During the pre-contemplation stage, patients do not even consider changing. For example, smokers who are "in denial" may not see that the advice applies to them personally or patients with high cholesterol levels may feel "immune" to the health problems that strike others.
During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I need to, doc, but ...") as well as the benefits of change.
During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, sampling low-fat foods may be an experimentation with or a move toward greater dietary modification.
At this point patients take definite action to change.
This is the stage of continued commitment to sustaining new behavior. Physician should plan for follow up support and also discuss coping with relapse.
Resumption of old behavior. Trigger for relapse should be evaluated. Motivation and barriers need to be reassessed and stronger coping strategies developed.
Bacteriuria, bladder cancer, pancreatic cancer, testicular cancer, spirometry for COPD, genital herpes, gonorrhea, hemochromatosis, and hepatitis B.
Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important to consider other factors, including family history, travel history, sexual history, etc.
low-carbohydrate, high-protein, high-fat diet (Atkins)
high-carbohydrate, low-fat diet (Pritikin)
high in fruits, vegetables, whole grains, nuts, beans, seeds, and monosaturated fats (Mediterranean diet)
high-protein, low-carbohydrate, fat-controlled diet (South Beach, Zone, ...)
high-fiber, low-fat, vegetarian diet (Ornish)
grapefruit or raw food diet (single food or food group)
pre-packaged diet (Jenny Craig, NurtriSystems, Weight Watchers, ...)
very low calorie or fasting diet
The AHA recommends eating fish twice a week. Eating more fatty fish like mackerel, lake trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk.
Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower heart disease risk.
Unfortunately, studies are showing that vitamins C, E, and folic acid do not reduce heart attacks or strokes.
Lack of iodine- Worldwide, the lack of iodine is the most common cause of goiter.
Hypothyroidism- Hashimoto's disease, which causes hypothyroidism, is a common cause of goiter.
Hyperthyroidism- Graves' disease, which causes hyperthyroidism, also causes goiter. In fact, an enlarged thyroid can be seen in patients with too much, normal amounts or not enough thyroid hormone.
Nodules- Nodules, either single or multiple, can also cause an enlarged thyroid.
Thyroid cancer- Thyroid cancer is usually detected by palpating an enlarged, nodular thyroid.
Pregnancy- Pregnancy can occasionally cause a slight enlargement in the thyroid.
Thyroiditis- Thyroiditis can also cause an enlarged, often tender, thyroid gland.
Gardner syndrome is a subtype of familial adenomatous polyposis (FAP or classic FAP), which usually causes benign, meaning noncancerous, tumors to form in many different organs, such as:
Multiple adenomatous colon polyps. An adenomatous polyp is an area where the normal cells that line the inside of the colon begin to make mucus and form a mass on the inside of the intestinal tract.
Benign tumors, including:
sebaceous cysts, which are closed sacs filled with liquid found under the skin
epidermoid cysts, which are lumps in or under the skin often filled with liquid
fibromas, which are fibrous tumors
desmoid tumors, which are fibrous tumors that can develop anywhere in the body
osteomas, which are bony growths, usually found on the jaw
People with Gardner syndrome also have a higher risk of developing colorectal cancer and other FAP-related cancers. Other features of Gardner syndrome that are similar to classic FAP include extra or unerupted teeth and congenital (present at birth) hypertrophy of the retinal pigment epithelium (CHRPE), an eye condition that does not affect vision but can be seen by looking at the retina using a special instrument called an ophthalmoscope.
1. Overweight or obese patients (body mass index 25 kg/m2) who have one or more of the following additional risk factors:
Race/ethnicity (e.g., Native American, Pacific Islander, Latino, African American, Asian American)
First-degree relative with diabetes
Previously diagnosed impaired fasting glucose (100-125 mg/dL) or impaired glucose tolerance (2-hour plasma glucose > 140 mg/dL following a 75 gram glucose load)
Hypertension (Blood pressure > 140/90 mmHg)
HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL (2.83 mmol/L)
History of gestational diabetes mellitus, or delivering a baby > 9 lbs.
