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Terms in this set (251)

Breast Cancer:
Screening mammography, with or without clinical breast examination (CBE),
every 2 years for women aged 50 and older. (Grade: B Recommendation.)
Refer women whose family history is associated with an increased risk for
deleterious mutations in BRCA1 or BRCA2 genes for genetic counseling and
evaluation for BRCA testing. (Grade: B Recommendation.)

Colorectal cancer:
Colorectal cancer is a good candidate for screening because it is common
(about 150,000 people are diagnosed in the U.S. each year), causes much
suffering (including about 50,000 deaths per year in the U.S.), has a long
preclinical phase, and early detection definitely improves outcomes.
USPSTF recommends fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75
years (Grade: A Recommendation).
If life expectancy is limited to less than 10 years (due either to age or to
life-limiting health problems), there is unlikely benefit to screening.
Cost-effective (less than $30,000 per additional year of life gained), though
no one screening method appears to be more cost-effective than the others.
It has been estimated that routine screening could save 18,800 lives per
year.
CT colography (sometimes referred to as virtual colonoscopy) is a
developing method of colon cancer screening. To date, there are no data
demonstrating improved outcomes for patients undergoing this test for
cancer screening. Smaller and flatter polyps are difficult to see via CT scan
and there is still variable skill at this procedure by radiologists.
*Due to its low sensitivity and low specificity, annual rectal exams with
guaiac testing is not an acceptable method of screening for colon cancer.*
1. Depression
One of the most common causes of fatigue
Needs to be evaluated in all patients presenting with this complaint
Can cause either increased sleep or decreased sleep
Depression screen: "Over the past few week.."
Have you found yourself feeling down, depressed, 1. or hopeless?"
2. Have you had little interest or pleasure in doing things?"
2. Obstructive sleep apnea
Associated with increased somnolence and non-restorative sleep, typically in
an obese patient.
Patients report improved wakefulness with activity.
Patients' partners often report snoring or altered breathing while asleep.
3. Anemia
Rectal bleeding and pallor are both indications of possible anemia.
Pale conjunctivae more reliable than skin pallor.
In adult men and post-menopausal women, *gastrointestinal (GI) blood loss
is the most likely cause of iron deficiency anemia*.
Bright red blood per rectum suggests lower GI tract bleeding such as:
Colorectal carcinoma
Colon polyps
Bleeding diverticuli
Guaiac-positive stool that is brown (chronic bleeding) or black (brisk
bleeding) suggest upper GI blood loss such as:
Peptic ulcer disease
Gastritis
Chronic hematuria can cause iron deficiency but is relatively rare. It can be
caused by nephritic syndromes, renal cancers, and bladder cancers.
Jejunal diseases and celiac sprue can lead to iron deficiency. Corresponding
history includes crampy abdominal pain or diarrhea.
Poor dietary intake may lead to iron deficiency (e.g., vegans may become
iron deficient). This may be exacerbated by menstrual blood loss among
young women. Dietary iron deficiency is a rare cause of anemia in the U.S.
4. Occult malignancy
Occult malignancy should always be considered in cases of unexplained
fatigue and is typically associated with other constitutional symptoms such
as weight loss, night sweats, or fevers.
5. Coronary artery disease
Coronary artery disease is the leading cause of death among North
American men.
Should always be considered in adults with fatigue, especially if they report
fatigue with exertion that is relieved with rest.
Consider risk factors for coronary artery disease. If there is not another,
more likely diagnosis, a stress test may be appropriate.
1.Anoscopy: Brief procedure that involves passing a short tube about 10
centimeters long into the rectum to look for hemorrhoids and other causes of
bleeding. It is a useful part of the evaluation of rectal bleeding. Some sources of
bleeding, such as anal fissures and some internal hemorrhoids, are easily treated
and can sometimes be missed with the colonoscope.
2.Colonoscopy: A colonoscope is a long, thin, bendable tube with a light and lens
at the end for viewing. It is inserted through the rectum into the colon. It also has
a tool to remove polyps or tissue samples, which are checked under a microscope
for signs of cancer.
Evaluation of bright red rectal bleeding warrants investigation as some
causes are serious. In younger patients, flexible sigmoidoscopy may be
sufficient and exposes the patient to fewer risks. If the patient is over 50
without a screening colonoscopy, opt to do a full evaluation of the colon with
colonoscopy, which can detect hemorrhoids, diverticuli, and polyps. 3.If the
colonoscopy does not reveal any issues, then perform an upper
gastrointestinal endoscopy to rule out other GI causes of iron deficiency,
such as gastric ulcers.
Side effects
Perforation: 4/10,000 procedures in the United States
Major bleeding: 12.3 per 10,000 procedures.
Serious complications (deaths or events requiring hospital admission,
including perforation, major bleeding, severe abdominal pain, and
heart problems): 25/10,000 procedures or 1 in 400 colonoscopies.
False-positive and false-negative results
Upper GI endoscopy: Detects other causes of bleeding, such as gastric ulcers.
Epidemiology: *Testicular cancer is the most common malignancy affecting
males between the ages 15 and 35*, although it accounts for only one
percent of all cancers in men. It is most common among African-Americans
with a frequency of 1.6 per 100,000.
Classification: There are 3 main types of testicular tumors:
*Germ cell tumor (GCT)
95%* of all primary testicular tumors
Classified as either seminoma (45%) or nonseminoma (50%),
based on histology
Seminoma more common than NSGCT (which include mixed
GCTs, teratomas, and teratocarcinomas)
Non-germ cell (e.g., Leydig cell and Sertoli cell tumors)
5% of all primary testicular tumors
Malignant in only about 10% of cases
2.
