FM Case Studies part 2

Terms in this set (272)

First choice analgesic for both short and long-term treatment of mild
to moderate pain related to osteoarthritis because of its tolerability
and low side-effect profile.
Dosing is up to 4 grams per day in divided doses, though some
recommend lower doses (2-3 grams/day in divided doses) if long-term
use is desired.
There is little risk of nephrotoxicity, and hepatotoxicity is a rare side
effect if taken appropriately.
2. Nonsteroidal anti-inflammatories (NSAID)
Elderly patients are at an increased risk of developing gastric ulcers
when using NSAIDs chronically.
Prolonged bleeding times present additional risk if patient is at risk of
Other NSAID side effects include decreasing the effectiveness of
hypertension medications, and increasing the effect of sulfonylureas.
Patients who use NSAIDs chronically, taking 5,000 or more pills, are
at an increased risk of developing end-stage renal disease.
NSAIDs, aspirin, and acetaminophen can all cause hepatotoxicity, and
contribute to coagulopathy.
NSAID creams appear to work better than placebo and have fewer
side effects.
COX-2 inhibitors: Celecoxib( Celebrex), Valdecoxib (Bextra) Rofecoxib (Vioxx)
Less risk of gastrointestinal bleeding, but increased cardiovascular risk, which is why several were removed from the market.
Monoamine uptake inhibitor is a centrally-acting analgesic that
appears to have actions at the μ-opioid receptor as well as the
noradrenergic and serotonergic systems.
Less potential for abuse than opioids.
Appropriate for moderate to severe pain.
C1. entrally acting analgesic with effects on mu-opioid receptors.
Also stimulates release of serotonin and inhibits reuptake of
Effective in alleviating moderate to severe pain.
Lower abuse potential than opiods.
2. Short-acting opioid
Given first to see how much is needed to control pain adequately over
a 24-hour period, and then converted to a long-acting alternative.
Act on several different receptors, including mu receptors in the
central nervous system.
Side effects: euphoria, bradycardia, sedation, physical dependence,
nausea, vomiting, and respiratory depression.
More risk of tolerance than long-acting opiods because of their short
half-life of 3-4 hours. Patients need to use them more frequently to
control their pain adequately.
Helpful for flares of acute pain, but if daily use is needed, long-acting
opioids should be considered.
A meta-analysis showed that strong opioids (oxycodone and
morphine) were more effective than naproxen or nortriptyline for
treating chronic non-cancer pain, but not the weaker opioids
(propoxyphene, codeine).
Long-acting opiods
For daily use to treat chronic pain.
Most common side effect: constipation. Treat with laxatives, stool
softeners, exercise, and a high water and fiber diet.
If the long-acting opioid alone is not sufficient, can add either
acetaminophen for breakthrough pain, or a short-acting opioid.
The goal should always be to use the smallest sufficient dose for the shortest period of time to achieve adequate pain control.
Tricyclic antidepressants
Anticholinergic side effects: dry mouth, constipation, urinary
retention, blurred vision and paralytic ileus.
Other side effects: gastrointestinal, sedating, and neurologic (ataxia,
tremors, paresthesias, and mental clouding).
Relatively contraindicated in patients with severe cardiovascular
disease or conduction problems because they can contribute to
tachycardia, arrhythmias, hyper- or hypotension, heart block, and
myocardial infarctions.
Helpful for trigeminal neuralgia, but evidence is lacking for other
chronic pain syndromes.
Lamotrigine (Lamictal) was shown to be ineffective for treating chronic
neuropathic pain in a meta-analysis.
Some anticonvulsants require blood level monitoring as well, and have
severe side effects like megaloblastic anemia.
Carbamazepine (Tegretol) can interfere with other medications
because it is a cytochrome P-450 inducer, including decreasing the
effectiveness of hormonal contraception.
Several are also known teratogens.
1. Breast cancer screening
Biennial screening mammography for women ages 50-74
Evidence is insufficient to make any recommendation for screening
over the age of 75.
2.Colorectal cancer screening
Fecal occult blood test (FOBT), flexible sigmoidoscopy, or colonoscopy
is recommended for patients age 50 to 75 years old.
The USPSTF recommends against screening for colorectal cancer after
the age of 75 years.
3.Cervical cancer screening
Women over the age of 65 should not be screened for cervical cancer if they have had adequate recent screening with normal Pap smears,
and are not otherwise at high risk for developing the disease.
4.Lipid disorder screening
The USPSTF strongly recommends screening women over 45 years old
for lipid disorders if they are at increased risk of coronary heart
The USPSTF makes no recommendation about screening women over
the age of 20 who do not have an increased risk of coronary heart
The USPSTF strongly recommends screening men over 35 years old
for lipid disorders.
The USPSTF recommends screening adults for depression in clinical
practices that have systems in place to assure accurate diagnosis,
effective treatment, and follow-up.
Patients 18 years old and older should be screened for elevated blood
Abdominal ultrasound
One-time ultrasound to screen for an abdominal aortic aneurysm
(AAA) is recommended in *men 65-75 year olds who have any history
of smoking.
The USPTF recommends against routine screening for AAA in women.*
Carotid artery stenosis screening
The USPSTF recommends against screening for carotid artery stenosis
in asymptomatic patients.
Low-back pain
Evidence is insufficient to make recommendations about the routine
use of interventions to prevent low back pain in adults in the primary
care setting.
Thyroid disease
There is not sufficient evidence to recommend for or against screening
for thyroid disease.