Polycystic ovarian syndrome
History of cardiovascular disease
A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans, severe obesity)
2. In the absence of the above risk factors, screening should begin at 45 years of age.
3. If results are normal, testing should be repeated at least at three-year intervals, with consideration of more frequent testing depending on risk status and initial results.
Classic symptoms of DVT include swelling, pain, and discoloration in the affected extremity.
Physical examination may reveal the palpable cord of a thrombosed vein, unilateral edema, warmth, and superficial venous dilation.
Classic signs of DVT, including Homan's sign (pain on passive dorsiflexion of the foot), edema, tenderness, and warmth, are difficult to ignore, but they are of low predictive value and can occur in other conditions such as musculoskeletal injury, cellulitis, and venous insufficiency.
Patients with venous thrombosis often complain of a dull ache in the leg that worsens with prolonged standing and resolves with leg elevation. Examination reveals increased leg circumference, edema, and superficial varicose veins.
Smoking and obesity, are the most robust risk factors in the development of DVT and are independent of other risk factors. Diabetes, sedentary lifestyle, hypertension, hyperlipidemia, increasing age, prolonged immobility, surgery, trauma, malignancy, pregnancy, estrogenic medications (e.g., oral contraceptive pills, hormone therapy, tamoxifen (Nolvadex)), congestive heart failure, hyperhomocystinemia, diseases that alter blood viscosity (e.g., polycythemia, sickle cell disease, multiple myeloma), and inherited thrombophilias are other potential risk factors in the development of DVT. sleep apnea, chronic kidney disease, primary aldosteronism, renovascular disease, pheochromocytoma, coarctation of the aorta, and thyroid or parathyroid disease. A review of all medications, including over-the-counter and complementary medications is crucial. Some common prescription medications like birth control pills, amphetamines, thyroid medications, steroids, and certain anti-depressants may elevate blood pressure. Some common over-the-counter medications can also elevate blood pressure, such as: pseudoephedrine, appetite suppressants, or NSAIDS. Some herbal remedies may elevate blood pressure such as ma huang, bitter orange, ginkgo, ginseng, licorice, and St. John's wort. As noted above, cocaine and ketamine use, narcotic withdrawal, excessive alcohol intake and smoking can also elevate blood pressure. Look for identifiable causes of hypertension and evidence of end organ damage and coronary vascular disease:
-Funduscopic Eye Exam (AV nicking, cotton-wool spots, flame hemorrhages, exudates, and other changes associated with hypertensive retinopathy, also papilledema in HTN emergencies)
-carotid, abdominal, and femoral bruits (PVD and CVD)
-Palpation of the thyroid gland
-Lung exam (CHF)
-Heart Exam (RR, m/r/g, displaced PMI)
-Abdominal exam (AAA pulsation, bruits, or masses, or enlarged kidneys as hypertension can contribute to PVD and CKD)
-Lower Extremities (CVD or PVD in the lower extremities such as diminished pulses, loss of extremity hair, thick toenails, cold or red skin)
-Neuro Exam (changes from ischemic or hypertensive brain disease. It is important to get a baseline.)
A. Recurrent unexpected panic attacks (See above)
B. At least one of the attacks has been followed by a month or more of one or both of the following:
Persistent concern or worry about additional panic attacks or their consequences (eg, losing control, having a heart attack, "going crazy").
A significant maladaptive change in behavior related to the attacks (eg, behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (eg, medication or illicit drug) or another medical condition (eg, hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder. As examples, the panic attacks do not occur only in response to
Feared social situations, as in social anxiety disorder
Circumscribed phobic objects or situations, as in specific phobia;
Obsessions, as in obsessive-compulsive disorder
Reminders of traumatic events, as in posttraumatic stress disorder
Separation from attachment figures, as in separation anxiety disorder
a medical condition typically affecting young men, characterized by arthritis, conjunctivitis, and urethritis, and caused by an unknown pathogen, possibly a chlamydia.
The infection usually occurs days to weeks before the onset of joint pain. In some cases a preceding infection may only be identified with laboratory testing.