Extragonadal
Lymphoma, leukemia, and melanoma are the most common
malignancies that metastasize to the testicle.
3.
Presentation: Testicular tumors could present as a nodule or as a painless
swelling of the testicle, 30% to 40% may present with dull ache or heavy
sensation in the lower abdomen, perianal area, or scrotal areas. Acute pain
is the presenting symptom in 10% of cases.
Screening: The USPSTF recommends against routine screening for
testicular cancer in asymptomatic adolescents and young adults.
Risk factors:
Genetics: Individuals with Klinefelter's syndrome (47XXY) have a
higher incidence, and their first-degree relatives have 6-10 times the
risk of the normal population. Other congenital conditions (such as
Down syndrome, testicular faminizing syndrome, true hermaphrodites,
persistant mullerian syndrome, and cutaneous ichthyosis) are also at
higher risk for developing germ cell tumors.
Family history: Reported 6-fold increased risk among male offspring of
a patient with testicular cancer.
Cryptorchidism (the absence of one or both testes from the scrotum,
usually as the result of an undescended testis): Individuals with
cryptochordism have a 20 to 40-fold increased risk. Orchiopexy, even
at an early age, appears to reduce the incidence of germ cell tumor
only slightly.
Environmental hazards: Industrial occupations and drug exposures
including diethylstilbestrol (DES), Agent Orange, and solvents used to
clean jets and ochratoxin A have been implicated in the development
of testicular cancer.
Testicular cancer: 1-2% will develop a second primary cancer in the
contralateral testicle (a 500-fold increased risk over normal
population).
Occurs when the testicle rotates around its vascular
supply. Timely diagnosis and treatment are vital for survival of the testis.
True testicular torsion is a surgical emergency with a limited window of
opportunity of four to twelve hours after the onset of pain to save the
testicle, which is accomplished by untwisting of the spermatic cord.
Presentation: Painful testicular swelling. Patients present with abrupt
onset of scrotal, inguinal, or lower abdominal pain. May occur several
hours after vigorous physical activity or minor testicular trauma. The
pain is severe, and the patient appears uncomfortable. May be
associated nausea and vomiting. (When present, nausea and vomiting
have been shown to have a positive predictive value of 96% and 98%,
respectively, for spermatic cord torsion.) There may be prior similar
episodes that might suggest intermittent testicular torsion with
spontaneous detorsion.
Epidemiology: Testicular torsion is not common. Each year only one in
4,000 men younger than 25 are diagnosed. Most common in neonates
and boys going through puberty, with peak ages being the first year of
life and age 14 years old. The majority of cases of testicular torsion occur between the ages of 12 and 18 years; however, can occur in
males of any age.
Etiologies:
Congenital anomaly: Failure of normal posterior anchoring of the
gubernaculum, epididymis, and testis is called a "bell-clapper
deformity" because it leaves the testis free to swing and rotate
within the tunica vaginalis of the scrotum, much like the gong
(clapper) inside of a bell. A large mesentery between the
epididymis and the testis can also predispose itself to torsion.
Contraction of the muscles shortens the spermatic cord and may
initiate testicular torsion.
Undescended testes: Although there is little solid evidence, the
incidence of testicular torsion is thought to be higher in
undescended testes than in normal, scrotal testes. Torsion of an
undescended testicle often occurs with the development of a
testicular tumor, presumably caused by increased weight and
distortion of the normal dimensions of the organ.
Recent trauma to the genital area, hard physical work, or
vigorous exercise may also cause testicular torsion. However,
testicular torsion may also occur without any apparent reason
Inguinal hernia: A painless swelling in the inguinal region that can be
enhanced by maneuvers that raise intra-abdominal pressure, such as cough
or Valsalva maneuver. The swelling becomes painful and tender when it is
incarcerated.
There are two types of inguinal hernia, direct and indirect, which are defined by their relationship to the inferior epigastric vessels. Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal, which is formed by the transversalis fascia. Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis
Henoch-Schönlein purpura (HSP): Characterized by
nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain,
gastrointestinal bleeding, and occasionally scrotal pain. The onset of scrotal
pain may be acute or insidious. In boys who lack other characteristic
findings of HSP, sonography can usually distinguish HSP from testicular
torsion. Treatment of HSP is supportive.
Referred pain: Boys who have the acute onset of scrotal pain without local
inflammatory signs or a mass on examination may be suffering from
referred pain to the scrotum. The scrotal pain is caused by three somatic
nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves. Retrocecal appendicitis is an important and rare
cause of referred scrotal pain in children and adolescents.
1. Asthma: Onset 1. is typically early, such as in childhood.
2. Bronchitis: Chronic bronchitis (productive cough for at least three months
for the past two years) differs from acute bronchitis (cough and shortness of
breath of 2-3 weeks duration) in having long-term inflammation that can
lead to irreversible structural changes.
3.
Congestive heart failure (CHF):
Dyspnea is one of the cardinal manifestations of CHF, but it is a
relatively nonspecific finding as it occurs with all of these diagnoses.
One study found that dyspnea on exertion has a specificity of only
17% for CHF.
PND is most closely associated with CHF. At night, when recumbent
for an extended period, peripheral edema is reabsorbed, increasing
total blood volume and blood pressure and leading to pulmonary
hypertension in people with underlying left ventricular dysfunction.
