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1 dose annually, including pregnant patients and patients wiht HIV
1 dose Tdap then 1 booster every 10 years. 1 dose Tdap for preg patients from 27-36 wks
all immnocompetent patietns lacking immunity
all non immunocomp persons 50 y including those vaccinated with inactivated vacine
women 19 to 26
also for men 22-26 if they are immunocomp or if MSM
adults born later than 1957
first year college students in dorms, travelers to edemic areas, military recruits, exposd persons. asplenia or complement def, boost q5 if risk remians
any adult requeting and at high risk
Do Not give preggos
live vaccines including MMR, intranasla flu, yellow fever, varicella, zoster
65 or > PCV 13 first then PPSV23 1 year after
Revacacinate with 23 at 5 years after first dose only if imunized before age 65
immunocomp with chronic heart lung liver DM alc or cig smoking
only 23 not 13
functional or anatomic asplenia, immnocomp persons
both 13 and 23
ASA is rec for primary prevention if
adult 50-59, 10 year CVD risk 10%, life expec > 10 years, no incr risk for bleeding, willing to take low dose asa for 10 years
One-time abdominal ultrasonography in all men ages 65-75 y who have ever smoked; selectively screen men ages 65-75 y who have never smoked
All adults, when staff-assisted depression care support is available
Ages 40-70 y who are overweight or obese as part of risk assessment for cardiovascular disease
All adults; obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment
Universal lipid screening in adults aged 40-75 y as part of risk assessment for cardiovascular disease
Women age ≥65 y; postmenopausal women <65 y of age when 10-year fracture risk is ≥9.3%
chylmydia and gonhor
All sexually active women age ≤24 y; all sexually active older women at increased risk of infection
One-time screening for adults born from 1945-1965; all adults at high risk
One-time screening for all adults ages 15-65 y; at least annually for adults at high risk
Biennial screening mammography for women ages 50-74 y; initiation of screening before age 50 y should be individualized
Women aged 21-65 y with cytology (Pap smear) every 3 y; in women aged 30-65 y who want to lengthen screening, screen with high-risk HPV testing (preferred) or cytology and high-risk HPV testing every 5 y
Do not screen women following hysterectomy and cervix removal for benign disease.
All adults aged 50-75 ya.
Annual low-dose CT scan in high-risk patients (adults ages 55-80 y with a 30-pack-year smoking history, including former smokers who have quit in the last 15 y)
Men aged 55-69 y should make an informed decision about prostate cancer screening with their clinician. Routine screening for men ≥70 y is recommended against.
colon ca screening tools
Guaiac fecal occult blood test (FOBT)
Fecal immunochemical test (FIT)
Every 5 years
Every 10 years when combined with annual FIT (not FOBT)
Every 10 years
Every 5 years
restless leg syndrome
rx iron if serum ferritin is < 75
The ACC/AHA recommend initiating statin therapy to reduce risk of ASCVD in
1 patients with clinical ASCVD,
2 patients with an LDL cholesterol level of 190 mg/dL or higher,
3 patients with diabetes mellitus who are aged 40 to 75 years with an LDL cholesterol level of 70 to 189 mg/dL and no clinical ASCVD, and
patients without clinical ASCVD or diabetes and an LDL cholesterol level of 70 to 189 mg/dL and estimated 10-year ASCVD risk of 7.5% or higher
The USPSTF recommends that adults use a low- to moderate-dose statin for the primary prevention of CVD events and mortality when all of the following criteria are met:
age 40 to 75 years
≥1 CVD risk factors (e.g., dyslipidemia, diabetes, hypertension, smoking)
a calculated 10-year risk of a CV event of ≥10%
Bariatric surgery is considered for patients
with a BMI >40 and also for patients with a BMI >35 with serious obesity-related comorbidities (severe sleep apnea, diabetes, severe joint disease).