Savannah is a healthy 16-year-old girl who presents with her mother for a routine
pre-participation sports exam. The visit includes development of a trusting
doctor-patient relationship to facilitate adolescent health promotion and disease
treatment. Immunizations are updated and an adolescent interview is conducted,
which reveals that Savannah is engaging in unprotected sex. Birth control and
preconception counseling are provided, and Savannah is scheduled to return for
Depo-Provera, a pelvic exam, and a chlamydia test.
When Savannah returns to the clinic two weeks later, she reports 5 weeks since
her last menstrual period, morning sickness, breast tenderness, and tiredness.
Urine pregnancy test is positive. She is given unintended pregnancy options counseling.
A week later, Savannah returns due to vaginal bleeding. Her pulse and blood
pressure are normal and pelvic exam is unremarkable. Quantitative beta-hCG is
1492 mIU/mL. Ultrasound does not reveal intrauterine pregnancy, but a left
ovarian cyst is noted. After reviewing the differential diagnosis, it is determined
none of the top three diagnoses (spontaneous abortion, ectopic pregnancy, or
idiopathic bleeding in a normal pregnancy) can be currently ruled out.
However, two days later, her serial beta-hCG has doubled, the bleeding has
subsided, and transvaginal ultrasound reveals an appropriately developing fetus
with a heartbeat. Ten days later, at 7 weeks and 4 days gestation, Savannah
presents to the emergency department with vaginal bleeding, some clots, and a
fair amount of pain. Pelvic exam reveals the cervical os opened 1-2 cm with
pooled blood in the vaginal vault. On ultrasound, the fetus no longer has a heart
beat, and the inevitable abortion is appropriately managed.
Initial pregnancy evaluation
1. Serum hCG
When urine hCG is positive, it is not necessary to obtain a serum hCG.
It is possible to have a positive serum hCG result, even with a
negative urine hCG result, as early pregnancy urine hCG
concentrations are lower than serum hCG concentrations.
Specify a qualitative (positive vs. negative) vs. a quantitative serum
Quantitative serum hCG levels rise at a predictable rate, so
serial testing of serum hCG levels can be useful to determine
viability or to diagnose an ectopic pregnancy, although one
measurement alone is not sufficient to accurately estimate
gestational age.
2. CBC
Detect various nutritional and congenital anemias6. 3. Blood type
Detect rhesus antibody presence.
Rh D negative women should receive *50mcg dose of Rho(D) Immune
Globulin (e.g., RhoGAM) to prevent hemolytic disease of the newborn at 28 weeks.*
When an Rh negative mother detects enough fetal Rho-D antigen, she
forms antibodies to this antigen.
This immune response is usually not robust enough to impact the first
gestation, but subsequent gestations are at significant risk of an
immune response.
When this occurs, the maternal antibodies attack the fetus' red blood
cells, causing hemolytic anemia, which can lead to fetal hydrops and
even fetal death.
Rho(D) Immune Globulin administered at appropriate times interrupts
the maternal immunologic process.
You can visualize this process by imagining the RhoGAM attaching to
all of the fetal Rho-D antigenic load, making it immunologically
"invisible" to the maternal immune system.

4. Rubella
Assess the presence of IgG antibodies. If the patient is NOT immune, they should receive a postpartum
The Rubella and the MMR vaccine is a live-virus vaccine and should
not be used during pregnancy.
5. Hepatitis B
Tests for Hepatitis B surface antigen
A major risk to the newborn.
6. RPR
Tests for syphilis
Risk of transplacental infection of the fetus.
Congenital infection is associated with several adverse outcomes in
the neonate:
Perinatal death
Premature delivery
Low birth weight
Congenital anomalies
Active congenital syphilis
7. HIV
Status should be checked as the risk of perinatal transmission can be
reduced from 15-40% without treatment to less than 2% with
antiretroviral therapy and avoidance of breastfeeding and labor.
1. Complete blood count (CBC)
Red blood cell count provides the hemoglobin and hematocrit.
White blood cell (WBC) count
Limited in its usefulness to detect infection (and thus a septic
abortion) during pregnancy because most pregnant patients have a
mild leukocytosis.
If significantly elevated, or associated with a bandemia, this test
would need to be factored into the consideration of a septic abortion.
2.Wet mount preparation for Gonorrhea, Chlamydia, and Trichomonas
All sexually transmitted infections can cause vaginal bleeding.
These tests should be obtained in this clinical context, despite a
previously normal recent result.
Culture should not be obtained as it is very expensive.
Chlamydia cultures should only be used in cases of forensic
investigation, such as rape or child abuse.
Type and screen
Knowing Rhesus status is critical, as all Rh negative women who are
pregnant need to be given RhoGam during any episode of bleeding.
Warranted for:
Potential transfusion
When the history, vital signs, and physical exam
consistent with a major bleed.
Kleihauer-Betke testing
To estimate the quantitative amount of fetal hemoglobin
in the maternal circulation and help with dosing RhoGam.
3.Quantitative beta-human chorionic gonadotropin (quant. beta-hcg)
In isolation, one beta-hCG can be challenging to interpret.
Combined with pelvic ultrasound, has definitive diagnostic modalities.
Human chorionic gonadotropin is secreted by the trophoblastic cells
very early in embryonic life (day 7, post-ovulation).
Testing for the beta-subunit is exquisitely sensitive (down to 5
mIU/mL) and specific (the placenta is the only normal tissue that
excretes beta-hCG).
The velocity of increase or decrease is a more useful diagnositic
modality than a point value in a stable patient.
If the patient is stable, 1-2 serial hCG measurement(s) can prove
diagnostically useful and often conclusive when combined with a
repeat ultrasound.