The pulmonary hypertension leads to pulmonary edema.
Orthopnea is often a symptom of left ventricular heart failure and/or
pulmonary edema. However, it can also occur with pulmonary
pathology such as asthma and chronic bronchitis, as well as in those
with sleep apnea or panic disorder. The absence of orthopnea or PND
makes CHF unlikely.
3.
4. Chronic obstructive pulmonary disease (COPD): Dyspnea on exertion: Cardinal symptom of COPD.
COPD develops slowly over years, so most people are at least 40
years old when symptoms begin.
Cigarette smoking is the most commonly encountered risk factor for
development of COPD. The risk is dose-related.
A winter cough that is becoming worse could indicate COPD, as
breathing cold, dry air causes constriction of the airways and restricts
air flow.
5. Lung cancer: Cigarette smoking is the single most important risk factor for
developing lung cancer and COPD. It also poses a risk factor for CAD, a
common cause of CHF. Asthma and pneumonia occur more frequently in
smokers, but the association is not as strong as it is with lung cancer and
COPD.
6. .
Pneumonia: 6. Unlikely in the absence of a fever and purulent sputum.
Also called spirometry, PFT is the most commonly used office-based device for
lung function screening.
Test Method:
Patient is asked to exhale completely, then to inhale deeply. This maneuver
is then followed by a rapid exhalation so that all the air is expelled from the
lungs. This measures the inspiratory and expiratory flow of air.
Forced Expiratory Volume in 1 second (FEV1), is the amount of air the
patient can expel in one second after having inhaled a full breath.
Forced Vital Capacity (FVC), is the total amount of air that the patient can
take into the lungs.
Results of spirometry tests vary, but are based on predicted values of a
standardized, healthy population.
Diagnosis of COPD:
Spirometry (PFTs) is the gold standard for diagnosing COPD.
COPD causes the air in the lungs to be exhaled at a slower rate and in a
smaller amount compared to a normal, healthy person (obstructive defect).
The amount of air in the lungs will not be readily exhaled due to either a
physical obstruction (such as mucus production) or airway narrowing caused
by chronic inflammation.
If the FEV1 to FVC ratio (FEV1/FVC) is less than 70% of predicted (or less
than the 5th percentile), then the patient has COPD.
Spirometry is sensitive enough to detect COPD in its early stages, long
before disabling effects are apparent. It should, therefore, be used as a
screening tool to confirm the presence of the disease in any patient thought
to be at risk of COPD.
However, the U.S. Preventive Services Task Force (USPSTF) and the
American College of Physicians do not recommend screening spirometry in
asymptomatic adult patients. Some experts recommend spirometry in
smokers over 45 years of age, but this recommendation may be based on
the testing increasing smoking cessation rates.
1.Bronchodilators:
Bronchodilators improve lung function by altering airway smooth muscle
tone and reducing dynamic hyperinflation.
Types of bronchodilators include:
-Beta-2 agonists (short-acting and long-acting)
Risks of overuse of beta-2 agonists include: tachycardia,
exaggerated somatic tremor, and hypokalemia (especially with
concurrent use of thiazide diuretics).
-Inhaled long-acting anticholinergics
oral methylxanthines.
All symptomatic patients with COPD should be prescribed a short-acting
bronchodilator such as albuterol on an as-needed basis. If symptoms are still
inadequately controlled, a daily dose of an anticholinergic or a long-acting
bronchodilator should be added.
The choice between beta-2-agonist, anticholinergic, theophylline, or combination
therapy depending on availability and individual response in terms of symptom
relief and side effects. Combining bronchodilators of different pharmacological classes may improve
efficacy and decrease the risk of side effects compared to increasing the dose of a
single bronchodilator. For moderate COPD, maintenance therapy of* inhaled
anticholinergics (ipratroprium or tiotroprium) alone or in combination with short
acting beta-2 agonists could be utilized.*
Bronchodilators and other inhaled medications are often administered with a
metered dose inhaler (MDI). (See "Skills" for how to teach a patient to use the
MDI and spacer.) Studies have shown that an MDI and spacer achieves equal or
better results than a nebulizer.
Inhaled glucocorticosteroids
1.Since infection is a common cause of COPD exacerbations, offer immunizations
that might avert certain infections.
Influenza:
Recommended annually for every adult 50 years old and older.
Reduces serious illness and death in COPD patients by about 50%.
Dispensed in two ways:
Inactivated preparations injected intramuscularly. More
effective in elderly patients with COPD, and therefore is
recommended for all adults.
Live-attenuated vaccines administered intranasally. Approved
by the United States Food and Drug Administration for healthy
adults up to 49 years old.
Neither of these vaccines should be given to patients with a history of
anaphylaxis to eggs.
The strains are adjusted each year for appropriate effectiveness and
should be given once each year.
Fewer than five percent of patients experience side effects including:
low grade fever and mild systemic symptoms for 8-24 hours
post-immunization.
2.Pneumococcal polysaccharide vaccine
Recommended for all people 65 years and older.
Reduces the incidence of community-acquired pneumonia in COPD
patients younger than age 65 with an FEV1 < 40% of predicted.
Recommended in patients younger than 65 years old who have certain
health conditions such as chronic lung disease.
Administered intramuscularly as a 0.5 mL dose at a site separate from
the influenza vaccine.
Approximately one-third of patients receiving pneumococcal vaccine
demonstrate mild side effects such as pain, erythema and swelling at
the injection site. Fever and myalgias and more severe local reactions
are rare.