Symptoms include joint pain and stiffness, most commonly in the knees, ankles, and feet. In a type of reactive arthritis called Reiter's syndrome, there may be discomfort during urination as well as eye inflammation.
If needed, treatment includes anti-inflammatory medication or steroids.
Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. osteoporosis, adrenal suppression, growth suppression, dermal thinning, hypertension, Cushing's syndrome, cataracts, increased emotional lability, psychosis, peptic ulcer disease, atherosclerosis, aseptic necrosis of the bone, diabetes mellitus, and myopathy According to the AAO-HNS updated guidelines (2015), to make a diagnosis of chronic sinusitis, the patient must have at least 12 weeks of at least two of the following symptoms: nasal obstruction/congestion, mucopurulent drainage, facial pain, pressure or fullness, or a decreased sense of smell. In addition, inflammation must be demonstrated by one of the following: purulent mucus or edema in the middle meatus or ethmoid region, polyps in the nasal cavity or middle meatus area, or inflammation of the sinuses on radiographic imaging. Therefore, being able to demonstrate any inflammation on either nasal endoscopy or a CT of the sinuses will confirm the diagnosis of chronic sinusitis. Eat a healthy diet with a variety of foods, including protein (meat, dairy), fruits, vegetables, and whole grains.
Avoid raw eggs, unpasteurized milk or milk products, soft cheeses (such as feta, brie, veined, Camembert, and Mexican queso fresco), unwashed fruits or vegetables, raw fish, shellfish, and large, steak-like fish (such as shark, swordfish, king mackerel, and tilefish).
Individuals with Down syndrome have a number of developmental and growth issues, including short stature, developmental delay and mental retardation, obesity, hearing loss, eye and gastrointestinal problems. They also have an increased risk for immune deficiencies, thyroid disorders, diabetes, leukemia, sleep apnea, and behavior disorders. Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.
Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.
In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans.
The primary function of menopausal hormonal therapy (HT) is to treat the bothersome symptoms of menopause.
Systemic estrogen is the most effective treatment for hot flashes, or vasomotor symptoms. Patients with an intact uterus must also be treated with progesterone to decrease the risk of endometrial cancer related to unopposed estrogen.
Estrogen, especially when used topically, is also the most effective treatment for symptoms of atrophic vaginitis, including vaginal dryness and dyspareunia, and may improve urinary symptoms such as urge incontinence and recurrent urinary tract infections. Topical estrogens available through the pharmaceutical companies are very safe in low doses and in low doses probably do not require coverage with progesterone even in women with an intact uterus.
Menopausal hormonal therapy, especially when started in the first five years after menopause, helps prevent osteoporosis by maintaining bone density. For many years, HT was used extensively for this purpose. It is still considered an option for certain women when the risk and benefit ratio favor it over other treatments.
Research on the use of HT for other quality of life issues, including cognitive and depressive symptoms which commonly occur in perimenopausal and postmenopausal women, is less clear.
Smoking cessation. Smoking increases the risk of osteoporosis.
Adequate intake of calcium and vitamin D are essential to normal human physiology including bone health. A number of organizations have recommended routine supplementation of these nutrients for a variety of reasons including the prevention of osteoporosis. However, this recommendation is now being questioned.
Lifelong weight bearing exercise (bones and muscles work against gravity as the feet and legs bear the body's weight) and muscle strengthening can improve agility, strength, posture, and balance, which may reduce the risk of falls. It may also modestly increase bone density. Examples of weight bearing exercise include walking, jogging, Tai-Chi, stair climbing, dancing, and tennis.
Other prescription medications, including the antidepressants SSRIs and SNRIs, and clonidine and gabapentin, although less effective than HT for vasomotor symptoms, can be very beneficial in selected patients.
NCCAM has found preliminary evidence to support the use of mind and body practices such as yoga, tai chi, qi gong, and acupuncture for management of menopausal symptoms, but outlines specific concerns and recommends against the use of compounded hormones marketed as Bioidentical Hormone Replacement therapy and against the use of DHEA. Furthermore, natural medicines, such as phytoestrogens and botanicals, have not been shown to be clearly safe and effective according to usual standards for prescription medications.