Bariatric surgery outcomes are associated with:
improved control or remission of type 2 diabetes
improved quality of life
reduced medication use
breast cancer prevention and screening
The Gail Model Risk Assessment Tool is used to estimate any woman's 5-year and lifetime breast cancer risk. Women age >35 years with a 5-year breast cancer risk of ≥1.7% or with lobular carcinoma in situ are candidates for breast cancer prophylaxis:
tamoxifen before menopause
tamoxifen and raloxifene, or exemestane after menopause
BRCA gene testing
women whose fam hx suggests that incr risk for mutations in brca1/2
one or more first-degree relatives on the same side ≤50 years with breast cancer or invasive ovarian cancer; two or more relatives at any age with breast, prostate, or pancreatic cancer
women with BRCA1/2 mutations should undergo:
breast cancer screening with MRI beginning at age 25 years, then mammography beginning at age 30 years
ovarian cancer screening with pelvic examinations, ultrasonography, and CA-125 measurement
Surgical prophylaxis options for carriers of BRCA1/2 mutations include prophylactic bilateral mastectomy and prophylactic bilateral salpingo-oophorectomy (after childbearing).
Palpable lump or mass and age <30 years
Consider observation to assess resolution within 1 or 2 menstrual cycles
If persistent, choose ultrasonography
If simple cyst on ultrasound, aspirate and repeat clinical breast examination in 4-6 weeks
If complex cyst on ultrasound, perform mammography and fine-needle aspiration or core-needle biopsy
If aspirate fluid is bloody or a mass persists following aspiration, choose mammography and biopsy
If solid on ultrasound, choose mammography and obtain tissue diagnosis (core biopsy or surgical excision)
Palpable lump or mass and age ≥30 years
Mammography: If BI-RADS category 1-3 (benign or close follow-up recommended), obtain ultrasonography and follow protocol above;
if BI-RADS category 4-5 (suspicious or highly suspicious), obtain tissue diagnosis
in patients with severe monpausal sx
he most effective treatment is systemic hormone therapy, which can be used in healthy women <60 years and within 10 years of menopause
Keep these treatment points in mind when using estrogen
Contraceptive needs must be addressed during perimenopause.
Transdermal estrogen may be associated with less VTE risk than oral estrogen.
All women with an intact uterus must receive progesterone.
Duration of treatment >5 years is associated with increased risk of breast cancer.
The need for continued treatment should be reevaluated annually.
Nonhormonal options for women with vasomotor symptoms and contraindications to hormone therapy include
low-dose antidepressant agents (venlafaxine, desvenlafaxine, paroxetine, citalopram, and escitalopram) and gabapentin.
Primary dysmenorrhea is treated symptomatically without further testing with NSAIDs and cyclooxygenase-2 inhibitors. Second-line therapy includes combined hormonal contraceptive therapy.
Topical (e.g., fluconazole, miconazole, clotrimazole)
Single dose of oral fluconazole (contraindicated during pregnancy); less effective in complicated conditions (e.g., diabetes, HIV infection)
oral or topical metro or clinda
oral metro also for male partner, safe during preg, test for other STIs, restest within 3mo of tx
combination of red eye ocular pain and visial loss warrats emergent opthalmogic consult
Unilateral then bilateral purulent discharge without pain or visual disturbance
Topical fluoroquinolones or bacitracin-polymyxin; culture not needed
herepse zosts (zoster opthalmicus)
Conjunctivitis associated with herpes zoster rash involving ophthalmic division of fifth cranial nerve
emergent optho eval
Acute hyperpurulent discharge in a sexually active adult
topical and systemic antibiotics and emergency ophthalmology referral
Unilateral then bilateral conjunctivitis with daytime watery or mucoid discharge
itching and tearing of the eye
iridocytits or keratitis
Pain, photophobia, inflammation confined to corneal limbus, corneal irregularity, edema
Consider associated spondyloarthropathies, sarcoidosis, and herpes zoster; emergency ophthalmology referral
acute angle closuire glaucoma
Unilateral deep ocular pain, nausea, vomiting, fixed nonreactive pupil, shallow anterior chamber
emergency optho eval
Severe ocular pain that worsens with eye movement and light exposure; a raised hyperemic lesion that may be localized or diffuse and obscures the underlying vasculature
Commonly associated with collagen vascular and rheumatoid diseases; emergency ophthalmology referral
Nonpainful red, flat, superficial lesion that allows visualization of the underlying vasculature
Red eye with scales and crusts around the eyelashes or dandruff-like skin changes and greasy scales around the eyelashes
staphylococcus (crusting) or seborrheic dermatitis (greasy scales, dandruff); warm compresses, washing with mild detergent, topical antibiotics
do not treat a red eye with
Age-Related Macular Degeneration
depositing of material in the mcula regiion of 1 or 2 eyes and causes diminihsed visual acutiy, need smoking cessation,
A small percentage of patients with dry AMD will progress to develop new vessel growth under the retina (wet AMD). Bleeding and exudation results in sudden (or rapid onset over weeks), painless blurring or warping of central vision. Laser photocoagula- tion and intraocular injection of VEGF inhibitors is recommended for wet AMD.