Upper airway cough syndrome (UACS): May present with upper airway
symptoms (rhinitis), cough, and wheezing, but no objective findings on
spirometry and no relief with typical asthma medications, including
bronchodilators and inhaled oral corticosteroids.
Asthma: Reversible obstructive findings on spirometry is the distinctive
diagnostic abnormality in patients with asthma, especially early in the
course. Patients with chronic, severe asthma may have less or no
reversibility of their obstructive findings, very similar to patients with
chronic obstructive pulmonary disease.
Non-asthmatic eosinophilic bronchitis: Pa 3. tients respond to inhaled corticosteroids similarly to patients with asthma, but they will have normal
spirometry and a normal chest x-ray. The diagnostic finding for this
condition is sputum eosinophilia (on induced sputum or bronchial wash
obtained at bronchoscopy).
Vocal cord dysfunction: Patients may have flattening of the inspiratory
loop on spirometry (in contrast to the reversible obstructive findings on
spirometry in patients with asthma). The diagnostic finding of this condition
is visualizing abnormal vocal cord movement during an episode of wheezing.
Chronic obstructive pulmonary disease (COPD): Obstructive findings
on spirometry that are not significantly reversible. Criteria for staging
patients with chronic obstructive pulmonary disease based on the FEV1/FVC
ratio are available.
Congestive heart failure (CHF): May on occasion have cough or
wheezing, but no relief with bronchodilators or corticosteroids. There are
more common symptoms and signs, which aid in the diagnosis of congestive
heart failure, including shortness of breath on exertion, extra heart sounds,
jugular venous distension, peripheral edema, and findings on
Gastroesophageal reflux disease (GERD): Present with either heartburn
symptoms or findings of esophagitis on upper endoscopy. Gastroesophageal
reflux may occur singly with symptoms or cough and wheezing or serve as a
co-morbid condition of patients with asthma. If a patient with asthma fails
to improve with standard treatment, it is reasonable to consider whether
gastroesophageal reflux is present.
Baseline screening for anemia
2.Blood type/Rh status
Assess risk of maternal-fetal transfusion reactions (i.e. hemolytic anemia in
the newborn due to the presence of maternal antibodies) should the baby's
blood type be different than the mother's.
Anti-Rh antibodies (RhoGam) can be given to mothers who are Rh negative
to prevent sensitization of the maternal immune system to Rh antigens if
the baby's blood type is Rh positive.
3.HIV test
Recommended for all pregnant women.
Opt-out" voluntary testing strategies may improve screening rates.
Blood type/Rh status
Assess risk of maternal-fetal transfusion reactions (i.e. hemolytic anemia in
the newborn due to the presence of maternal antibodies) should the baby's
blood type be different than the mother's.
Anti-Rh antibodies (RhoGam) can be given to mothers who are Rh negative
to prevent sensitization of the maternal immune system to Rh antigens if
the baby's blood type is Rh positive.
Baseline screening for anemia
HIV test
Chicken pox
Women should be asked about a history of chicken pox; women with no
history can have serologic testing for varicella zoster IgG.
Non-immune women should be offered preconception or postpartum
varciella vaccination.
Varicella vaccination is contraindicated in pregnancy.
Bacterial vaginosis
Universal screening NOT recommended.
Symptomatic women should be treated.
Screening may be considered in women with risk factors for pre-term
Routine ultrasound screening
In pregnancy has not been linked to improved perinatal outcomes.
Ultrasound can be useful for accurately determining gestational age early on
in pregnancy.
Most experts agree that pregnant women should be offered routine
ultrasound screening for structural anomalies between 18-20 weeks'
Consists of measuring three or four chemical markers present in the
mother's blood during pregnancy:
Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (hCG)
Unconjugated estriol
only in the quad screen) dimeric inhibin A
Abnormal levels of these serum markers may indicate increased risk for
neural tube defects, trisomy 21, and trisomy 18.
Serum screening is not usually performed until 15-21 weeks' gestation, but
it would be appropriate to begin a conversation about this at 10 weeks.
Sensitivity of these tests is not ideal, as false positives and negatives occur.
If a serum triple or quad screen is positive, it identifies patients at
higher risk but does not rule disease in or out.
False positives - Although they do occur, it would be misleading
to minimize the potential meaning of the test or provide "false
If a clinician has encountered a particular situation many times
before and feels it is "routine," it may also be tempting to
dismiss the patient's concerns prematurely
Patients should be given accurate information about the test, the
potential for Down's, as well as the possibility of false-positive results.
Patients should be offered genetic counseling and further testing,
including ultrasound for evaluation of fetal anatomy and
Lab error is a common reason for an elevated triple or quad screen,
and rechecking the dates and timing of the test is prudent.
The triple screen detects Down's syndrome in about 69% of cases,
and the quad screen detects Down's in about 81% of cases with a
false-positive rate of 5%.
Surgical excision: Most widely used treatment for cutaneous squamous-cell carcinomas
(SCCs), particularly high-risk lesions
Well-defined, small (< 2 cm) SCC lacking any high-risk features require a *4
mm* margin of normal tissue around the visible tumor to result in 95%
histologic cure rate.
Mohs microscopic surgery
Surgeon can immediately review the pathology to confirm complete excision
during a staged excision.
Indicated in cosmetically sensitive areas.
Useful for lesions with indistinct margins where more tissue than clinically
apparent may require removal.
Patients with any non-melanoma skin cancer greater than 2 cms,
lesions with indistinct margins, recurrent lesions, and those close to
important structures (including eyes, nose, and mouth) should be
considered for referral for complete excision via Mohs micrographic surgery,
with possible plastic repair.