Associated with rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, and ptosis.
Severe unilateral orbital, periorbital, supraorbital, or temporal pain.
Last 15-180 minutes.
Tend to recur many times in a row, appearing in "clusters"
5 episodes needed for diagnosis.
triptans - dizziness, sleepiness, nausea, fatigue, paresthesia, throat tightness/closure, chest pressure
ergotamine (Ergostat), ergotamine/caffeine (Cafergot), dihydroergotamine (DHE)
-severe reactions possible; MI, ventricular tachyarrhythmias, stroke, hypertension, nausea, vomiting, diarrhea, dry mouth, rash
Metoprolol (47.5-200 mg)
FDA approved: Yes
Caution in: Asthma, depression, severe COPD, DM requiring insulin, Raynaud's disease
S/E: Fatigue, bronchospasm, lightheadedness, insomnia, bradycardia, depression, sexual dysfunction
1. Gastroesophageal reflux -- epigastric burning that sometimes radiates to the throat and tends to worsen when:
gastric volume is increased (after large meals)
gastric contents are located near the gastroesophageal junction (reclining or bending)
intra-abdominal pressure is increased (such as with obesity, pregnancy, tight binders or girdles).
2. Esophageal spasm -- sharp, stabbing, substernal pain and can be triggered by temperature extremes (e.g. hot coffee, ice water).
Heartburn and esophageal reflux and spasm commonly occur at night or after the consumption of a large meal.
Symptoms of GERD may also be precipitated by:
spicy and fatty foods
alcohol and caffeinated beverages
eating large portions
lying flat in close proximity to a meal
wearing tight clothing around the waist
some medications (calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives)
When severe reflux reaches the pharynx and mouth or is aspirated, it can cause atypical signs and symptoms of GERD, or laryngopharyngeal reflux (LPR). Atypical symptoms may point to (but don't sufficiently support by themselves) a diagnosis of GERD.
Dysphagia -Difficulty in swallowing. Dysphagia to solids suggests possible development of peptic stricture. Rapidly progressive dysphagia potentially indicates adenocarcinoma. Dysphagia to liquids suggests development of a motility disorder.
Initial onset of upper GI symptoms after age 50 -Increased chance of cancer.
Early satiety -May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer).
Hematemesis -Vomiting blood, which suggests bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices.
Hematochezia -Passing red blood with stool, which may indicate a rapidly bleeding ulcer or mucosal erosions.
Iron deficiency anemia -The presence of hematemesis, hematochezia, and/or iron deficiency anemia may indicate possible bleeding from a peptic ulcer, mucosal erosions, or cancer.
Odynophagia -Painful swallowing, which is associated with infections (e.g. candida), erosions, or cancer.
Recurrent vomiting -Suggestive of gastric outlet obstruction.
Weight loss -Associated with malignancy.
Signs of Complications or Other Associated Diseases
Hemodynamic status-Hypotension or tachycardia may indicate significant blood loss from a gastrointestinal bleed.
Signs of anemia -Brittle nails and cheilosis (cracks and sores on the lips) are signs of anemia. Pallor of palpebral (eyelid) mucosa or nail beds may also be present with anemia.
Signs of malignancy -Weight loss, palpable mass, presence of signal lymph nodes (Virchow's nodes) and acanthosis nigricans (velvety, light-brown-to-black skin, usually on the neck, under the arms or in the groin) are signs of possible malignancy.
Signs of gall bladder disease -Jaundice or a positive Murphy's sign
Signs of hypothyroidism -Constipation, cool or pale skin, coarse hair, or non-pitting edema (myxedema) or delayed relaxation phase of deep tendon reflexes (DTRs) may be present in hypothyroidism.
Hyperthyroidism -Diarrhea, warm skin, thinning hair, eyelid lag, brisk DTRs, or tachycardia may be present in hyperthyroidism. Though a very rare cause of dyspepsia, thyroid disease should be considered.
