fixed
mobile uterus. Tenderness or nodularity of the
uterosacral ligaments and posterior uterus. Diagnosis:
Transvaginal ultrasound is 100% S&S. Laparascopy to
confirm and evaluate the extent. RX: Induce
amenorrhea. Leuprolide acetate, OCPs or DMPA can
reduce symptoms if symptoms recur after treatement.
These go straight to OR:
*Low risk surgery/ *4+ mets without symptoms/
*Goldman 0 + intermediate risk surgery (regardless of
METs)/ * Goldman 1or2 + 4+ mets (regardless of
surgery risk)/ *Goldman 3+ and Negative Stress Test
in Last 2 years
These go for stress testing:
>(Any Goldman) High risk surgery + <4 mets.
>(Goldman 1 or 2) + (High Risk Surgery OR <4 mets
OR CAD)
>Goldman 3+
If +ve, do cath:< 2vessel dis gets PCA; 3 vessel disease
or Left Main CA gets CABAG.
Give perioperative beta blocker if 2+ F-E factor.
Do U/A to r/o bacteruria because of foley (possible
urosepsis).
Pulmonary risk: 1 score for each of the following:
BMI>27, smoking, wheezes or rhonchi, cough within 5
ds of surgery, FEV1/FVC<70%, PaCO2>45. Scale 1
thru 6.
Qaseem A et al (Ann Int Med 2006;144:575) state that
the risk is increased with COPD, CHF, ASA class 2+
(mild systemic disease=2), age 60+, functional
dependency, and serum albumin < 3.5. Obesity, asthma,
and OSA are not risk factors. For proven effective
pulmonary interventions, lung expansion maneuvers
(deep breathing exercises), chest PT, incentive
spirometry or PEEP. Using 2 or more is no more
effective than one alone (Smetana GW. JAMA
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2007;297:2121.)
SEIZURES & DRIVING: No driving for 1 year since
last seizure.
Szr: increased w/ tramadol, buproprion & TCAs.
RETINAL DETACHMENT: Refer in 24 hrs:
Flashing lights, floaters, side visual loss, central visual
loss
SKIN
Seborrheic dermatitis: Ketoconazole shampoo 2% BID
for 1 month.
Pruritis: Causes of:
1) PRIMARY SKIN DISORDERS:
No etiology:
Bullous pemphigoid
Xerosis
Psoriasis
Urticaria: Evanescent rash arms & trunk.
Pityriasis Rosea (Herald Patch)
Contact dermatitis (hydroxyzine 25-100QID or
doxepin
Atopic dermatitis (eczema)
Lichen simplex chronicus (paroxysms of pruritis on
lateral arm & calf, posterior neck.)
Lichen planus (flat tyopped, shiny, violaceous
polygonal pruritic papules 1-15 cm in diameter on
ankles, wrists, and trunk)
2) Corynebacterium:
Erythrasma brown scaly patches sharply demarcated.
Rx=topical fusidic acid & PO erythromycin 250 QID.
3) Infestations:
Scabies
Tinea Corporis, Tinea Cruris, Tinea pedis, or Tinea
Capitis: Fungal  dermatophytes.
Body Lice: Pediculosis corporis and pediculosis pubis.
Permethrin cream 5%: For scabies: apply head to toe,
leave on for 10 hours, wash off. Repeat in 1 week.
Pediculosis capitus:Permethrin lotion 1% leave on 10
minutes.
Pediculosis coporis: Permethrin cream 5% leave on 10
minutes.
For bedding and furniture, there is an OTC spray (A200
Lice, 0.5%).
4) Systemic:
HIV
Iron Deficiency anemia.
Celiac disease, SLE, Cholestasis, primary biliary
cirrhosis, hepatitis C/
Renal failure (85%)/ Hyperthyroidism or
hypothyroidism/ DM  xerosis/
PCV (50%), HD (30%), T cell lymphoma Sezarys:
100%/ HIV: eosinophilic folliculitis/ Stasis dermatitis.
Tumor: Hodkgin’s dis, myocosis fungoides, PV.
3) Rx: tacrolimus, gabapentin up to 1200 mg TID,
pregabalin 200 mg BID, amitriptyline 25-150 HS,
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naltrexone 12.5-50 mg daily, capsaicin
SKIN STEROIDS:
Ointment>cream>lotion>gel>solution>shampoo.
Relative absorption: Genitalia 42. Mandible 13.
Forehead 6. Scalp 4. Forearm 1. Palm 0.8. Sole 0.14.
Potency: Ointments > Creams > Lotion.
I. Clobetasol ointment 0.05% . III Betamethasone
valerate ointment or cream 0.1% . V. Triamcinolone
0.1%. VI. Triamcinolone 0.025%. VII. 1%
hydrocortisone (OK for eyelids & groin).