3. TdaP
Contains tetanus toxoid, diphtheria, and acellular pertussis. Previously
the recommendation was to administer all tetanus boosters without
the pertussis antigen. But this recommendation has changed because
of the increasing incidence of pertussis (whooping cough) and the
development of an acellular pertussis component for the vaccine,
reducing the side effects. Currently, this is a one-time booster, with
Td recommended every 10 years following
the initial TdaP.
Vaccine administration procedure: Specified on the manufacture's package
insert. Most adult vaccines are given either:
Intramuscularly with a 1.0 to 1.5 inch needle to achieve at least 5 mm
of deltoid muscle penetration, or
Subcutaneously with a 23-25 gauge needle with a needle length of
5/8 to ¾ inch.
1.Inhaled bronchodilators (particularly inhaled beta 2-agonists with or without
anticholinergics) and 2. oral glucocorticosteroids are effective treatments for
exacerbations of COPD.
3. Antibiotics should be given to patients with exacerbations of COPD if they:
Have all three of the following three cardinal symptoms: *increased
dyspnea, increased sputum volume, and increased sputum purulence*
Have two of the cardinal symptoms (if increased purulence of sputum
is one of the two symptoms)
4. Require mechanical ventilation (invasive or noninvasive)
Noninvasive mechanical ventilation in exacerbations:
Improves respiratory acidosis
Increases pH
Decreases the need for endotracheal intubation
Reduces PaCO2, respiratory rate, severity of breathlessness, the
length of hospital stay, and mortality.
Medications and education to help prevent future exacerbations should be
considered as part of follow-up, because exacerbations affect the quality of
life and prognosis of patients with COPD.
Educate the patient about COPD exacerbations
Instruct patients to call if symptoms get worse (becomes much harder
to take a breath) or if they have chest tightness, more coughing or a
change in cough (becomes more productive, more mucus is expelled),
with or without a fever.
Instruct patients to seek emergency help if usual medications are not
working and they have one or more of the following:
Unusual difficulty walking or talking (such as difficulty
completing a sentence)
Heart is beating very fast or irregularly
Lips or fingernails are gray or blue
Breathing is fast and hard, even when using medication
Emphasize the importance of regular checkups to assess response to
treatment (via PFTs) and nutrition monitoring.
Mr. Marshall, a 72-year-old retired school
principal with past medical history significant for hypertension, chronic obstructive
pulmonary disease, and moderate Alzheimer's dementia diagnosed four years
ago, is brought to the office by his wife. She reports increased confusion,
nighttime restlessness, visual hallucinations, and urinary incontinence - all over
the past four days. His general physical exam is unremarkable with the exception
of slight tachypnea, and a mildly enlarged prostate. A Mini-Mental State Exam MMSE) is administered and interpreted, and Mr. Marshall's MMSE score is noted
to have worsened from a baseline of 18 to 12 today.
In the evaluation of this acute change in mental status, students learn about the
etiology and diagnosis of dementia and how to differentiate between the
presentations of delirium, depression, and dementia. They consider the differential
for delirium and order tests to rule out easily treatable causes.
When urinalysis indicates the presence of a urinary tract infection (UTI), Mr.
Marshall is admitted to the hospital where his UTI is treated with IV ceftriaxone
and his delirium is treated with a variety of pharmacological and
non-pharmacological approaches. Mr. Marshall's delirium clears rapidly with the
treatment of his UTI and he is discharged from the hospital after two days with an
oral prescription of cephalexin to finish his course of antibiotics.
After his discharge from the hospital, Mr. Marshall is seen in the office again, and
the course of Alzheimer's dementia and short and long-term treatments are
discussed. Special attention is also given regarding available options to reduce
his wife's caregiver stress.
Urinary Tract Infection (UTI): UTI is among the most common causes of
delirium in older patients. Such patients are seldom able to identify the
common symptoms of UTIs such as dysuria or frequency, so the absence of
these symptoms does not rule out this diagnosis. UTIs also may cause or
exacerbate urinary incontinence
1.
Respiratory Infection: Respiratory infections (e.g., pneumonia) frequently
complicate dementia and often cause delirium in such patients. The
mortality rate of patients with advanced dementia is high and is primarily
attributable to infections such as pneumonia and urosepsis. Aspiration
pneumonia may also cause delirium.
2.
Electrolyte Disturbance: A wide range of electrolyte disturbances may
cause delirium (e.g., hypo or hypernatremia, hypercalcemia, hypokalemia,
and metabolic acidosis [leading to tachypnea, or compensatory respiratory
alkalosis]). These conditions are easily detected and highly treatable, so
they should always be considered in the work-up of acute change in mental
status and delirium.
3.
Urinary Retention: Any condition that makes patients uncomfortable may
cause delirium in a patient with dementia. Chronic urinary retention (most
commonly due to benign prostatic hypertrophy [BPH]) leads to incomplete
emptying and distention of the bladder (may be palpated in the suprapubic
area), which further may lead to UTI and overflow incontinence. Risk factors
for urinary retention include male sex, age over 70, and BPH. When this is a
consideration, a post-void residual should be measured.
4.
Pain: Pain from any source may cause delirium among patients with
dementia. This presents a clinical challenge, since the treatment of pain with
opiates also can cause delirium. Since patients in this condition are
frequently unable to localize and report their symptoms, it is important to
perform a full physical exam looking for hidden sources of pain (abdominal
tenderness, joint or bony injury).
