Common Illnesses in Family Practice

Abdominal Pain Asthma Chest Pain Cough Depression Diabetes Hyperlipidemia Hypertension Joint Pain Low Back Pain
Migraine Headache New Onset Headache Pharyngitis Preparticipation Sports Physical Exam Somatization Disorder Tobacco Dependence Upper Respiratory Infection Urinary Tract Infection Pharmacotherapy
2 17 30 49 58 72 92 108 120 128 136 146 155 171 179 188 200 206 217
University of South Alabama, Department of Family Medicine
June 30, 2008
Abdominal Pain
789.0X GENERAL CONSIDERATIONS Scope of This Article This article discusses atraumatic abdominal pain in adults and older children. Definition of Abdominal Pain Complaint of pain in the area between the ribcage and pelvis. Overview Abdominal pain is frequent symptom encountered by a large portion of the otherwise healthy population (in some studies more than 50%). Most commonly it is a benign complaint reflecting a disease process that can be treated symptomatically. However, it may be the presenting symptom to an acute life-threatening illness that requires rapid assessment and immediate triage to an acute care facility. Red Flags: Red flags are historical or physical findings that suggest a higher severity of illness, requiring further investigation. Red Flag Fever Diarrhea Persistent constipation Hematochezia Persistent Vomiting Hematemesis Severe Pain Pregnancy Jaundice Possible Etiology Infection Infection Intestinal obstruction Lower or upper GI bleed Multiple etiologies Upper GI bleed Perforation, peritonitis Ectopic pregnancy, placental abruption Liver failure, biliary obstruction Possible Consequence Dehydration, sepsis Dehydration Dehydration Hemodynamic instability Dehydration, metabolic acidosis Hemodynamic instability Sepsis, hemodynamic instability Increased fetal and maternal morbidity, mortality Hepatic encephalopathy
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History The history should include: Duration and frequency of pain Severity and nature of pain. Location and radiation of pain. Aggravating/alleviating factors, such as food, antacids, exertion, defecation. Associated symptoms, including fever, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool. Family history of bowel disorders. Alcohol intake. Medication use, including over the counter medications such as aspirin and NSAIDs. Menstrual history. Pain Duration Acute: Pain of less than a few days duration, that has worsened progressively until the time of presentation. Chronic: Pain that has remained unchanged for months or years. Pain that does not clearly fit either category might be called subacute, and requires consideration of the differential diagnoses for both acute and chronic pain. Pain Type Pain Type Visceral Pain Character Dull and aching, but can be colicky Sharp Localization Poorly localized Cause Distention or spasm of a hollow organ Parietal peritoneal irritation Examples Intestinal obstruction, cholecystitis Acute appendicitis
Parietal Pain
Well localized
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Pain Location Causes of Abdominal Pain by Location Location Causes Hepatitis Cholecystitis Cholangitis Pancreatitis Budd-Chiari Syndrome Pneumonia Splenic Abscess Splenic Infarct Gastritis Gastric Ulcer Pancreatitis Appendicitis Salpingitis Ectopic Pregnancy Inguinal Hernia Nephrolithiasis Inflammatory Bowel Disease Diverticulitis Salpingitis Ectopic Pregnancy Inguinal Hernia Nephrolithiasis Inflammatory Bowel Disease Peptic Ulcer Disease GERD Gastritis Pancreatitis MI Pericarditis Aortic Aneurysm Early Appendicitis Gastroenteritis Bowel Obstruction Aortic Aneurysm Ventral Hernia Gastroenteritis Mesenteric Ischemia Metabolic Irritable Bowel Syndrome Bowel Obstruction Peritonitis
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Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
Epigastric
Periumbilical
Diffuse