Pituitary-Adrenal Axis suppression occurs in 3 weeks
with high potency and/or high absorption.
DVT AND PE
acp guidelines (Qaseem A et al. Ann Int Med
2007;146:454)
1. Use prediction rules
2. For low pretest probability of DVT or PE obtain high
sensitivity D dimer. A negative tests, rules out DVT and
PE
3. US is used for medium to high pretest probability
Wells prediction rule for DVT:
Each gets one point:
Cancer/ Immobilization/ Bedridden for 3+ days or major
surgery within 3 months/ Localized tenderness of deep
vein/ Swollen leg/ Calf 3 cm > calf of opposite leg 10
cm below tibial tuberosity/ Pitting edema in
symptomatic leg/
Negative 2 points for Alternative diagnosis at least as
likely as PE.
Low is <0/Intermediate is 1 - 2/Hi 3+
Wells prediction rule for PE:
Evidence of DVT = 3
Alternative diagnosis less likely than PE = 3
HIP: 1.5 each for Heart rate>100/ immmobilization/
prior DVT or PE
HM:1.0 each for Hemoptysis/ malignancy.
Low 0-1/Intermediate 2-6/Hi 7+
Hepatitis C screening: born between 1945-1965.
Rosacea: DDx: SLE, seborrheic dermatitis, periorbital
dermatitis, demodex infestation (a mite). Rx: topical
metronidazole 0.75% BID, or oral doxy 100 bid
Fatigue: Meds, Heart (chf), lung (OSA, COPD), liver &
renal disease, anemia, hypothyroidism, infections (SBE,
HIV).
Pericarditis criteria: 1) chest pain, 2) rub, 3) ECG
changes, 4) effusion on imaging.
Rx: colchicine + (ASA 800 or ibuprofen). Prednisone
blunts the response to NSAIDs
12
STDS
Disease
Hallmark
Rx
HIV
Flu syndrome, no cough, oral ulcers, rash (70%), spleen (30%). ELISA > 95% S&S.
Confirm with Western Blot. If indeterminate obtain viral load. NA copies >2,000 to 10,000/ml
likely not false positive.
Gonorrhea
&Chlamydia
Urethritis, arthritis, skin pustules. PCR on urine.
(Ceftriaxone 125 IM or Cefexime 400 PO x1) + (Azithro
1gm PO x 1 or doxy 100 BIDx 7ds)**
Syphilis
Solitary painless ulcer. Inguinal nodes. VDRL; FTA-Abs
2.4 M U Benzathine PEN. Doxy 100 BID x 2 wks.
Chancroid
Painful multiple ulcers PCR on urine.
Cipro 500 BID x 3ds. Azithro 1gm PO x 1 or
Ceftriaxone 250 x1.
HSV
Painful multiple vesicles. Fever. Incub 2 - 7 ds. Reactive lymph nodes common. PCR.
Acyclovir 200 mg Q4HRS x 10 Ds. Valacyclovir 1gm
BID x 10 ds.
Warts
Send for HPV typing & Cervical ca screen
Podofilex BID x 3days for up to 4 weeks.
*Remember Hep C and Hep B co-infect with HIV. HPV warts: Podofilex BID x 3ds for up to 4 wks. **In PEN allegic: 2gm azithromycin x 1 treats both.
Rx for PID: Levofloxacin 500 QD + Metronidazole 500 BID x 14 days.. Or: ceftriaxone 250 IM x 1 + doxy 100 BID x 14days. This reflects GC & Chlamydia STD:
ceftriaxone 125 and doxy 100 BID x 7days.
Chlamydophila
Chancroid
Calymatobacter (Donovanosis)
Lymphogranuloma venerium (LGV)
Haemophylus ducrei
Granuloma inguinale
Screen asymptomatic women for GC, chlamydia, HIV, hep B when there are risk factors, namely: young age, unmarried, urban resident, a new sex partner, multiple sex partners.
SYNCOPE:
1. METABOLIC: Hypoglycemia Hyperthyroidism
2. NEUROGENIC Migraine / Seizure
3. NEURALLY MEDIATED: Vasovagal/ neurogenic orthostatic hypotension/ Situational/ Carotid sinus/
4. CARDIAC: Obstruction to flow/ Pump Failure (MI) / Arrhythmias.
5. VASCULAR: TIA, Subclavian steal; vertobrobasilar insufficiency.
6. Medications
Neurogenic orthostatic hypotension (Freeman R. NEJM 2008;358:625). Normally, a fall in aortic pressure is sensed by the baroreceptors of the carotid
sinus and aortic arch which reduces vagal charge to the sinus node, stimulate sympathetic responses of the peripheral blood vessels and release of vasopressin from the pituitary.