Short course of oral haloperidol
Aids sleep
Diminishes agitation
Clears hallucinations
Possible side effects: Sedation, constipation, tardive dyskinesia
Some providers prefer newer atypical antipsychotics such as
olanzapine and quetiapine, which have fewer extrapyramidal side
effects. However, these agents can lead to a prolonged QT interval
and do not have the long safety record of haloperidol.
Off-label use of atypical antipsychotic medications for symptoms such as
psychosis, mood alterations, and aggression associated with dementia in
elderly patients can have a small but statistically significant benefits for
aripiprazole, olanzapine, and risperidone. However, these agents can lead to
a prolonged QT interval and don't have the long track record of haloperidol.
A one-to-one sitter can reduce confusion and minimize use of physical and
chemical restraints.
Frequent reorientation and redirection
Avoid sedative medications and medications with anticholinergic effects
(e.g., narcotics, benzodiazepines, and tricyclic antidepressants).
Mobility and range of motion exercises provide physical touch, cognitive and sensory stimulation, and can prevent decubitus ulcers.
Minimize unnecessary lines, cables, and catheters.
Interventions that increase stimulation seem effective at preventing or
minimizing delirium (e.g., rooms with adequate lighting, windows, large
clocks, calendars, and close to the activity of the nursing station).
Visual and hearing disturbances can contribute to delirium. Dim lighting,
ambient noise, and the removal of hearing and visual aids therefore should
be avoided.
1. Four *anticholinesterase inhibitors (donezepil, rivastigmine, tacrine and
galantamine*) show statistically significant, though clinically small, benefits
for patients with mild to moderate dementia.
2.The use of vitamin E in the treatment of dementia is controversial. The
American Academy of Neurology recommends the use of vitamin E in the
management of dementia, but concern has arisen from a recent
meta-analysis of vitamin E supplementation that demonstrated a rise in all
cause mortality. Clinicians should discuss the potential risks and benefits
with patients and their families on an individual basis.
3.*Memantine (Namenda) is an N-methyl d-aspartate (NMDA) receptor
antagonist* that is approved by the Food and Drug administration for use in
moderate to severe dementia. Studies show it leads to small but
statistically significant improvements in cognition.
For patients with dementia living at home, provide support and respite to their caregivers.
Medicare and most private insurances will cover a short stint of skilled
services (nursing, physical therapy, speech therapy, etc.) at home.
Home health aides help with ADLs such as bathing and dressing;
homemakers assist with some IADLs such as laundry, light
housework, and errands; and companions provide sitting and respite
services. These types of "non-skilled" services are not covered by
most insurance plans, and generally cost between 15 and 30 dollars
an hour.
If there is a need for skilled services, Medicare will cover 100% of the
cost for the first 20 days of a nursing home stay after a
hospitalization. Long-term care is not covered at all, however. Adult
day programs cost anywhere from 50 to 100 dollars a day, while
nursing homes cost between 150 and 250 dollars a day. Most states
have payment assistance programs to help families that cannot afford
these rates, but still the costs can be prohibitive.
Identification of factors that exacerbate neuropsychiatric effects (e.g.
aggression and psychosis) can lead to specific approaches to alleviate
the problem (for example, recognition and treatment of constipation
leading to agitation). The atypical antipsychotics olanzapine (Zyprexa)
and risperidone (Risperdal) are also useful, but may increase
mortality. Behavioral interventions should be used first.
Cognitive rehabilitation therapy and gingko biloba therapy have not
been proven useful in the management of Alzheimer's dementia.
1.Chest x-ray: rule out other contributing causes of dyspnea.
Cardiomegaly: Defined when the width of the heart is more than half of the with of the thorax.
Central vascular congestion and hilar fullness: Patients in failure frequently have hilar fullness on a PA chest film.
Individual vessels may appear enlarged. The azygous vein is frequently identified as an almond-shaped density
just above the right main bronchus.
Pleural effusions: Identified by a blunting of the costophrenic angles. This can be seen posteriorly on a lateral film
as well. Occasionally, prominent fluid in the horizontal fissure will be seen in the right lung.
Cephalization of pulmonary vasculature: Typically, pulmonary vessels are not well seen in the upper lung fields. In
CHF, however, they become engorged and can be seen extending from the hilum.
Kerley B lines: These are small linear densities 2-3 cm in length seen in the periphery of the lung fields on the PA view. They represent interstitial fluid in the lung tissue.
2. EKG:
Determine if in sinus rhythm (P-wave before every QRS)
Rate
Axis (normal when QRS complex is upwards in I and AVF)
Intervals
Signs of ischemia:
T-wave inversions may indicate prior injury or acute ischemia
ST-elevations
Signs of left ventricular hypertrophy (LVH)
Variety of insensitive criteria for diagnosing LVH by EKG
ST-depressions (often downward sloping) with T-wave inversions in the lateral precordial leads.
Very large S-wave in V3
Echocardiography is the test of choice to assess presence of LVH.
3. Echo/ Doppler: (Establish diagnosis and guide therapy)
Measures the size of the chambers, the thickness of the walls, and the size of the cavity.
Evaluates the movement of heart structures.
Doppler assesses blood flow (direction and velocity) through the valves and chambers.
Measures ejection fraction, which is an indication of the severity of the CHF.
Ejection fraction of greater than 45% along with symptoms of heart failure, indication of diastolic dysfunction
1. Complete blood count: Iron deficiency anemia
Common in women of reproductive age
Augments fatigue
Responsive to therapy (oral iron)
2. Pregnancy test: Should be done on every woman of reproductive age with any changes in bleeding pattern or amount.
Normal pregnancy
Ectopic pregnancy (life-threatening)
Unusual forms of pregnancy, like molar pregnancies.