Pain Severity The severity of the pain generally is related to the severity of the disorder, especially if acute in onset. As an example, the pain of biliary obstruction, renal colic, or mesenteric infarction is of high intensity, while the pain of gastroenteritis is less marked. Age, mental status, and general health may affect the patients clinical presentation. A patient taking corticosteroids may have significant masking of pain, and the elderly often present with less intense pain. Associated Symptoms Symptoms that occur in relation to abdominal pain may give important information. Nausea and vomiting occur with a number of disorders. Weight loss may occur in association with malignancy. A change in bowel habits suggests a colonic lesion. Women should be asked whether they are sexually active, the number of sexual partners, whether any sexual partners are new, and whether any sexual partners are experiencing symptoms suggestive of a sexually transmitted infection. Physical Examination General Exam General appearance. Patients with peritonitis try to remain immobile. Vital signs, including measurement of orthostatic changes in blood pressure and heart rate. Obstruction or peritonitis can cause large amounts of third spacing of fluid and intravascular volume depletion or overt shock. Jaundice. Abdominal Exam Auscultation. Hypoactive sounds may be noted in advanced peritonitis or ileus. Highpitched bowel sounds are a feature of early bowel obstruction. Gentle percussion is useful to identify acute peritonitis. Percussion is also used to identify ascites, liver span, and bladder and splenic enlargement. Tympany signifies distended bowel, while dullness may signify a mass. Palpation must be performed gently and while the patient is distracted. Muscular rigidity or guarding is an important and early sign of peritoneal inflammation. Palpation also may detect enlarged organs, masses, or hernias. Rectal and Pelvic Exam A rectal is generally required in all patients with acute abdominal pain. Fecal impaction might be the explanation for signs and symptoms of obstruction in the elderly. Stool for occult blood should also be obtained. A pelvic exam is generally required in all women with acute lower abdominal pain, and is critical for determining whether abdominal pain is due to pelvic inflammatory disease, an adnexal mass or cyst, uterine pathology, or an ectopic pregnancy.
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ACUTE ABDOMINAL PAIN Surgical Abdomen (AKA Acute Abdomen) The first priority in patients with acute abdominal pain is to determine who has a rapidly worsening prognosis in the absence of surgical intervention. Only after the clinician is satisfied that the abdominal presentation is not an acute surgical emergency can consideration of other diagnostic possibilities begin. Patients should not eat or drink while a diagnosis of a surgical abdomen remains under consideration. The two syndromes that cause most surgical abdomens are obstruction and peritonitis. The latter encompasses most severe abdominal pathology since intraperitoneal hemorrhage or viscus perforation typically present with common features of peritonitis. Obstruction Obstruction generally presents as pain together with anorexia, bloating, nausea, and vomiting. Physical examination may reveal distension and high-pitched or absent bowel sounds. Abdominal percussion reveals tympany from proximally dilated loops of bowel. An abdominal mass, if present, may suggest an etiology for the obstruction. Peritonitis Patients with peritonitis of any cause tend to appear ill and lie still to minimize their discomfort. Rebound tenderness, abdominal wall rigidity, and percussion tenderness are classically thought to reflect peritonitis. Other subtle signs of peritonitis include diminished bowel sounds and pain worsened when an examiner lightly bumps the stretcher. Initial Diagnostic Testing Complete blood count with differential Electrolytes, BUN, creatinine, and glucose Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis Pregnancy test in women of childbearing potential While these laboratory tests are important, they are not sufficient to rule in or rule out a diagnosis of surgical abdomen, as a surgical abdomen is a clinical diagnosis. Subsequent Diagnostic Testing Patients clearly in need of urgent laparotomy may proceed directly to the operating room for diagnosis and management. In particular, patients with a painful pulsatile abdominal mass, with or without bruit, should be suspected to have a ruptured aortic aneurysm.