Causes: Primary autonomic disorders: multisystem atrophy (Shy-Drager: Parkinsonism, cerebellar dysfunction); putaminal atrophy on MRI),
Parkinsons disease, Lewy Body dementia; pure autonomic failure.
Peripheral autonomic disorders: diabetes; amyloidosis, immune mediated; Sjogrens, paraneoplastic)
Treatment:
Non-pharmacologic: Gradual postural change; leg crossing, head of bed at 12-20 degrees; minimize anti-hypertensives (trade off); increased fluid and salt intake. Pharmacologic: fludrocortiso
0.05-0.3 mg; midodrine 2.5 - 10 mg 2- 4x/day; pseudo-ephedrine 30-60mg tid.
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13
ULCERS:
Arterial ulcer: Painful with claudication, distal to angle, absent pulses, dependent rubor, necrotic base, no granulation; d/c/ smoking, exercise, avoid elevation,
revascularize.
Diabetic ulcer: Painless, pressure spots, within callus, punched out. Avoid elevation and avoid compression. Debride necrotic tissue, reduce edema; dry nonocclusive dressing, Custom shoes. Inspect feet daily, dilantin (?)
Venous ulcer: Painful. Maleoli, distal leg, dorsal foot, leg edema, weeping brawny; present pulses. Rx: Gell occlusive dressings and elevation, compression
stockings..
VAGINITIS
CONDITION
Clinical
Rx
Yeast
Pruritis, burning, Cheesy. Hyphae on KOH prep
Fluconazol (Diflucan) 150mg x 1 **
Bacteria
Painless, Yellow, frothy. Pos. Whiff test with KOH prep.
Wet prep: clue cells
Metronidazole gel 0.75% intravag x 5days
Metronidazole 500 mg BID x 7days.
Trichomonas
Burning, pruritis, grey d/c, dysprareunia., motile orgms on
wet prep.
Metronidazole 2 gm x 1.
**Contraindicated in pregnancy.
In pregnancy or suspect pregnancy, a UTI is treated with amoxicillin or ampicillin.
WEIGHT LOSS: Goal: 5% reduction (will v risk for Ht dis & DM).
Those with HTN, CV dis, hyperlipidemia, SSRIs, MAOs, erythromycin, or azoles:
For those without these: Sibutramine (Meridia): Blocks norepidnephrine and serotonin reuptake. 15 mg/ day: 10 QAM x 1 mo to 15 QAM. $120/month.
Orlistsat (Xenical) 120 mg tid. Alli (OTC) 60 mg (2 Tabs TID). Pregnancy X. Blocks lipase. Causes ADEK deficiency and prolongs the INR. Fecal incontinence.
Phentermine-topiramate (Qsymia) 3.75/23 to 15/92 Daily. Pregnancy X. Contraindications/ AEs: Suicidality, CVD, ^ P, v Cognition, sedation, renal stones, ^ Creatiniine.
Qsymia (phentermine topiramate)
Women of child bearing age: avoid statins, ACEIs, ARBs, orlistat (Xenical or Alli), phentermine topiramate (Qsymia).
Generalized Anxiety disorder criteria: 1) excessive anxiety most days for 6+ months, 2) can’t control worrying, 3) associated with 3 or more of the following: a) irritability, b) fatigue, c)
restlessness, d) difficulty concentrating, e) sleep disturbance, f) muscle tension; 4) Impaired functioning, 5) Organic causes are ruled out. 6) rule out other
anxiety disorders (phobias, ptsd, ocd, psychosis, adjustment disorder).
Rheumatoid arthritis, new criteria, requires a score of 6+: (1) joint involvement: 0-1 large joints=0/ 2-10 medium & large joints=1/ 1-3 small joints=2/ 4-10 small joints=3/ >10 joints=5/
(2) serology RF or anti-citrulanated peptide antibody: a) low titer = 2 points/ high titer = 3 points. (3) acute phase reactants (ESR or CRP) elevated = 1
point (5) . (4) 6+ weeks of these symptoms.
Old criteria are 4 or more of the following: 1) 3+ joints, 2) bilateral involvement, 3) RA distribution (MP and PIP joints, wrists), 4) morning stiffness, 5) rheumatoid nodules, 6) RF +ve,
7) erosive changes on hand films.
Avoid abrupt withdrawal of TCAs, BBs, clonidine.
Avoid in women of child bearing age: ACEIs, ARBs, Statins…
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14
Ddx of asthma: GERD, bronchiectasis, CF, chronic PE (loud P2), CHF, hypersensitivity pneumonitis.