3. Ultrasound: Study of choice for pelvic pathology.
Intracavity: Sensitivity 60%, specificity 93%.
Intramural: Sensitivity high, not as high.
High positive predictive value for detecting adenomyosis.
Does not require any radiation to the ovaries (CT scans will), no intravenous dyes are needed, and it is generally
painless for the patient.
The pelvic ultrasound does require an intravaginal portion and all women should be told this in advance from their
physician. (Not painful but can cause psychologic distress) from patients not realizing this will be done.
Acceptable initial evaluation whenever the physician thinks the patient has secondary dysmennorhea, based on
clinical history and physical exam.
4. Thyroid disorders:
Easy to check for and easy to treat. Fatigue and bowel symptoms overlap.
Thyroid disorders primarily effect frequency of menses and should be considered if other causes of abnormal
bleeding are excluded.
Hypothyroidism is common in women of reproductive age.
The American College of Obstetrics and Gynecology has not recommend this test for all women initially without
compelling history. However, guidelines from the United Kingdom do recommend thyroid testing.
Computed tomography (CT) scans: Do not give a well-defined look at pelvic pathology and are not routinely used for
gynecologic problems
Magnetic resonance imaging (MRI): being used more often in diagnosing gynecologic pathology.
Adenomyosis and leiomyomas.
More accurately assess changes in tumor volume preoperatively.
Can give better analysis of ovarian masses as well.
Expensive and time-consuming.
Not used as an initial study for secondary dysmenorrhea, menorrhagia, or a patient with both.
Testing for von Williebrand's disease: In the initial work-up of just dysmenorrhea, this is never recommended.
However, when dysmenorrhea is added to menorrhagia, it should be considered.
1. *Serotonin reuptake inhibitors
Most effective treatment for premenstrual syndrome.
Continuous daily treatment.*
Intermittent treatment just as effective for decreasing both psychologic and physical symptom and is
associated with less side effects and cost.
Start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts.
Start on the first day a woman has symptoms and continue until the start of menses or three days
later.
If one medication does not work, another in the same class should be tried prior to considering the
treatment a failure.
Follow-up should occur after two to four cycles.
2. Oral contraceptives
Effective for dysmenorrhea, anovulation, and in some cases menorrhagia.
Ethinyl estradiol and drospirene decreased the placebo pills to four days from seven.
3. Danazol
Androgen with progesterone effects.
Inhibits ovulation.
Side effects: weight gain, suppressing high density lipids, and hirsutism.
4. Other GnRH agonists (leuprolide)
Effective at treating premenstrual syndrome through ovulation inhibition.
Anti-estrogen effects (hot flashes and vaginal dryness) make this not as popular.
Oophorectomy: For severe refractory cases in women done with childrearing.
Spironolactone: Inconsistent effectiveness for bloating, weight gain, and breast tenderness.
Vitamin B6: Inconsistent data regarding effectiveness. Patients should be cautioned about overdosing as it may
cause peripheral neurotoxicity.
Other non-drug interventions:
Regular exercise, decreasing carbohydrates in the luteal phase, and relaxation therapy - mildly effective.
Human milk is recognized by the American Academy
of Pediatrics as the optimal food for infants. (Breast milk plus fortifier is
recommended for premature babies.)
Absolute contraindications to breastfeeding are rare and may include
1. maternal HIV infection, 2.active maternal drug abuse and 3. infants with
galactosemia.
Exclusive breastfeeding is recommended for the first 6 months of life, and
then breastfeeding plus complementary foods until the infant is at least 12
months of age.
1. Stimulates gastrointestinal growth and motility
2. Decreased risk of acute illness during time infant is fed breast milk
Lower rates of diarrhea, acute and recurrent otitis media, and urinary tract
infections
3.Associations between the duration of breastfeeding and a reduction in incidence of obesity, cancer, adult coronary artery disease, certain allergic
conditions, type 1 diabetes mellitus, and inflammatory bowel disease
4.Small neurodevelopmental advantages, including cognitive and motor
development
5. Potential maternal benefits, including decreased risk of breast and ovarian
cancer and osteoporosis.
Prior to hospital discharge, evaluate mother and baby for adequacy of
latch-on, suckling and milk transfer and progress of lactogenesis (milk
production).
Provide mothers with the education, resources and follow-up to ensure
breastfeeding success.
Mothers should nurse their babies whenever there are signs of hunger,
which often is 8-12 times per day.
Within 24 to 48 hours after discharge an in-home lactation specialist or
physician should
1.Sensory impairment: Hearing or vision impairment can mimic inattention.
2.Sleep problems: Inadequate sleep—due to obstructive sleep apnea,
narcolepsy, or poor sleep hygiene—may adversely affect schoolvperformance. Patients with ADHD often have poor sleep hygiene, but
typically do not seem overtired.
3.vMood disorder: The prevalence of mood disorders increases with age.
Depression affects an estimated 1-2% of elementary school age children
and 5% of adolescents. Depressive symptoms may mimic inattention. Childhood depression has high rate of conversion to bipolar disorder, which
may look like hyperactivity. Children with ADHD have a higher rate of mood
disorders than control populations. These disorders may mimic or
accompany ADHD.