Topical 5-fluorouracil (5-FU)
Approved by the U.S. Food and Drug Administration (FDA) for the treatment
of actinic keratoses.
Although topical 5-FU is not approved for the treatment of Bowen's disease
(squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in
these diseases when other treatment modalities are impractical and for
patients who refuse surgical treatment.
Destroys malignant cells by freezing and thawing
Useful for small, well-defined, low-risk, invasive SCCs and Bowen's disease
Does not permit histologic confirmation of the adequacy of treatment
margins; thus, a substantial amount of training and experience is required
to achieve consistently high cure rates.
Radiation therapy
*Option for the initial management of small, well-defined, primary SCCs,
especially in older patients and those who are not surgical candidates.*
Contraindicated on tumors located on trunk and extremities. These areas
are subjected to greater trauma and tension than skin on the head and
neck, and they are more prone to break down and ulcerate as a result of the
atrophy and poor vascularity of irradiated tissue.
1. Cervical polyps:
Common in postpartum and perimenopausal women
Rare in pre-menstrual and uncommon in postmenopausal women
Ruled out via pelvic exam
2. Endometrial hyperplasia:
Simple hyperplasia progresses to cancer in < 5% of patients.
Atypical complex hyperplasia is a premalignant lesion that progresses to
cancer in 30-45% of women.
3. Endometrial cancer: Fourth most common cancer in women, accounting for ~ 6,000 deaths per
90% of patients with endometrial cancer have abnormal vaginal bleeding
Main diagnosis to consider in a woman presenting with postmenopausal
bleeding; also must be considered in women > 35 with symptoms
suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia)
Risk factors:
Any characteristic that increases exposure to unopposed estrogen
(including unopposed estrogen therapy, tamoxifen, obesity,
anovulatory cycles, estrogen-secreting neoplasms, early menarche
[before age 12], late menopause [after age 52], menstrual cycle
irregularities, and nulliparity)
Age (incidence more than doubles from 2.8 cases per 100,000 in
those aged 30 to 34 years to 6.1 cases per 100,000 in those aged 35
to 39 years)
Protective factors:
Smoking seems to decrease estrogen exposure, thereby decreasing
the cancer risk
Oral contraceptive use increases progestin levels, thus providing
Proliferative 4. endometrium:
In premenopausal women, this is the normal response to estrogen
May also be seen in postmenopausal women, particularly in higher estrogen
No increased risk of endometrial cancer
5. Iatrogenic causes:
These include anticoagulants, selective serotonin reuptake inhibitors,
antipsychotics, corticosteroids, and hormonal medications.
Systemic disorders:
Transvaginal ultrasound (TVUS):
Most cost-effective initial test in women with abnormal uterine bleeding at
low risk for endometrial cancer
Highly sensitive for the detection of endometrial cancer (96%) and
endometrial abnormality (92%)
If the endometrium is > 5 mm on ultrasound (some sources say > 4 mm), it
is significant, and more workup is required.
TVUS also reveals leiomyomas (fibroids), focal uterine masses, and ovarian
pathology (although may miss endometrial polyps and submucosal fibroids).
Endometrial biopsy: Tissue sample for histologic evaluation of the
Gold standard for evaluation of postmenopausal bleeding or for abnormal
bleeding in younger women at high risk for endometrial cancer.
Sensitivity of up to 99% for detecting endometrial cancer in postmenopausal
Widely done in the outpatient setting:
A small pipelle is inserted into the cervix and samples of the lining of
the uterus are aspirated.
Ibuprofen, 800 milligrams, 30 minutes before the procedure is
recommended for cramping.
1. Complete blood count and liver function studies:
Looks for anemia, thrombocytopenia, and hepatic function abnormalities
that may could account for bleeding.
2. Thyroid function tests:
Thyroid hormone exerts negative feedback control over the hypothalamus
and gonadotropin hormone release.
Thus, thyroid disorder can interfere with the hypothalamic-pituitary-gonadal
axis and cause postmenopausal bleeding.
Test thyroid function using thyroid-stimulating hormone (TSH).
3. Gonadotropins (follicular stimulating hormone [FSH] and luteinizing
hormone [LH]:
Sufficiently elevated FSH levels can be used to confirm menopause (during
menopause, ovarian granulosa cells produce less inhibin—the negative
feedback regulator of pituitary FSH secretion and synthesis; with less inhibin
production, FSH and LH levels increase)
Understand underlying cause of pain.
Use as many non-pharmacologic remedies as possible.
Discuss with patients that you cannot take the pain away but will try to
improve the patient's functional abilities and help them live with their pain.
When you use medicines, first select those non-narcotic options that work
for the cause of pain (anti-epileptic drugs for neuropathic pain,
anti-inflammatories for musculoskeletal pain, and so on).
*Most short-acting narcotics such as acetaminophen/hydrocodone (Lortab)
and acetaminophen/oxycodone (Percocet) are indicated for use only in acute
pain or for breakthrough pain when long-acting agents are insufficient to
control symptoms.*
These drugs are to be used cautiously, since they cause effects like euphoria
that are not related to their ability to control pain. It is because of these
effects that narcotics are frequently overused or diverted for other
*When you must use narcotics, the goal is to use long-acting agents along
with the other agents and use the lowest possible dose that improves
patients' function.*
Once patients have started narcotics, the nature of their care changes. In
addition to office visits for their other conditions, like diabetes, they are required to keep separate office visits just for the pain.
Have patient sign a narcotic contract. Expect compliance; check urine drug
screens, check with the state's reporting system whether patient has
received drugs from other providers.