RX FOR ASTHMA
(No NSAIDs.. blocks dilation.. or beta blockers)
September 23, 2004
Severity
Albuterol
(ventolin)
Low dose inhaled
STEROID
Beta agonist
long acting
Luekotriene receptor
antagonist
Other
Mild intermittent
Sxs < 2 x/wk and <2 x/mo at night.;
FEV1, PEF 80%+; PEF variability20%
Y
no
(1)
no
R/o Stridor (upper respirtory obstruction),
GERD & sinusitis. Avoid NSAIDs and ASA.
Mild Persistent
Sxs 3-6 x/wk but not daily ; Night: 3-4x/mo
FEV1orPEF 80%+; PEF variability20-30%.
Y
Low dose: Fluticasone
(Flovent)
(1)
Alt: Monteleukast
(Singulair)
Ditto
Aternative is cromolyn or sustained release
theophylline
Moderate Persistent
Sxs daily, Night: >4x/mo.
FEV1orPEF 60-80%, PEF variability30%+
Y
Medium dose.
Salmetrol
(Servent
disc)
Alt: Ditto
Ditto
Theophylline.
Severe Persistent, Continual Sxs
Limited physical activity, FEV1 or PEF <60%
Y
High Dose;
+ oral steroid if needed
Ditto
yes
Ditto
Drug
Trade
dose
Advantages
Disadvantages, Side Effects
Albuterol
MDI2-3pgsQ3hr. PO med: XR 8mg BID.
Bronchodilation,
v hyperinflation,
^exercise cap, quality of
life
Tremor, tachycardia, SVT, v K
Metoproteronol
Ventolin,
Proventil
Alupent
Steroid
Fluticasone
Flovent
DPI 1-2 puffs BID. 100, 200 mcg.(powder) (3)
Anti-cholinergic
Tiotropium
Spiriva
One inhalation/day
(similar to salmeterol)
Upper resp infn
leukotriene recept
antagonist,
monteleukast
Singulair
10 mg PO qpm
v airway inflammation,
very safe, use in ASA
sensitivity and for
singers.
Lower potency Weak bronchodilation. Rarely eosinohilic
vasculitis.
Combo
Fluticasone &
Salmetrol
Advair
1 puff DPI BID. Available doses are: 100/50 or 250/50 or
500mcg/50mcg. MDI 2PffsBID.
Combo
Albuterol &
ipratropium
Combi-vent
Duoneb
(nebulized)
1 puff Q4Hr
Combo is synergistic
contraind with soy & peanut allergy
Epinephrine
release
Theophylline
Theo24
10mg/kg/day. 300 or 400xmg tabs. QD
Beta Agonist
.
Insomnia, anxiety, ^ pulse, seizures
(1) For asthma, never give a long acting beta agonist alone, but always with fluticasone (NEJM2009;360:1592). In African Americans, salmeterol by itself may increase mortality.
(2) Beclomethasone & albuterol PRN are better than regular beclomethasone & albuterol (Papi Q. NEJM 2007;356:2040). Patients controlled using BID fluticasone can be switched
to once daily fluticasone plus salmeterol (Am. Lung Association. NEJM 2007;356:2027).
(3) Powder is preferred over spray because it is used more effectiv
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15
Diagnosis of COPD: FEV1/VC < 0.70 after a bronchodilator.
COPD THERAPY BY STAGE OF SEVERITY
Gold
A
B
C
D
MRC*
0,1
2+
0,1
2+
FEV1
50%+
‘’
<50%
“
Exacerbns/yr hospitalizations RX
0 or 1
Albuterol or ipratropium
‘’
Tiotropium or salmeterol
2+
Or 1+
(Tiotropium or salmeterol) + ICS
“
“
Tiotropium+salmeterol+ICS
Or
Salmeterol+ICS+roflumilast (Daliresp)
*MRC: 1=SOB with strenuous exercise. 2+ is anything above that.
(1)Tiotropium is more effective than salmetrol in preventing exacerbations in moderate to very severe COPD (Vogelmeier. NEJM 2011; 364: 1093.
For oxygen supplementation, the criteria are < 88% O2 saturation or < 55 pO2 mmHg.
Or with evidence of cor pulumonale with erythrocytosis (HCT >55%) or right heart failure elevated pressure at O2 Staturation of 89% or < 59 pO2 mmHg.
Indications for hospitalization in an acute exacerbation of COPD:
Hx: Age
H/O frequent exacerbations
Marked increase in symptoms
PMH:
Severe COPD
PE: New physical signs
Prior intubations
Co-morbidities
New arrhythmias
A: Uncertain diagnosis
Poor home support.
P: Failure to respond to therapy.