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However, many patients will not have a firm diagnosis after initial assessment, and in these cases, careful observation of the patients course will be the most important factor in their management. In addition, the following additional investigations can also be considered: Blood and urine cultures, in the presence of fever or unstable vital signs. CT Scan. When available, CT scanning is the test of choice for detecting partial or complete bowel obstruction, hernias, diverticulitis, renal stones, and aortic aneurysms. It can also be useful in investigating appendicitis, peritonitis, ischemia due to strangulation/adhesions, and pancreatitis. CT scan may play a decision-making role when evaluating demented or obtunded patients. Plain Abdominal Films. Where CT scanning is immediately available, abdominal plain films are not necessary, as they do not provide additional information. However, in the absence of CT scanning, flat and upright or lateral decubitus radiographs are a crucial step in decision making for the suspected surgical abdomen, as proximally dilated loops of bowel are the hallmark of intestinal obstruction, and free intraperitoneal air can confirm a suspicion of hollow organ perforation. Ultrasound. Ultrasound is the preferred test in pregnancy, and evaluating biliary and pelvic pathology. If more readily available, it may also be useful for many of the conditions listed above under CT Scan. Right Upper Quadrant Pain Usually caused by involvement of the liver or biliary tree. Initial assessment The presence of fever and jaundice in a patient with right upper quadrant pain leads to a clinical diagnosis of ascending cholangitis. Acute cholecystitis can also present as a systemically unwell patient with low-grade fever. Patients with an acute rise in aminotransferases and right upper quadrant pain most likely have choledocholithiasis, particularly if there is also an acute rise in bilirubin. Initial Diagnostic Testing Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Abdominal ultrasound. (Plain films of the abdomen are unlikely to yield much information.) Subsequent Diagnostic Testing (if available) Endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography (ERCP). Magnetic resonance cholangiopancreatography (MRCP).
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Epigastric Pain Epigastric pain that is relatively sudden in onset is suggestive of pancreatitis, particularly when it radiates to the back and is associated with nausea, vomiting, and anorexia. Epigastric pain that is less acute and is associated with bloating, abdominal fullness, heartburn, or nausea can be classified as dyspepsia. Most of these patients can safely undergo a therapeutic trial or watchful waiting. However red flags that suggest a need for further investigation include: Age over 50. Weight loss. Persistent vomiting. Dysphagia. Anemia. Hematemesis, melena, or heme positive stool. Palpable abdominal mass. Family history of upper gastrointestinal carcinoma. Previous gastric surgery. Refractory/recurrent symptoms. It is also important to consider nonabdominal etiologies of upper abdominal pain: Cardiac pain. Pleural or pulmonary pathology. Initial Diagnostic Testing Many patients can be managed with a therapeutic trial of antisecretory therapy without further investigation. However, those with red flags or suspicion of pancreatitis should have the following: Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Elevated lipase in the presence of epigastric pain is very suggestive of pancreatitis. Amylase is a less specific alternative, if lipase is not available. Subsequent Diagnostic Testing Esophagogastroduodenoscopy (EGD), especially for those with red flags and dyspepsia. Testing for Helicobacter pylori may be considered, especially in refractory/recurrent cases. Abdominal ultrasound if pancreatitis is being considered, since biliary disease is a common etiology for pancreatitis. CT Scan is more sensitive for the diagnosis of pancreatitis than ultrasound; consider if doubts remain after an ultrasound has been obtained.
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Lower Abdominal Pain Pain in the lower abdomen can be associated with pathology in the following: Distal intestinal tract. Upper abdominal structures with pain radiating into the lower abdomen. The pelvis. The history should include risk factors for infectious and ischemic causes, medication use (e.g., NSAIDs, laxatives), and family history of inflammatory bowel disease (IBD). Patients should be asked about urinary symptoms such as frequency, urgency, and dysuria. Left and/or right lower quadrant pain, when occurring together with diarrhea, is suggestive of colitis and/or ileitis. Diverticulitis presents more frequently as left lower quadrant pain, often with leukocytosis. In older patients, abdominal pain and a change in bowel habits can be the first sign of colon cancer. It is also important to consider nonabdominal etiologies of upper abdominal pain: Retroperitoneal pathology. Cystitis can cause suprapubic pain. Renal colic results in pain that may radiate to the lower abdomen. Lower abdominal pain (pelvic pain) in women is frequently caused by disorders of the internal female reproductive organs. (Discussed below.) Initial Diagnostic Testing Complete blood count with differential. Urinalysis (and culture if results dictate). Subsequent Diagnostic Testing Stool studies in patients with severe or persistent lower abdominal pain associated with diarrhea, and immunosuppressed patients, should include culture for enteric pathogens, microscopy for ova and parasites, and measurement of Clostridium difficile toxin. However, many patients with less severe presentations will often have self-limited illness, and can be managed expectantly. Colonoscopy in patients with illness exceeding two weeks with negative cultures, systemically unwell patients, immunosuppressed patients, and when ileal pathology is suspected. (Note that patients over age 50 are also candidates for screening colonoscopy, and their presenting symptoms provide an opportunity to discuss this.) CT scan, especially in cases suggestive of diverticulitis.