Keep an open line of communication and prescribe the medicines
Varies across geographic regions, ethnic groups, and household conditions
Rare in developed countries, and worldwide prevalence is decreasing
§ ri.
80-90% of all adults, regardless of age, in developing nations
(including Latin and Central America), are infected with H. pylori.
Results of study of Latinos in San Francisco Bay Area:
Immigrants (31% infected with H. pylori)
First-generation U.S.-born Latinos (9%)
Second-generation U.S.-born Latinos (3%)
Both household and birth-country environment have probably
contributed to declining H. pylori prevalence among successive
generations of Latinos.
In underdeveloped nations, thought to occur fromfecal-oral transmission
during childhood
Mechanism of action
H. pylori is uniquely adapted to life in the stomach. Its location in the gastric
mucosa, where it does not invade the gastric epithelium, provides the
organism with protection from the host immune mechanisms, which creates
challenges in the delivery of antimicrobial agents to eradicate infection.
Colonization renders underlying gastric mucosa more vulnerable to peptic
acid damage by disrupting the *mucous layer, liberating enzymes and toxins,
and adhering to the gastric epithelium.
Host immune response to H. pylori incites an inflammatory reaction, which
further perpetuates tissue injury.*
Chronic inflammation leads to chronic gastritis (in most cases,
asymptomatic and nonprogressive).
In some cases, altered gastric secretion coupled with tissue injury leads to
PUD, while in other cases, gastritis progresses to atrophy, intestinal
metaplasia, and eventually gastric carcinoma.
Rarely, persistent immune stimulation of gastric lymphoid tissue leads to gastric lymphoma.
90% of patients worldwide with duodenal ulcers are infected withH. pylori.
The strongest evidence to support the role of H. pylori as an etiology of PUD
is the elimination of ulcer recurrence after eradication.
1. Upper GI series: Useful in diagnosing complications of GERD (e.g., esophageal stricture)
Poor utility in diagnosing GERD
*May reveal gastric or duodenal ulcer, but not considered the diagnostic gold
2.24-hour pH probe
Most appropriately utilized when the diagnosis of GERD cannot easily be
When patients desire referral for surgical treatment of their GERD/hiatal
hernia (Nissen fundoplication)
When patients with classic symptoms of GERD (heartburn, regurgitation) do
not improve after appropriate trials of PPIs
3. Fecal immunochemical testing (FIT) and fecal occult blood testing
Consider one of these tests if no improvement with PPI test-and-treat
FIT more sensitive and specific than FOBT for detecting occult lower GI
FIT is not suitable for detecting gastric bleeding and should not be used if
the suspected source of bleeding is proximal to the ligament of Treitz
4. Guaiac-based FOBT (including Hemoccult II SENSA) best used to check for
occult upper GI bleeding
Multiple negative FOBTs or FITs do not exclude the presence of either upper
or lower GI blood loss
Diets high in red meat, iron, and vitamin C may cause false positive results
with guaiac-based tests.
Multiple negative FOBTs or FITs do not exclude presence of either upper or
lower GI blood loss
Diets high in red meat, iron, and vitamin C may cause false positive results
in guaiac-based tests
5. Complete blood count: Useful to evaluate for anemia, but neither sensitive nor
specific for GI bleeding
6. H. pylori testing: Should be performed only if clinician plans to offer treatment
for positive results.
7. H. pylori IgG serologic test:
A useful first-time test in population with high prevalence of active infection
Confirms evidence of past infection and an immunologic response
Cannot be used to confirm eradication of H. pylori after treatment
A test-and-treat strategy for both GERD and PUD is the most widely
accepted initial therapeutic intervention.
Often, patients begin a self-directed trial of over-the-counter
anti-secretory therapy (AST): either a histamine-2 receptor antagonist
(H2RA) or a PPI. Patients consult their primary care physicians
because their symptoms have persisted or because they would like a
prescription (to reduce out-of-pocket cost).
1. "PPI test" (short-term trial of a PPI)
Sensitive and specific for diagnosing GERD and can significantly
reduce the need for upper endoscopy/EGD and 24-hour pH
Saves over $350 per patient evaluated, reduces upper
endoscopies by 64%, and reduces the number of esophageal
monitoring tests by 53%
Anti-secretory therapy should be stopped after a successful 4 to
8-week course, or used on demand (only when symptoms recur).
Refer for upper endoscopy/EGD to rule out significant disease if:
There are alarm or extra-esophageal symptoms, or
In cases that do not respond to the test-and-treat strategy after 8
Endoscopy should include biopsies of gastric body and antrum to test
for H. pylori
Lifestyle modifications for patients with GERD (although there is little
evidence to support improvement in symptomatic outcomes in the absence
of pharmacotherapy):
Avoid large meals
Avoid acidic foods (citrus- and tomato-based products), alcohol,
caffeinated beverages, chocolate, onions, garlic, and peppermint
Decrease dietary fat intake
Avoid lying down within 3-4 hours after a meal. Avoid medications that may potentiate GERD symptoms, including
calcium channel blockers, beta agonists, alpha-adrenergic agonists,
theophylline, nitrates, and some sedatives
Elevate head of bed 10 to 20 cm (4-8 inches)
Avoid wearing clothing that is tight around the waist
Lose weight
Stop smoking
Domestic violence is a pattern of increasing episodes of violence in which one
partner exerts control over another through intimidation, physical and/or
emotional violence, and threats. It is common for there to be a tension-building
phase, a crisis phase—when overt violence is likely to occur—followed by a calmer
phase, when the abuser might ask for forgiveness and even be affectionate.