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16
RX FOR COPD
Indications for antibiotics: Increased dyspnea, sputum volume, or sputum purulence.
Indications for oral steroids: FEV1 < 50% predicted.
Category
Drug
Trade
dose
Advantages
Disadvantages, side effects
Beta
Agonist
Beta Agonist,
Albuterol
Ventolin,
Proventil
MDI 2puffs Q4-6hr prn
[1 form only:90mcg]
v hyperinflation, improve
exercise, improve QOL.
tremor, tachycardia, SVT, v K.
Steroid
Fluticasone
Flovent
DPI 1-2 puffs BID. 100,250, 500
mcg.(powder) (3)
Beta
agonist
Salmeterol
(a)
Servent Diskus
1 puff BID (use only w/ steroid)
longer acting
Anticholin
ergic(1)
(3)
Ipratropium
Atrovent
2-3 puffs qid
Improve exercise,
decrease mucus. Safe.
contraind with soy & peanut allergy.
Acute narrow angle glaucoma, bladder neck obstruction, BPH,
anaphylaxis, dry cough, paradoxical bronchospasm.
Tiotropium(1)
spiriva
Inhaled QD. Avoid eye contact.
Daily administration.
Selective antagonist(2)
Acute narrow angle glaucoma, bladder neck obstruction, BPH,
anaphylaxis, dry cough, paradoxical bronchospasm.
Albuterol &
ipratropium
Combivent(aeros
ol). Duoneb
1 puff 4 to 12 x/day
3ml Q6Hr
Combo is synergistic
contraind with soy & peanut allergy
Shown to prolong life.
Indications (4)
Combinati
on
O2
Cushings begins at 1,000 mcg/day.
For FEV1<60%, give 1 of : long acting B agonist, steroid, or anti-cholinergic. Give O2 for resting PA02<55..
(a) ADVAIR doses 50/100, 50/250, and 50/500. Given BID.
(1). Tiotropium is better than salmeterol (Vogelmeier C. NEJM 2011;364:1093).. For severe disease with frequent exacerbations, give combo therapy with fluticasone +
salmeterol (NEJM 2007;356:775).
(2) Tiotropium selectively blocks M1 and M3 receptors; M2 blocks M1 and M3 via negative feedback.
(3) Singh S. Inhaled anticholinergics increase risk for CV death, MI or CVA. RR=1.6 (1.2,2.1). Metanalysis of 17 trials & 14,783 patients. JAMA 2008;300:1434.
(4) Indication: p02< 55 or O2%< 88% OR Deoxygenation to < 88% on exercise OR p02 56-60 with RH failure as shown by ^HCT, pedal edema, or EKG.
PROPER SPACER TECHNIQUE
*Remove cap from the MDI & spacer and shake well.
*Insert the MDI into the open end of the spacer (opposite the mouthpiece).
*Place the mouthpiece of the spacer between your teeth and seal your lips around it tightly.
*Breathe out completely.
*Press the canister once.
*Breathe in slowly and completely through your mouth. If you hear a horn-like sound, you are breathing too quickly... slow down.
*Hold your breath for at least 10 seconds to allow the medication to deposit in your lungs.
*Wait at least 1 minute and repeat the above steps. Some MDIs require more than 2 puffs.
*Replace the cap on your MDI when done.
*If you are using a steroid MDI, gargle and rinse your mouth with water or mouthwash after each use.
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17
AGENTS FOR DIABETES type 2.
November 1, 2005
Class, mechanism
Drug
advantages/ 2indications
disadvantages
Dosing
Incretin analogue(3)
Liraglutide (Victoza) (4)
(exenatide[byetta])
V Weight; V HbA1c1%. No dose
n,v,d. Contraindicated in DM1 & cc <30.
0.6mg SC/f x 1 wk; then 1.2 mg, then to1.8 mg
if needed
Sitagliptin (Januvia)
Linagliptin (Tradjenta)
Weight neutral.
For DM2 only d, abd pn, nausea; pregnancyB
25,50, 100. V when ^ creatinine
Binds sulfonuryl receptor,^insulin
repaglinide(Prandin)
vHbA1c1.5%
Wt gain. V platelets, wbcs, diarrhea, URI
0.5 to 2mgPOTID  hr preprand.
Amylin agonist:vglucagon,
gastric emptying, appetite
pramlinitide(Symlin)
Weight loss. v HbA1c 0.6%.
GI side effects. Hypoglycemia. ? lng term safety
60 to 120 mcg s.c. pre-prandial
Thiazolidine-dione
(insulin sensitizer)
pioglitazone(Actos)
Improves lipid profile. No
hypoglycemia.