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Lower Abdominal Pain in Women Additional history in women should include: Regularity and timing of menstrual periods. Possibility of pregnancy. Presence of vaginal discharge or bleeding. Recent history of dyspareunia or dysmenorrhea. In addition to the causes of lower abdominal pain discussed above, other common etiologies of acute lower abdominal pain in women include: Pelvic inflammatory disease (PID). Adnexal cysts or masses with bleeding. Ovarian torsion. Ectopic pregnancy. Uterine pain due to infection (endometritis) or torsion of leiomyomas. A pelvic examination is part of the physical examination whenever pelvic pathology is in the differential diagnosis. Purulent cervical discharge, cervical tenderness, uterine enlargement, or adnexal masses may be detected. PID should be considered when acute left, right, or bilateral abdominal pain is accompanied by fever and an elevated white blood count with left shift. Initial Diagnostic Testing In addition to tests discussed above, women with lower abdominal pain should have the following: Pregnancy test in women of childbearing potential, even when pregnancy is felt unlikely. Wet prep of any abnormal vaginal discharge. Tests for Chlamydia and gonococcus in women with risk factors for sexually transmitted infections, mucopurulent cervical discharge, or suspected PID. Subsequent Diagnostic Testing Pelvic ultrasound, especially if pregnancy test is positive, or pelvic exam is suggestive of PID or adnexal masses. Generalized Abdominal Pain (not meeting the criteria of surgical abdomen) Generalized abdominal pain with vomiting and/or diarrhea, alone or in association with systemic symptoms, often represents an acute self-limited illness, such as viral or bacterial enteritis or colitis, or toxin-mediated food poisoning. Multisystem symptoms, such as upper respiratory tract involvement or myalgias, may suggest a viral etiology.
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A condition that may require urgent surgical management, yet present without clear peritoneal findings, is acute mesenteric ischemia/mesenteric infarction. If clinically reasonable, the diagnosis of ischemic bowel disease should be entertained, particularly if the patient has the classic finding of pain out of proportion to physical findings, or risk factors such as congestive heart failure, recent myocardial infarction, hypotension, hypovolemia, sepsis, or cardiac surgery. Young patients should have mesenteric ischemia considered if they have a known personal or family history of hypercoagulable state or venous thrombosis. Diffuse abdominal pain can also be a nonspecific symptom of underlying metabolic, toxic, neurogenic, or other extra-abdominal disease. The presence of systemic illness, fatigue, weakness, nausea, flu-like symptoms, or signs and symptoms of endocrinopathies that are associated with abdominal pain should signal a search for metabolic abnormalities, such as diabetic ketoacidosis or Addisons disease. One should inquire about drug use/withdrawal, toxin/poison exposures, or possible black widow spider bite. Pain localized to one unilateral dermatome is highly suggestive of herpes zoster. Extra-Abdominal Causes of Acute Abdominal Pain Cardiac Myocardial ischemia Myocarditis Endocarditis CHF Pleurodynia PTE Pneumothorax Empyema Esophagitis Esophageal spasm Esophageal rupture Radiculitis Herpes zoster Uremia Diabetes mellitus Hyperlipidemia Hyperparathyroidism Acute adrenal insufficiency Sickle cell anemia Hemolytic anemia Henoch-Schnlein purpura Acute leukemia Hypersensitivity reactions Lead poisoning Osteomyelitis Typhoid fever Narcotic withdrawal Heat stroke Psychiatric disorders
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Thoracic
Neurologic
Metabolic
Hematologic
Toxins Infection Miscellaneous
Initial Diagnostic Testing In patients with symptoms suggestive of an acute infectious gastroenteritis or toxin-mediated food poisoning, the most useful diagnostic tool will often be watchful waiting for spontaneous recovery. Patients for whom a metabolic etiology of abdominal pain is suspected should have the following: Complete blood count with differential. Electrolytes, with calculation of an anion gap. BUN, creatinine, blood glucose. Calcium. Subsequent Diagnostic Testing An imaging procedure (angiography, CT/MRI angiography) will generally be required for patients with suspected ischemic bowel disease.