4. Learning disability: A disorder of cognition that manifests itself as a problem involving academic skills. Most states require documentation of a
discrepancy between intelligence quotient (IQ) and academic achievement for the diagnosis of a learning disability. Learning disabilities clearly impair academic performance, but may also lead to behavioral and attention
problems, particularly at school. Poor school performance frequently
prompts the evaluation for ADHD. Inattention may stem from an
inappropriate classroom assignment (applies to gifted students as well). Comorbidity between learning disabilities and ADHD is common; many
experts feel that one diagnosis should not be made without evaluating for
the other. An educational assessment should be part of the evaluation for
any child with behavioral problems and poor school performance..
5. Oppositional defiant disorder (ODD): Characterized by a pattern of
negativistic, hostile, and defiant behavior. Conduct disorder (CD) is a more
severe disorder of habitual rule-breaking, characterized by a pattern of
aggression, destruction, lying, stealing, and/or truancy. ODD and CD have
high comorbidity rates with ADHD.
Transmission

The case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than two thirds of reported cases in the U.S. now occur.


The signs and symptoms of primary pulmonary tuberculosis (due to M. tuberculosis) in most children are few to none, often in sharp contrast to their degree of radiographic changes.More than 50% of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing.

Lung Findings
The hallmark of tuberculosis in the lung is a primary complex (relatively large size of the hilar lymphadenopathy compared with the relatively small size of the initial lung focus).
The common sequence is hilar adenopathy (C), focal hyperinflation and then atelectasis, with minimal evidence of the primary lung focus itself.
Small local pleural effusions are common.
The chest x-ray findings may be confused with foreign body obstruction.
Small local pleural effusions are common; large effusions are rarely seen in children under 6 years.
Diagnosis

The Mantoux skin test (formerly called a "PPD" but now more correctly referred to as a "TST," which stands for "tuberculin skin test") is the only practical tool for diagnosing TB infections in asymptomatic children. A test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children and > 15 mm in low-risk children.
In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.
Air exchange: Refers to airflow in and out of the lungs during respiration.
Good air exchange implies no clinically significant airflow obstruction.
Increased anterioposterior (AP) diameter: A hyperinflated thorax is a
sign of air-trapping as seen in significant chronic obstructive lung disease.
Crackles: Discontinuous fine or coarse sounds, typically inspiratory,
generally associated with alveolar or small airway conditions such as
pneumonia, pulmonary edema, bronchitis, or interstitial diseases.
Inspiratory to expiratory (I:E) ratio: Normally = 1:2. Obstructive
illnesses (i.e., asthma or cystic fibrosis) increase the I:E ratio to 1:3 to 1:4.
Restrictive illnesses (uncommon in children) diminish the I:E ratio to 1:1.
Rhonchi (or coarse crackles): Continuous, low-pitched sounds suggestive
of secretions in the larger airways, such as with pneumonia or bronchitis.
Rales (or fine crackles): Suggest secretions or early collapse of small
airways, such as in pneumonia.
Retractions: Abnormal retraction of the intercostal, supraclavicular, and
subcostal spaces can be seen in children in significant respiratory distress.
Stridor: High-pitched inspiratory noise that suggests partial obstruction of
the larynx or trachea (extrathoracic airway). Stridor in children most often
seen in croup, inhaled foreign body with partial obstruction, and
laryngotracheomalacia.
Tracheal deviation: Suggests mediastinal mass, pneumothorax, or foreign
body aspiration.
Wheezes: Continuous musical noises, typically expiratory, associated with
a variable obstruction of small and moderate-sized airways (i.e., bronchi
and bronchioles). Most commonly seen in asthma and bronchiolitis
1. Beta2-agonists (short- or long-acting)
Primary medication for patients with mild intermittent disease and exerciseinduced
bronchospasm.
Short-acting beta agonists serve as rescue medications in patients with
persistent disease.
Minimize use of short-acting inhaled beta2-agonists. Over-reliance on these
medications (e.g., use of approximately one canister a month even if not
using it every day) indicates inadequate control of asthma and the need to
initiate or intensify long-term-control (maintenance) therapy.
2.Inhaled corticosteroids
Used in all patients with persistent asthma as daily prophylaxis.
Diminishes need for systemic steroids.
Inhaled steroids require several weeks of daily use before the beneficial
effects are realized.
Monitor children receiving long-term therapy for elevation in blood pressure,
serum blood sugar, growth delay, and cataract development. Varicella
status should be checked and immunization given if needed.
Leukotriene receptor antagonists and leukotriene-synthesis inhibitors
These agents block the inflammatory pathway response to the inhaled
allergen.
In chronic asthma, they can allow for reduced doses of inhaled
corticosteroids, but these medications are less effective than steroids and
not recommended as monotherapy.
Oral antihistamine
Antihistamines (H1 antagonists) are safe and effective for controlling
sneezing, nasal pruritis, and rhinorrhea associated with intermittent or
short-term allergies.
Newer antihistamines are significantly less sedating than the earlier ones.
Laboratory studies:
1. Complete blood count - Anemia can contribute to ischemia by
decreasing oxygen carrying capacity.
2. Electrolytes - Electrolyte abnormalities can contribute to cardiac
disease.
Blood urea nitrogen and creatinine - Screen for kidney disease as this can contribute to heart disease.
3. Thyroid-stimulating hormone - Hyperthyroidism increases oxygen
demand of the heart while hypothyroidism adversely affects lipids.
4. Fasting lipid panel - Further characterize cardiac risk.
5. Electrocardiogram
Rule out an ST elevation myocardial infarction.
Look for evidence of prior infarction (pathologic Q waves).
Make other diagnoses, such as pericarditis.