More wt gain. May ^ CHF & LFTs(stopif2xnl). (Rltve
contraind). 2 to 10 weeks to have an effect.
QD or Divided.Pioglitazone: 15 -45 mg.
15,30,45 mg tabs
alpha glucosidase inhibitor
decrease gluc absorption
Acarbose
(Precose)
weight loss
fecal incontinence; weight may return over time. Abd pain
25, 50, 100 mg TID with meals. Add multivits.
Incretin effect; blocks DPP-IV(4)
Adjustment for ^ creatinine
5 mg /day Excreted in feces.
(3) incretin analogue, GLP1( glucagon like peptide 1), increases insulin secretion, decreases glucagon secretion, increases b-cell growth & replication, slows gastric emptying. Inhibiting the enzyme DPP-IV
(dipeptylpeptidase IV) allows persistence of incretin.(4)
Don’t give in gastroparesis.
GLIMEPERIDE: 1,2, OR 4 MG QAM/ GLIPIZIDE: 2.5, 5, 10, up to 40/day.
Diabetes points:
Start insulin if HgbA1c > 10%+ or FBS = 250+.
Dx: 1) symptoms + random glucose 200+, 2) Fasting glucose 126+, 3) 2 hr GTT 200+, 4) Hgb A1c 6.5%+.
Pre DM: 1) Random glucose 140-199. 2) Fasting glucose 100-125. 3) HgbA1c 5.7-6.4%.
HgbA1c is Increased by increased RBC age (e.g., splenectomy) and by Fe deficience. HgbA1c is decreased by decreased RBC age (hemolysis, dialysis), HIV, & hi dose Vit C & E.
(See Pallais JC. NEJM 2011;364:957).
st
When to screen: 1) Age 45+, or 2) <age 45 & BMI25+ plus [1 deg rel, inactive, high risk ethnicity, gestational DM, infant weighed 9 lb+, HTN, vascular disease, HDL<35, TG 250+.
Repeat at 3 year intervals.
In ACCORD (NEJM 2010), the lower target (<120 vs <140) reduced total CVEs by 12% (P=0.2), and CVA by 41% (11%-61%).
The prior goal of <130/80, stemmed from the HOT trial (Lancet 1998;351:1555), suggesting a beneficial effect for diastolic less than 80.
Avoid beta blockers in DM due to blockade of sympathetic response to hypoglycemia.
Do not prescribe sulfourea’s in those age 70+.
SGLT2 inhibitor, empaglflozin (Jardiance). No hypoglycemia.
Give an ASA in all diabetics.
TREATMENT OF HYPERLIPIDEMIA (Stone NJ. ACC/AHAA Guidelines on treatment of cholesterol….Circulation. November 2013)
Hi intensity statins: 1) ASCVD and age <75; 2) LDL cholesterol 190+; 3) DM (age 40-74) ASCVD risk 7.5%+; 4) None of these but ASCVD risk 7.5%+ (optional)
Moderate intensity statins: 1) ASCVD and age 75+; 2) DM (age 40-74) ASCVD risk < 7.5%
Hi intensity: atorvastatin 80, rosuvastatin 20. Moderate intensity: atorva, rosuva or simvastatin 10 mg
Lipids and LFTs at baseline. After 1 month, repeat Lipids and then annually.
The most common causes of 2ndary hyperlipidemia are: uncontrolled DM, alcohol use, hypothyroidism, and albuminuria.
Non-statin drugs:
1) No role for gemfibrozil unless intolerant to statins, 2) fenofibrate 200/day. 3 ) Lovaza. Add Vitamin E. 4) Niacin (niospan) 500 qhs increase to 2gm/d. Flushing,
hepatotoxicity. 5) Ezetimibe 10/d bloating, cp, ha, diarrhea, abdominal pain, arthralgia.
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18
TARGETS:
Hgb A1 C varies 1% with every 28 – 29 mg/dL of glucose. For example,
Hgb A1 C
Glucose (mean)
Hgb A1c
Glucose (mean)
5
100
10
240
6
125
11
270
7
150
12
300
8
180
(Herman WH. J Diab Sci Technol 2009;3:656).
9
210 BEGIN THE USE OF INSULIN AT HgbA1c > 9%.
Basically, keep the blood sugar between 90 and 180mg/dL USE THE 110/ 170/ 130 RULE(Pass,Tit,Tak,Dam)
90 mg/dl
fasting
110 mg/d (+ 20)
before meals
170 (+10) mg/d
2hr PP;
130(+20) mg/dL at bedtime.