Unfortunately, in most cases, the cycle begins again, and often the violence is
increasingly severe.
25% of women in the U.S. report being victimized by an intimate partner at
some point in their lifetime.
Anyone is at risk for domestic violence, regardless of his or her education or
socioeconomic status. Domestic violence is based on issues of power and
While the majority of intimate partner violence (IPV) victims are women,
IPV victims are both male and female, occur in both heterosexual and
same-sex relationships, and cross all socioeconomic, age, and ethnic
In addition to the trauma incurred, the rates of chronic disease—including
heart disease, diabetes, depression and suicide—is significantly higher in
victims as well as in adults who were victimized as children as a result of
direct abuse and exposure to domestic violence.
Escaping is not always the best answer to domestic violence. Victims are at
their highest risk immediately around the time of escape, when the
perpetrator feels the power shift.
Domestic violence is a vicious cycle. Children tend to identify with the
same-sex parent. A girl exposed to domestic violence may identify with the
"victim mentality," that she should expect to be abused later in life because
her mother accepted this treatment. Similarly, a young boy who observes
abusive behavior may feel that it is okay to be an abuser, and may display
acting-out behavior. The risk to a child in a household where a parent is being abused is that the
child may be verbally abused, beaten, or worse by the abuser. Observing
and/or hearing physical abuse is especially devastating to children.
While alcohol and drugs do not cause domestic violence, violent offenders
are more likely to inflict harm when under the influence and when weapons
are readily available.
Gastritis: Mid-epigastric pain may be exaggerated by stress/emotions, diet,
medication—particularly non-steroidal anti-inflammatory drugs. Patients
frequently give a history of tobacco or alcohol use; they may use NSAIDs.
Patients may state that spicy foods seem to aggravate the pain. May have
nausea and decreased appetite. Bowels are usually not affected, unless
there is a component of irritable bowel syndrome and stress, in which case
there may be either decreased or increased stooling.
Irritable bowel syndrome (IBS):
Abdominal pain
Loose stools or diarrhea
Abdominal bloating
Increased flatulence
Mucus in stools
Diagnosis of exclusion
Symptoms can be initiated by gastroenteritis and can be aggravated
by stress, dietary changes or change in activity, often unpredictable.
Often starts with dull visceral pain in periumbilical region
Presentation hallmark: Fairly acute onset of moderate to severe right
lower quadrant pain.
Vomiting, nausea, loss of appetite, mild fever, and decreased stooling
or constipation.
Because of its morbidity and mortality, it is important to rule this out
with more history and a good physical exam.
Look for positive psoas sign, rebound tenderness.
Pelvic inflammatory disease (PID):
Abdominal or pelvic pain that is worse with sexual intercourse or with
activities such as running or jumping, which cause jarring of the pelvic
*Pathognomonic: Cervical motion tenderness, known as a positive
"chandelier sign"*
Mild menstrual irregularities
Significant morbidity, which increases with the severity of the disease
and length of time to diagnosis.
1 in 4 women who have a single episode of PID later experience tubal
infertility, chronic pelvic pain, or an ectopic pregnancy (as a result of
scarring and adhesions).
Tubal adhesions leading to infertility in 33% of women after their first
episode of PID, and up to 50% after the second pelvic infection.
Need sexual history for both partners, pelvic exam, labs, and imaging
Normal pregnancy
Growth of the uterus and stretching of the broad ligaments during a normal pregnancy can cause mild to moderate discomfort in the lower
Symptoms of nausea and vomiting could be caused by pregnancy.
This is more a diagnosis of exclusion, but you would not want to miss
a pregnancy. (Certain medications should not be given to women who
are pregnant. Fetuses should not be exposed to radiation.)
History and labs may be needed.
Ectopic pregnancy
Patients present with divergent symptoms ranging from no pain and
normal menses to intense pain and irregular or absent menses
Medical emergency. Early medical treatment reduces need for
surgery, but if a fallopian tube is in danger of rupture, surgical
intervention may be necessary.
Need date of the patient's last menstrual period (LMP), her menstrual
history, most recent intercourse dates, types of contraception used in
past few years, history of any vaginal or pelvic infections, and history
of previous ectopic or normal pregnancies
Patients who are pregnant, or even those in whom there may be the
suspicion of pregnancy, are at increased risk of being victims of
domestic violence.
The stress of being the victim of domestic violence may cause
irregular menses in some women.
Abdominal pain and cramping may come, not only from the inflicted
trauma, but also from the patient's somatization of her stress.
Bruises, of various colors, denoting various stages of healing, can be
seen on any part of the body, but especially on the abdomen as this
would cause trauma to a fetus, and because they would be less visible
to the general public.
Careful history: Be aware of the patient's body language and response
to touch. Consider the consistency of the history with the exam.
Examine the patient thoroughly in a gown so that all areas can be
If patient is trying to hide the diagnosis, serious injuries may be
missed, such as ruptured internal organs or fractures. There is always
a risk of recurrent violence. The source of the trauma should be
determined, because, for example, it might be life-saving to uncover
that the patient is at increased risk due to weapons in the home.
Generally a moderately severe to severe epigastric pain accompanied
by nausea and vomiting.
Usually a history of alcohol use/abuse or a family history of
Other causes include gallstones or hypertriglyceridemia.
Acute attacks generally require hospitalization.
KOH/Saline wet prep: Quick test. Could indicate inflammation (white blood
cells) or diagnose trichomoniasis, bacterial vaginosis, or yeast vaginitis.
Chlamydia/gonorrhea DNA probe: Preferred method for diagnosis of
chlamydia and gonorrhea because both can be performed with the same sample.