CHRONIC ABDOMINAL PAIN Chronic abdominal pain is a common complaint, and the vast majority of patients will have a functional disorder, often irritable bowel syndrome. The initial workup is therefore focused on differentiating benign functional illness from organic pathology. Helpful historical clues include the overall time course of the problem, whether pain is constant or intermittent, abnormalities in bowel habits, and aggravating/alleviating factors. Since many multisystem illnesses could contribute to a nonspecific abdominal complaint, a full physical exam should be performed. Specifically, the physical examination should clarify any focus of abdominal tenderness that may merit and focus further investigation. The following features suggest an organic illness: Unstable vital signs. Weight loss. Fever. Dehydration. Electrolyte abnormalities. Symptoms or signs of gastrointestinal blood loss, anemia, or malnutrition.
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Initial diagnostic testing The following tests should be considered in most patients with chronic abdominal pain: Complete blood count with differential. Electrolytes, BUN, creatinine, and glucose. Calcium. Aminotransferases, alkaline phosphatase, and bilirubin. Lipase. Ferritin. C-reactive protein and erythrocyte sedimentation rate are sensitive but nonspecific markers that may suggest the presence of occult organic disease; in selected cases, they may have some utility in ruling out organic causes of chronic abdominal pain. Subsequent Diagnostic Testing At the conclusion of the initial workup, young patients with no evidence of organic disease can be treated symptomatically. The use of further invasive testing should be directed at ruling in or out specific diseases and not as a general screen. A diagnosis of new-onset functional illness should only be made with great caution in patients over 50 years of age. These patients, by virtue of their increased risk of malignancy, will likely require investigation with endoscopy, CT, and/or ultrasound.
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FLOW CHARTS Initial Approach to Abdominal Pain
History Physical exam Initial lab tests Radiographs
Patient hemodynamically stable
YES
Rigid (surgical) abdomen? YES
NO
Non-rigid abdomen algorithm
NO
Suspect AAA
CBC, lytes CT if available or abd films & CXR Surgery consult
Nonspecific
Obstruction
Perforation
Limited resuscitation/ urgent CT/surgery
Resuscitation/ surgery
Consider unusual causes of rigid abdomen
Investigate
Treat
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Non-Rigid Abdomen
See chronic abdominal pain discussion above
Chronic
See pain location table above
Signs & Symptoms Acute Localized?