For every pre-meal 50 mg/dL above goal, give an extra unit
INSULIN PREPARATIONS
GENERIC
TRADE
ONSET, hrs
PEAK, hrs
DURATION
Lispro
mn
Aspart
Humalog
0.25
0.5-1.5
6-8
L
NovoLog
0.5
1-3
3-5
A
Regular
Humulin R/ Novolin R
0.5 - 1.0
2-3
4-8
R
NPH (or
protamine)
Humulin N/ Novolin N
1 - 1.5
4 - 12
10 - 18
Insulin Zinc
Lente
1 - 2.5
8 - 12
18 - 24
Extended Zinc
Ultralente
4-8
16 - 18
> 36
Glargine
Lantus
4-6
6 - 24
24
H
N
G
L
NPH/Lispro combinations: Humalog 75/25 or 50/50;
Humalog/Novolog/ ... in/
NPH/Aspart combinations: Novolog 70/30; NPH/Regular combination: Humulin 70/30 or 50/50 or Novolin 70/30
HgbA1c is falsely low in hemolysis & splenomegaly falsely high in iron deficiency and splenectomy.
units of Lispro (Humalog).
DETERMINING DOSAGE:
Healthy person: 24 - 36 U/day; Type I DM: 0.5 - 1u/kg
Total daily dose: Lean: 0.3 - 0.5 u/kg/day/ Obese 0.5
- 1.0/ Stress: 1+
REGIMENS:
1. CONVENTIONAL (Inexpensive) Regimen. (Humalin:
NPH/Reg. Novolin: NPH/Reg.)
*Use short & intermediate (e.g., Aspart and NPH)
*60% of total daily dose is given in morning and 60% of the total is
intermediate. So Give NPH/Regular: AM: 40%/20% and PM:
20%/20%.
*Before breakfast and before supper or Before breakfast and at HS.
E.g.: Weight = 60kg, lean.
0.5 units/kg x 60kg = 30 U. Divide 30 by5= 6.
Give in A.M.: 12 NPH and 6 Regular.
Give in P.M. : 6 NPH and 6 Regular.
2. MULTIPLE DAILY INSULIN REGIMENS (Expensive)
*50% as basal insulin supply.
*50% with meals, giving doses of rapid acting insulin.
*Calculate the usual pre-meal dose by dividing the 50% by 3.
*Then give the patient a sliding scale for pre-meal glucose values:
>If the pre-meal glucose is less than 70, give no rapid
acting insulin.
>If the pre-meal glucose is about 80 mg/dL, give one unit
less than the usual pre-meal dose.
>Otherwise, for every glucose increment of 50mg over a
premeal glucose of 110mg/dL, give an additional unit.
(For very heavy patients... e.g., 200 lb, give an additional
1.4 units per increment of 50 mg/dL.K)
(This is based on 0.015 U/kg with the pre-meal dose.)
E.G.: Wt = 60kg, lean: 0.5u/kg x 60kg = 30 U.
Glargine (Lantus) 15 Units QHS. (Reduces risk of hypoglycemia in
Type II DM compared to NPH.)
Lispro (Humalog), 5 Units with each of 3 meals when the food is in
front of you.
E.G. of mealtime adjustment: Suppose a 60 kg man. You will give
Glargine (Lantus) 15, Lispro (Humalog) at each meal of 5 units, and
an additional unit of Lispro (Humalog) for every 50 mg of glucose
over 120 mg/dL. So for a pre-meal glucose of 150 mg/dL, give 6
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GLUCOSE MONITORING:
OBTAIN A1 C INITIALLY THEN Q 3 MOS
Diet: periodically.
Oral agents: 1-2x/d.
Insulin QD: 1-2x/d.
BID insulin: 2-4 x/day
TID insulin: 3- 6x/day
SCREENING: Begin at age 45 then Q 3 years.
FOR DM -2(Mooradian. AnnIntMed 2006;145:125.:
1. Glargine 10 U HS or morning.
2. Check fasting (goal=90); if not at goal, increase by 2
to 4 units Q 3 days.
3. HbA1c >7% and fasting at goal, check prelunch,
presupper and bed time. Target is 110+ 20 mg/dL.
Add 2 to 4 units Q 3 days as needed. (E.g., if predinner is elevated, then add rapid acting at lunch or
NPH at breakfast).
Counter regulatory hormones to insulin:
Glucagon, cortisol, epinephrine and growth hormone.
In DKA, the ketoacids are acetoacetate and B
hydroxybutyrate. Even though the latter is
6 times more than the former, the former is what is
measured. So, look at anion gap rather than ketones.
19
Pain
OA
Patellar
+
Medial
++++ (bony enlargement &
genu varum1: either is 93%
spec
Tendons
Extensor_tendonitis MCL (most common knee
(or
Pain on resisted
ligament injury), rapid
ligaments) extension
effusion, valgus2 stress
Meniscus
+++++
Pain with varus3 stress or
McMurray
Other
PFPS*:
Pes Anserine Bursitis
^pain with flexion; (Positive valgus stress test)
Paon on descent
Laterally displaced,
Apprehension test
with lateral force,
AP
Sunrise x ray view.