Side effects are rare but can include headache, diarrhea, abdominal pain, nausea, constipation, and bloating. PPIs may interact with other medications by affecting the absorption of drugs for which bioavailability is dependent upon gastric pH (e.g. ampicillin, aspirin, iron, ketoconazole, methadone). Some PPIs may also inhibit cytochrome P-450 metabolism. Dose adjustment is rarely necessary in the elderly, patients with renal insufficiency, or those who have mild to moderate hepatic impairment. Current literature has turned its attention toward more potentially serious side effects of PPIs. Many patients who are prescribed PPIs in the ambulatory care setting do not have a valid indication, and may be left on them indefinitely without documented re-evaluation to determine appropriateness of therapy. Adverse events associated with non-judicious short- and long-term use of PPIs include community-acquired pneumonia, Clostridium difficile-associated diarrhea, osteoporotic fracture, anti-platelet agent inhibition, iron, magnesium, and vitamin B12 deficiencies. The H. pylori IgG serologic test only confirms evidence of past infection and an immunologic response to H. pylori . In a population with a high prevalence of active H. pylori infection, it is a useful first-time test. However, if the prevalence of active infection is low, then the test may yield a high number of false-positive results. It should not be used to confirm eradication of H. pylori after treatment as it can remain positive for years.
The urea breath test accurately detects active infection but is more expensive than serologic testing. It is less accurate during PPI therapy, and patients would need to stop the PPI for at least two weeks before a urea breath test (bismuth and antibiotics should also be stopped for at least two weeks before a urea breath test.). However, urea breath testing may be appropriate depending on the characteristics of the population being tested.
The stool antigen test for H. pylori is also accurate and widely available, but it is more expensive and less convenient than serologic testing. The stool antigen and urease breath tests may also be used as confirmatory tests after a positive serologic test.
If an endoscopy is indicated (i.e. due to the presence of alarm symptoms), or in patients who have been taking a PPI, antibiotics, or bismuth, endoscopic testing for H. pylori, (which consists of tissue biopsies from the gastric body and antrum for rapid tissue urease testing or histology) should be performed in lieu of other H. pylori tests.
Tricyclic antidepressants have been found to improve symptoms in patients with functional dyspepsia without affecting the sensation of gastric distention.
A systematic review determined that there is insufficient evidence to support the efficacy of psychological therapies, including cognitive behavioral therapy, hypnotherapy, relaxation training and interpersonal therapy, for the treatment of functional dyspepsia. However, individual trials have reported some modest clinical benefits in symptomatic improvement.
Alternative therapies are gaining popularity in patients with gastrointestinal conditions, and studies of varying quality suggest that slippery elm, capsaicin, peppermint oil, caraway oil and artichoke leaf may improve symptoms in some patients; however, there is as yet no compelling evidence on which to base a recommendation for these alternative therapies. Note: peppermint oil decreases lower esophageal sphincter pressure and may worsen GERD symptoms. Patients should be educated that herbal remedies are not regulated by the US Food and Drug Administration (FDA), may not have been studied for safety, and can have adverse side effects, which very often include GI side effects.
Many patients will describe abdominal pains of varying location, associated with either soft, frequent loose stools, or constipation, or alternating stool pattern. They may also describe abdominal bloating, increased flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious or depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, dietary changes, change in activity, and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. There is no specific test or lab finding to determine that a patient definitely has IBS; it is a diagnosis of exclusion. This should remain in your differential. Migraines, frequent headaches
Chronic pain syndrome
Heart and blood pressure problems
Stomach ulcers, frequent indigestion, diarrhea, constipation, irritable bowel syndrome, spastic colon
Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic inflammatory disease, chronic pelvic pain syndrome, and other gynecological diagnoses
Invasive cervical cancer and preinvasive cervical neoplasia
Depression, anxiety and post-traumatic stress
Unexplained or poorly explained findings on physical exam
Often characterized by an atypical presentation, i.e., chills, fever, dry, nonproductive cough, and the predominance of extrapulmonary symptoms such as GI symptoms and arthralgias.
It can be caused by influenza (usually as part of a community outbreak in winter), respiratory syncytial virus in children or immunosuppressed individuals, and measles or varicella along with their characteristic rashes. Adenovirus, rhinovirus, and parainfluenza virus are also common causes.