Sample can be endocervical, urethral, vaginal, or urine. Both diseases can present
with a yellow discharge, abdominal pain, and dyspareunia.
Gonorrhea culture: Good test for gonorrhea. Separate tests need to be done on
vaginal or urine samples. However, this is still the preferred method for sexual
assault tests, for tests of cure, and for oral and rectal specimens.
Urine dipstick: May help rule out a urinary tract infection (UTI).
Pap smear: Performed to detect cervical cancer, which is caused by the human
papilloma virus (HPV), a sexually transmitted disease
Urine pregnancy test: All women of childbearing age
Human chorionic gonadotropin beta subunit (HCG beta sub, or qualitative
beta HCG): Generally not indicated because of the sensitivity of the urine
pregnancy test. If results of a urine pregnancy test are inconclusive, a blood test
such as HCG beta sub would be needed.
Rapid plasma regain (RPR): Part of the STI screen to rule out syphilis
Human immunodeficiency virus (HIV): Part of the STI screen. Human Papilloma Virus (HPV):
Follow-up of Atypical Squamous Cells-Undetermined Significance (ASCUS)
on Pap
ASCUS is an abnormal Pap smear result (atypia without clear evidence
of intraepithelial lesions).
Early stage is treatable and may prevent progression to cervical
Reflex HPV: An abnormal Pap will automatically be tested for HPV. If the Pap is
normal, the HPV testing will not be done.
Colposcopy: Not indicated until second abnormal pap result, and/or if HPV is
Perform risk assessment for domestic violence, give patient information about
resources, and find out about local laws in regard to reporting exposure to
domestic violence.
Address the level 1. of risk and safety issues for the patient.
Give contact information to the patient and offer a means for them to
contact services while in your office (since it may be impossible for them to
access these resources from home).
o Local resources: National Domestic Violence Hotline at (800)
799-SAFE, TTY (800) 787-3224.
Acknowledge the abuse, recognize health implications, and share this with
the patient.
Even if not always in agreement with the decisions made by the patient, it is
important that you support her or his decisions.
Couple's therapy has been shown to increase the level of risk for the victim.
(Victim exposes the abuse, perpetrator feels like they are losing control and
tries to regain it through further violence.)
Cultural differences can give the appearance of abuse. Practicing sensitivity
in caring for patients from different backgrounds is key to a supportive
patient/physician relationship.
Laws differ from state to state. Know what the local laws are.
Whenever a child is abused, either intentionally or unintentionally, as
a result of intimate partner violence, all state law requires health care providers to report this abuse to child protection services.
Clinicians must also report any high-risk situation of intimate partner
violence in which children are at risk.
State laws are less consistent about whether exposure to domestic
violence in the absence of injury or serious risk of injury to the child
requires a report to children's protective services.
In some states, physicians must notify child protection services
whenever a child is in the home and has been exposed to a
parent's abuse, whether or not the child has been directly
In other states, a child's exposure to intimate partner violence
does not automatically require a mandatory child protection
The rules for victims who are adults and are not disabled vary
dramatically from state to state, from mandatory reporting for
evidence of abuse to reporting only if the victim asks the clinician to
do so.
Documenting abuse:
Document abuse history as reported by patient in the subjective. Use
patient's own words in quotes and fill in names after pronouns are
used. Use neutral language.
Give a detailed description of the patient's appearance, behavioral
indicators, injuries and stages of healing, and health conditions. If
patient consents, use photos to document injuries; one with a face
included in the photo, and then close-ups of the injury. If photos are
not possible, draw and describe injuries on a body map in blue ink, as
this is difficult to alter or reproduce.
Document results of health and safety assessments, recommendations
for support, and plans for follow-up as well as referrals and materials
given to the patient.
Include any laboratory and radiology tests ordered and results.
Maintain strict confidentiality.
1. Type II diabetes: Has become more common among 6-19 year olds (comprises 8-45% of all
new cases of diabetes).
The prevalence of diabetes mellitus in persons < 20 years old is about 1 in
Risk factors for diabetes in children include BMI ≥ 85%, an increased fasting
glucose level of ≥ 100 mg/dL, and an elevated fasting insulin level.
2.High cholesterol
10% of children 2-19 years of age have high cholesterol. This is higher
than it was previously.
The strongest risk factor for elevated cholesterol is elevated BMI.
3. Hypertension
Incidence in children has increased from 1-3% to currently up to 5-11% of
The strongest risk factor for hypertension in children is obesity.
Hypertension in children can lead to hypertension in adults and put them at
risk for cardiovascular complications.
4. Metabolic syndrome
Adults with at least 3 of the following:
Low high-density lipoprotein (HDL)
Elevated fasting blood glucose levels
Excessive waist circumference
Affects 20% of adults ages 20-40 and 40% of adults > 40 years of age
Increased risk for cardiovascular disease and diabetes
If we apply the diagnostic criteria to children, substituting elevated BMI for
waist circumference, we have started to see increased rates in adolescents.
Meeting criteria for metabolic syndrome and facing increased health risks
7% of overweight adolescents
29% of obese adolescents
50% of severely obese adolescents
Smoking also increases risk of metabolic syndrome.
5. Musculoskeletal disorders
Blount's disease
Slipped femoral epiphysis
Gastrointestinal disorders
Gallbladder disease
Early menarche
Polycystic ovary syndrome
Acanthosis nigricans
6. Psychosocial
Low self-esteem
Obstructive sleep apnea
Pseudotumor cerebri
Time is crucial.