Lateral
+
LCL
(rapid effusion, varus stress)
++ (Locking: Valgus stress
or McMuray)
ITBS (Noble’s test: press on lateral
femoral epicondyle while flexing &
extending the knee)
Prepatellar bursitis
(pain & warmth)
1
2
3
Bow legged.
Force applied to outside of knee.
Force applied to inside of knee.
Aspirin for CVD prevention (USPSTF Ann Int Med 2009;150:396.)
Age
Men
Women
MI prevention
CVA prevention
Minimum 10 year risk minimum10 year risk
45-59 4%+
3%+
60-69 9%+
8%+
70-79 12%+
11%+
Begin screening for lipids at age 40.
Repeat lipid screen in 5 years.
Satin use
Category
Moderate
High intensity
Clinical ASCVD
Age > 75
Age < 75
LDL > 90
Yes
DM (age 40-75)
ASCVD risk < 7.5% ASCVD risk 7.5%+
ASCVD risk 7.5%+ and age 40-75 Yes
Yes
High intensity: rosuvastatin 20 or 40 or atorvastatin 80
Moderate intensity: rosuvastatin 10 or atorvastatin 20 or simvastatin 10 mg
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20
BODY & HAIR PARASITES
Parasite
Appearance
Scabies
Delayed hypersensitivity,
3-4 weeks or
1-2 days. Burrows 2-3
mm
Bedbugs
Most are asymptomatic.
Resolve in 1 week.
Red papules in a linear
pattern
Pediculosis
Regional pruritis, linear
corporis (body
distribution
lice)
Pediculosis pubis Ditto
Pediculosis
capitis (head lice)
Fleas
Body area
Webs, flexor
Diagnosis
Scraping, Wood Lamp
Treatment
Permethrin 5% cream overnight (apply from
neck to toes) or
oral ivermectin, repeat in 1 week.
Legs, ankles
Inspection of clothing or
luggage with a magnifying
glass and flashlight
Topical steroid
Body
Visible with naked eye: seams
of clothing
Inguinal (may have
lymphadenopathy)
White concretions on hair
Shaving or combing. “Louse buster”. Topical
permethrin 5% cream x 10 minutes, or
spinosad, or oral ivermectin
As above
*
Pruritic papules,
hemorrhagic crusts
Ankles
Visible with naked eye.
Oral antihistamine, manual removal, treat
Examine pets (“my dog has
pets.
fleas”)
* Wash hair with shamppo, rinse, towel dry. Apply 1% lotion (cream rinse) to saturate hair & scalp, also behind ears & base of neck. After 10 minutes,
rinse and remove nits. If lice are resistant, use 5% lotion (cream rinse) under a shower cap.
For HSV2 the initial infection may be accompanied by systemic symptoms. Chronic suppressive RX reduces transmission by 75%
DISH (Diffuse idiopathic skeletal hyperostosis): 1) calcification and ossification of spinal ligaments & peripheral enthuses. 2) M >>> W and W > blacks.
3) Thoracic spine pain in 60% and possible dysfphagia, mornic stiffness, and spinal cord compression. Lab: flowisng osteophytes acros 4 contiguous
vertebrae (diagnostic). Rx = heat, ultrasound, swimming, and stretching.
PNEUMOVAX:
Age <65, intermediate risk (e.g., DM, CAD, COPD): s PPSV 23
Age <65, high risk (HIV or CA): PPSV 13 >> 2 months >> PPSV 232
Age > 65, PPSV 13 >> 2 months >> PPSV 23.
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AMENORRHEA:
Primary: Turner’s congenital agenesis
Secondary:
1) Pregnancy
2) Hypothalamic: stress, heavy exercise, eating disorder.
3) Pituitary: psycho active or antihistamine meds. Injury, pituitary infarct. Increased prolactin.
4) Ovarian: PCOS, Autoimmune or chemotherapy or androgens or ovarian ca.
5) Anatomic: Asherman’s syndrome.
Work up: Beta-HCG, TSH,, prolactin, FSH, LH.
Rx for PCOS: Metformin, OCPs (ortho-cyclen)
IRREGULAR MENSES: Anovulatory (unopposed progesterone): thyroid disease, PCOS, DM,
hyperprolactemia.
HEAVY MENSES: Ovulatory: coagulopathy (e.g., von Willebrand’s), polyp, Ca, hypothyroidism.
Losartan 50 mg or 100 mg daily
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