6. Chest x-ray
Screen for some non-cardiac causes of chest pain.
May suggest underlying cardiac disease by demonstrating an enlarged
cardiac silhouette.
Chest CT
Not a first-line test in the workup of likely angina.
*Appropriate choice to evaluate for pulmonary embolism or aortic
dissection.*
RUQ ultrasound
Evaluate for gallbladder and biliary tree disorders, which can also
present as chest pain.
Stress testing:
Indications - Consider pretest probability.
High pre-test probability -A negative stress test will not
convince you the patient doesn't have a disease, so the patient
should probably go straight to coronary angiogram.
Low pre-test probability - Patient should not have a stress test,
because it is unlikely to be positive.
The best patient for a stress test is one with an intermediate pre-test
probability.
Treadmill exercise stress testing without additional imaging:
If the patient can exercise and the electrocardiogram is normal,
this is a reasonable first-line option.
However, some have argued that women have higher rates of
false positives and often cannot exercise to the extent needed
for a diagnostic test and therefore women should have a stress
test with imaging.
Exercise stress testing with nuclear or echocardiographic imaging:
Imaging increases the sensitivity and specificity of the test but
increases cost, too.
Nuclear imaging utilizes technetium 99m sestamibi or
thallium-201.
Echocardiography can be technically difficult in the obese
patient.
Pharmacologic Stress with imaging:
Alternative for patients who cannot exercise to the degree
needed to produce a diagnostic result.
Dipyridamole or adenosine with nuclear imaging or dobutamine
with echocardiography.
Coronary angiogram: Allows the cardiologist to directly visualize the
coronary anatomy, give definitive diagnosis, and potentially perform
interventions on stenotic segments.
Echocardiogram:
Useful test to evaluate wall-motion abnormalities, valvular function,
and cardiac function (ejection fraction).
Not indicated given a normal baseline EKG and absence of murmurs or
signs/symptoms of heart failure.
Statins:
First-line therapy for most patients with elevated LDL cholesterol
Can decrease LDL by 18-55% while increasing HDL by 5-15% and
decreasing triglycerides by 7-30%
Side effects: Hepatic dysfunction and myopathy
Check liver function before initiation of statin therapy, after 12 weeks
of therapy, after any dosage adjustment, and periodically while on a
stable dosage.
No recommendation for routine monitoring of creatine kinase.
However, baseline may be useful in the event patient develops muscle
symptoms
Bile acid sequestrants:
More modest effect on lowering LDL and raising HDL but can cause an
increase in triglycerides.
Usage has been limited by severe gastrointestinal distress and constipation.
Nicotinic acid:
More modest effect on LDL
*Most effective agent to increase HDL (by 15-30%)
Can also decrease triglycerides (by 20-50%)*, but usage has been limited by
symptomatic body flushing
Flushing can be reduced by taking aspirin before the niacin dose
Some over-the-counter supplements are promoted as niacin that has
been specially formulated to prevent flushing; however, a study of
several such supplements found they did not contain clinically
significant amounts of niacin
Fibric acid derivatives:
First-line therapy for reducing triglycerides
Modest effect on reducing LDL
Can increase HDL cholesterol by 10-20%.
Ezetimibe:
Inhibits absorption of cholesterol at the intestinal brush border
Increases cholesterol clearance
Decreases LDL decreases, but unclear whether it decreases atherosclerosis
or CHD events
Monitoring medication effectiveness:
NCEP recommends checking lipids six weeks after starting therapy and
every six to twelve months when patient is on a stable dosage.
Lifestyle interventions that raise HDL cholesterol:
Exercise
Weight loss
Smoking cessation
Moderate alcohol consumption (benefit must be weighed against risk;

Nutrition
A patient needs to have an approximately 3500 calorie deficit to lose one
pound of weight

Physical activity: Encourage moderate exercise at least 30 minutes on most
days, or at least 20 minutes of vigorous activity at least three days a week.
Increased frequency or duration of exercise may be needed to achieve and
maintain weight loss.

Medication: Pharmacologic therapy for obesity should be considered in patients
with BMI > 30 (or BMI > 27 with other risk factors such as hypertension,
diabetes, and/or dyslipidemia).
Orlistat:
Gastrointestinal lipase inhibitor (decreases fat absorption)
Only medication currently approved by the Food and Drug Administration
(FDA) for long-term treatment of obesity
Available without a prescription
Shown to result in modest (3-5 kg) weight loss when used in conjunction
with calorie restriction and physical activity
Side effects: Gastrointestinal discomfort, fecal incontinence, malabsorption
of fat-soluble vitamins
Phentermine:
Shown to result in modest weight loss
Side effects: Tachycardia, hypertension, restlessness, insomnia, tremor
Due to potential for addiction and withdrawal, phentermine is indicated only
for short-term use
Over-the-counter weight loss supplements:
Not regulated by the FDA
No evidence of benefit or safety
Potential risks include GI side effects, increased heart rate, and increased
blood pressure.

Surgery: Bariatric surgery is indicated in patients with BMI > 40 (or BMI ≥ 35
with associated severe health complications) who have not succeeded in losing
weight with other treatment methods. Procedures most commonly performed
include: Gastric bypass (partitioning of the stomach with attachment of the proximal
stomach to the jejunum)
Adjustable gastric banding (placement of an inflatable, adjustable band
around the stomach)
Vertical-banded gastroplasty (partial partitioning of the proximal stomach
with placement of a small, fixed-diameter gastric outlet stoma)