Retinal detachment occurs mainly in myopic patients. Symptoms are floaters, flashes of light (photopsias), and squiggly lines, followed by a sudden, peripheral visual field defect that resembles a black curtain and progresses across the entire visual field. Emergent ophthalmology referral is crucial, as prognosis depends on the time to surgical treatment.
central retinal artery occlusion
caused by thrombi or emboli; usually the elderly and present with profound sudden and painless vision loss.
unduscopic examination reveals an afferent pupillary defect and cherry red fovea that is accentuated by a pale retinal back- ground. Treatment may include measures to lower the intraocular pressure and emergent ophthalmology consultation.
central retinal VEIN occulison
CRVO is usually caused by occlusion of the central retinal vein by a thrombus. Patients with CRVO present with sudden, pain- less, unilateral visual loss. Funduscopic examination may reveal afferent pupillary defect, congested retinal veins, scattered reti- nal hemorrhages, and cotton wool spots in the region of occlusion. Immediate ophthalmologic consultation is necessary.
Ramsay Hunt syndro
caused by varicella-zoster viral infection and characterized by facial nerve paralysis, senso- rineural hearing loss, and vesicular lesions on and in the ear canal.
Aspirin-exacerbated respiratory disease (triad asthma or Samter syndrome)
Rhinitis, nasal polyps, asthma, and aspirin intolerance (respiratory symptoms)
The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults
≥65 years who are not known to have osteoporosis or vitamin D deftciency
do not order urodynamic testing for urinary incontinece sx
pre op testins
routine preoperative laboratory studies in healthy patients undergoing elective or low-risk surgery
preoperative chest radiography in the absence of cardiopulmonary symptoms
repeat laboratory studies within 6 months of surgery in the absence of a clinical change
CV risk assessment
Low-risk surgeries (cataract extraction, carpal tunnel release, breast biopsy, inguinal hernia repair) do not require cardiac testing even if a calculated risk score is elevated.
Obtain an ECG within 1 to 3 months of surgery (except low-risk surgery) in any patient with
cerebrovascular disease (stroke or TIA)
patietns with known recent mjor adverse cardiac event should not undergoe surgeyr if
60 days of an MI
30 days of a bare-metal coronary stent implantation
6 months of a drug-eluting coronary stent placement
stopbang to sxreen for OSA
anticoag must be stopped except for surguical procedures with mimnal expected blood loss
cataract, derm procedures, endo procedures without biopst
5 days before
1-2 days before if GFR >50, longer if less
no bridging if low risk
Low-risk patients do not receive bridging anticoagulation (bileaflet mechanical aortic valve, AF with CHADS2 score <2, VTE >12 months ago).
bridging if high risk
High-risk patients receive bridging anticoagulation (mitral or caged ball valve or aortic tilting disc aortic mechanical valve, AF with CHADS2 score >4, rheumatic heart disease, recent CVA or TIA, VTE within the past 3 months
Start heparin 36 hours after the last dose of warfarin.
Stop UFH 4 to 6 hours before surgery.
Stop LMWH 12 hours before surgery.
Restart heparin 24 hours after surgery.
Restart warfarin 12 to 24 hours after surgery.
Restart dabigatran, rivaroxaban, and apixaban 24 hours after surgery.
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