More common in children aged four months to five years.
The patient's age is a key factor in differentiating between typical and atypical pneumonia. Young adults are more prone to atypical causes, and very young and older persons are more predisposed to typical causes. Atypical organisms, such as Mycoplasma or Chlamydia pneumoniae, are more common in older children and adolescents.
In addition to the pneumonia symptoms observed in younger children, adolescents may have other symptoms such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.
In one study, patients with bacterial pneumonia were significantly more likely to present with pan-inspiratory crackles, whereas patients with atypical pneumonia were more likely to present with late inspiratory crackles.
Characterized by upper and lower respiratory tract symptoms accompanied by systemic symptoms such as myalgia, fever, headache, and weakness, though children with influenza frequently present first with a headache, sore throat and generalized malaise before the upper respiratory symptoms of cough appear.
Influenza is so abrupt that patients can often tell the precise time of onset.
Outbreaks typically occur during the winter months.
Presents in many ways, and headache can be the first symptom for some adults and children. Fever >39° C is often the first sign in younger children. However, older children can have a constellation of symptoms, and it can be difficult to determine if influenza is present. Very young children can present with febrile seizures.
High fever of 102-104 F and chills are common, along withsevere myalgias and headache.
The influenza virus can cause upper and lower respiratory tract symptoms resulting in rhonchi being heard on the lung exam. Rhonchi are a result of the complications of influenza and are not one of its primary physical exam findings.
Affects between 15 and 42 % of preschool and school age children each year, children younger than two years of age have higher rates of complications and hospitalization.
All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg.
Class I, Level A
Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period.
The JNC 8 guidelines recommend a thiazide diuretic or a calcium channel blocker as first line therapy for African American patients with hypertension. Other agents may be added as needed to achieve the appropriate blood pressure goal.
For more REQUIRED information about hypertension management, see the MedU Hypertension module.
Class I, Level A
All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke.
Class I, Level C
The ACC/AHA Lifestyle Guidelines recommend all adults consume a Mediterranean diet to reduce their risk of ASCVD.
Furthermore, patients with hypertension should limit sodium intake to 2,400 mg per day or less.
Class I, Level A
On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity physical activity 3-4 times per week for 40 minutes per session. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended.
Class IIb, Level C
Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual's own risk factors.
A diagnosis of pertussis should be considered for any child with a prolonged cough, even when appropriately immunized. No vaccine is 100% effective at preventing disease, and previously immunized, or under-immunized, children will often present with milder symptoms.
Infection with Bordetella pertussis is transmitted from person to person by aerosolization of droplets from coughing and sneezing. Pertussis is a clinical diagnosis. Early on in the disease, patients present with general upper respiratory symptoms: sneezing, runny nose, and typically just a mild cough. The classic paroxysmal cough and inspiratory "whoop" do not become prominent symptoms until about 14 days into the illness. Pertussis is very contagious and can cause serious, even life-threatening, illness, particularly in infants.
Universal immunization of children younger than age 7 has been essential to the control of pertussis. Vaccination with acellular pertussis is highly effective, providing 64% protection against mild disease, and 95% protection against serious disease after completion of the primary series. However, pertussis is the only vaccine-preventable illness whose incidence rate has continued to rise over the last 20 years, especially in adolescents and adults, and outbreaks occur among both immunized and unimmunized populations.
Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanching, sandpaper-like exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia's lines). The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue).
Complications of strep throat are usually divided into suppurative and non-suppurative categories. Even though rheumatic fever and post-streptococcal glomerulonephritis are serious, they are relatively rare. Other complications include: peri-tonsillar abscess, mastoiditis, meningitis, and bacteremia.
Fires/burns/test smoke alarms/fire escape plan
Appropriate booster seat placed in back seat; seatbelts
Keep home and car smoke-free
Pool/tub/water safety - swimming lessons
Use bike/skating helmet
Supervise near pets, mowers, driveways, streets
Limit time in sun, use hat/sunscreen
Childproof home (matches, poisons, guns, cigarettes, cords, cleaners, medicines, knives)