YES
NO NO Suspect AAA
Early obstruction Early appendicitis Mesenteric ischemia IBD Enteritis Pancreatitis Metabolic diseases Narcotic withdrawal
YES
Not Confirmed
CT scan Consider GI and/or surgery consult Confirmed
Limited resuscitation/ surgery
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References: Penner, Robert M., Sumit R. Majumdar; Diagnostic Approach To Abdominal Pain In Adults; UpToDate.com; August 2007. ---------------------Tintinalli, Judith E., Gabor D. Kelen, J. Stephan Stapczynski, O. John Ma, David M. Cline; Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6th Edition; 2004; American College of Emergency Physicians ---------------------Ables, Adrienne, I. Simon, Emily Melton; Update On Helicobacter Pylori Treatment; American Family Physician; Volume 75, Number 3; February 1, 2007 ---------------------Ramakrishnan, Kalyanakrishnan, Robert Salinas; Peptic Ulcer Disease; American Family Physician, Volume 76; Number 7, October 1, 2007
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Asthma
493.XX Definition: Asthma is defined as a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways. Environmental factors, (e.g. allergens, irritants, cold air, and viruses) play a role in provoking the airway inflammation, which in turn results in wheezing, breathlessness, chest tightness, and coughing due to airway hyper-responsiveness which characterizes the asthma patient. These symptoms are often reversible either spontaneously or with treatment. General Approach to the patient: There are four main components in the management of asthma patients: 1. 2. 3. 4. Assessment and monitoring Pharmacologic therapy Control of factors contributing to asthma severity Patient education
Overview: More than 22 million people suffer from asthma in the US; 6 million of them are children. Asthma accounts for nearly 500,000 hospitalizations 13.6 million visits to office based physicians, 1.8 million emergency department visits, and 3780 deaths in the United States each year. Despite an increased understanding of pathophysiology and treatment options, the disease remains undertreated. Asthma guidelines have been established to address the disparity between scientific knowledge and actual management. The Encounter
Chief Complaint: Patients often seek medical attention complaining of episodes of wheezing, shortness of breath, or coughing. In the case of exercise induced asthma patients present with similar symptoms brought about mainly by physical exercise. History of Present Illness: Symptoms of asthma are often worsened by allergens or irritants and in a lot of cases by upper respiratory tract infections. Symptoms are often worse at night. Some patients will give a history of multiple doctor visits or emergency room visits for similar symptoms prior to being diagnosed with asthma. Emotions and stress may also act as a trigger for exacerbation of symptoms. Asthma patients often have a history of other allergies (e.g. allergic rhinitis or atopic dermatitis). A family history of asthma may also be elicited.
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Physical: It is important to keep in mind that asthma patients may have no pertinent findings on examination due to the episodic nature of the illness. However, symptomatic patients may have one or more of the following findings: Wheezing during normal respiration or induced by forced expiration. In acute exacerbations, evidence of respiratory distress in the form of tachypnea, hypoxia and use of accessory muscles may be seen. Hyper-expansion of the lungs. Manifestations of other allergic illnesses as described above. Lab Testing: Pulmonary function testing: Establish the presence of airflow obstruction: FEV1 <80% Establish reversibility: FEV1 increases 12% or more after using a short-acting inhaled beta2 agonist (e.g. albuterol) Special Considerations: Children younger than 5 years of age suffering from asthma are often mislabeled as having recurrent upper respiratory tract infections or reactive airway disease. In this population, the diagnostic criteria discussed above apply as well, however, spirometry is not possible. Hence, a diagnosis is not needed to begin to treat recurrent episodes of wheezing. Classification of Asthma severity: The following classification is used to describe asthma severity in individual patients and aids the physician in choosing the appropriate medication for every patient. Days With Symptoms Step 4 Continual Severe Persistent Step 3 Daily Moderate Persistent Step 2 3-6/week Mild Persistent Step 1 2/week Intermittent Nights With Symptoms Frequent PEF or FEV1 60% >60%<80% 80% 80% Interference with Normal Activity Extreme Limitation
5/month
Some Limitation
3-4/month 2/month
Minor Limitation None
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NOTES: Patients should be assigned to the most severe step in which any feature occurs. Clinical features for individual patients may overlap across steps. An individuals classification may change over time. Patients at any level of severity of persistent asthma can have mild, moderate, or severe exacerbations of asthma. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. Management: Goals of Asthma Therapy: 1. Prevent chronic asthma symptoms and exacerbations. 2. Maintain normal activity levels 3. Have normal or near-normal lung functions 4. Minimizing side effects of therapy Patient Education: The following key points should be addressed following the diagnosis of asthma: Patients can live a normal life if the asthma is managed correctly. Asthma is better controlled if the patient works together with the physician. Lack of symptoms does not equal absence of inflammation of the airways, hence, longterm anti-inflammatory medications, if indicated, are important in asthma control. Many exacerbating factors exist in the home, school, or work environment which may lead to asthma attacks. Long-term care and monitoring is essential for the proper management of asthma.