Initial evaluationand treatment:
Triage patients with suspected stroke, regardless of severity of deficits
Complete evaluation and treatment plan within 60 minutes of patient's
arrival in the emergency department
If symptoms < 3 hours prior, preferentially route to a certified stroke center
Assess neurological deficits and possible co-morbidities:
The National Institutes of Health Stroke Scale (NIHSS) is awidely used
clinical assessment tool to help evaluate acuity of stroke patients, determine
appropriate treatment, and predict patient outcome.
*Evaluate for use of intravenous recombinant tissue plasminogen activator
Administration of rt-PA within 3 hours salvages hypoxic brain tissue.*
Emergency CT scan to look for:
Intracranial hemorrhage (contraindication for rtPA)
Nonvascular etiology of symptoms (e.g., brain tumor)
Early signs of infarction (correlated with a higher risk of hemorrhagic
transformation after treatment with thrombolytic agents)
While desirable to know the results of hematologic, coagulation, and
biochemistry tests before giving rtPA, thrombolytic therapy should not be
delayed while awaiting the results unless:
Clinical suspicion of a bleeding abnormality or thrombocytopenia
Patient has received heparin or warfarin
Use of anticoagulants is not known
Secondary prevention:
Antithrombotic therapy
For non-cardioembolic (atherothrombotic, lacunar) stroke or TIA:
Daily antiplatelet therapy:
Aspirin in combination with extended- release dipyridamole
(Aggrenox) reduces thrombotic stroke risk by 37% (compared to 18%
for aspirin alone).
Ticlopidine (Ticlid)
Marginally better than aspirin alone
Significant common side effects
Use in aspirin-sensitive patients*
Safety profile similar to aspirin
*Exceeds benefit of aspirin in stroke patients with co-morbid diabetes
and prior myocardial infarction*
For cardioembolic events:
*Warfarin (Coumadin) for long-term oral anticoagulation therapy
Goal = International normalized ratio (INR) of 2.5 (range 2.0-3.0)
Aspirin may be used if anticoagulation is contraindicated or unacceptable.*
Carotid endarterectomy or carotid artery balloon angioplasty and stenting is
recommended for patients with symptomatic carotid stenosis
1. Viral pharyngitis
Most common cause of a sore throat, often the first symptom of a viral
upper respiratory infection
Throat irritation
Non-descript rash
Rhinorrhea and/or cough
2. Mononucleosis
Etiology: Epstein-Barr virus (EBV) or cytomegalovirus (CMV)
Low-grade fever, pharyngitis, and lymphadenopathy
Posterior cervical adenopathy is common and specific for
Palatal petechiae of the posterior oropharynx distinguish infectious
mononucleosis from other causes of viral pharyngitis but do not
distinguish it from group A streptococcal pharyngitis, in which palatal petechiae may occur.
May have early appearance of faint nonpruritic maculopapular
generalized rash that rapidly disappears
Suspicion for this diagnosis usually occurs after a negative rapid strep
or throat culture in a patient who is ill for more than 7-10 days.
If misdiagnosed as strep and treated with amoxicillin or ampicillin,
90% of patients will develop a classic prolonged, pruritic,
maculopapular rash.
3. Group A Beta-hemolytic streptococcal (GABHS) pharyngitis
High fever
Anterior cervical lymphadenopathy
Tonsillar exudates
Palatal petechiae (7% sensitive; 95% specific for GABHS pharyngitis)
Tongue may be bright red with white coating (strawberry tongue)
Usually no rhinorrhea, cough, or conjunctivitis
Scarlet fever: Diffuse, punctate, blanching, erythematous,
sandpaper-like texture accentuated in body folds and creases (Pastia's
lines). Begins around the neck, axillae, and groin and then spreads
over the trunk and extremities.
Non-suppurative (rare but serious): Rheumatic fever,
post-streptococcal glomerulonephritis
Suppurative: Peri-tonsillar abscess, bacteremia, endocarditis,
pneumonia, mastoiditis, meningitis, otitis media, and cervical
4. Peri-tonsillar abscess
Difficulty swallowing
Neck or ear pain
Muffled "hot potato" voice
Asymmetric tonsillar enlargement and deviation of the uvula
No imaging studies are recommended in the initial evaluation of rotator cuff
X-ray indicated in the setting of acute injury if fracture and/or dislocation
are suspected. In a chronic setting, X-rays are warranted if there is concern
for a "red-flag" diagnosis such as infection or tumor. X-ray findings in the
setting of rotator cuff tendonitis or other pathology like impingement may
be normal or demonstrate calcium deposits in the region of the rotator cuff
attachment to the greater tuberosity of the humerus ("calcific tendonitis").
Rotator cuff tears may be indirectly suggested on plain film radiographs by
the narrowing of the subacromial space. Other areas of interest with plain
film radiographs of the shoulder include the acromioclavicular and
glenohumeral joints to check for degenerative or inflammatory changes.
Magnetic Resonance Imaging (MRI): The most commonly used
advanced imaging study of the shoulder used to evaluate for rotator cuff
and related soft tissue injury. The sensitivity of MRI imaging for rotator cuff
tears is excellent, though it should be noted that a number of older adults
will demonstrate tears of the rotator cuff on MRI imaging in the absence of
significant symptoms or dysfunction.
Computed Tomography (CT) imaging of the shoulder is indicated in the
setting of complicated fracture, suspected tumor, or in situations where MRI
is contraindicated. CT arthrograms are rarely performed on the shoulder,
though may be both diagnostic and therapeutic in the setting of adhesive
capsulitis and can indicate a rotator cuff tear.
Ultrasound imaging is becoming increasingly common in the US, and is
desirable for its lower cost and lack of radiation exposure.