Pharmacotherapy: Medications used to control asthma consist of: Long-term control medications: These medications are used daily in the treatment of persistent asthma and include anti-inflammatory agents, long-acting bronchodilators, and leukotriene modifiers. Corticosteroids: Most potent and effective anti-inflammatory medication currently available. The Inhaled form is used as the first line of therapy in the treatment of persistent asthma. Systemic corticosteroids are often used during asthma exacerbations for prompt alleviation of symptoms. Cromolyn sodium and nedocromil: Mild-to moderate anti-inflammatory medications. May be used as initial choice for long-term-control therapy for children. Long-acting beta2-agonists: Long-acting bronchodilator used concomitantly with antiinflammatory medications for long-term control of symptoms. Methylxanthines: Theophylline is a mild-to-moderate bronchodilator used principally as an adjuvant to inhaled corticosteroids in severe cases. Leukotriene modifiers: Leukotriene modifiers may be considered an alternative or used as an adjunct therapy to low doses of inhaled corticosteroids.
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L O N G - T E R M C O N T R O L M E D I C AT I O N S Name/Products Indications Potential Adverse Effects

Inhaled Corticosteroids: Beclomethasone dipropionate Budesonide Flunisolide Fluticasone propionate Triamcinolone acetonide - Long-term prevention of symptoms; suppression, control, and reversal of inflammation. - Reduce need for oral corticosteroid. - Cough, dysphonia, oral thrush. - In high doses, systemic effects may occur, although studies are not conclusive, and clinical significance of these effects has not been established.
Systemic Corticosteroids: Methylprednisolone Prednisolone Prednisone
-For short-term (310 days) burst: to gain prompt control of inadequately controlled asthma. - For long-term prevention of symptoms in severe persistent asthma: suppression, control, and reversal of inflammation.
-Short-term use: reversible, abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, hypertension, peptic ulcer, and rarely aseptic necrosis of femur. - Long-term use: adrenal axis suppression, growth suppression, dermal thinning, hypertension, diabetes, Cushings syndrome, cataracts, muscle weakness, andin rare instancesimpaired immune function. - Consideration should be given to coexisting conditions that could be worsened by systemic corticosteroids, such as herpes virus infections, Varicella and tuberculosis.
Cromolyn Sodium and Nedocromil
Long-Acting Beta2-Agonists
- Long-term prevention of symptoms; may modify inflammation. - Preventive treatment prior to exposure to exercise or known allergen. - Long-term prevention of symptoms, especially nocturnal symptoms, added to antiinflammatory therapy - Prevention of exercise-induced bronchospasm. - Not to be used to treat acute symptoms or exacerbations.
-15 to 20 percent of patients complain of an unpleasant taste from nedocromil.
-Tachycardia, skeletal muscle tremor, hypokalemia, prolongation of QTc interval in overdose.
Methylxanthines Theophylline
- Long-term control and prevention of symptoms, especially nocturnal symptoms.
- Dose-related acute toxicities include tachycardia, nausea and vomiting, tachyarrhythmias (SVT), CNS stimulation, headache, seizures, hematemesis, hyperglycemia, and hypokalemia. - Adverse effects at usual therapeutic doses include insomnia, aggravation of peptic ulcer or reflux, increase in hyperactivity in some children, difficulty in urination in elderly males with prostatism.
Leukotriene Modifiers Zafirlukast tablets Zileuton tablets
- Long-term control and prevention of symptoms in mild persistent asthma for patients >12 years of age.
-Elevation of liver enzymes has been reported.
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Quick relief medications: These medications are used to provide prompt treatment of acute airflow obstruction and may be the sole medication used in intermittent asthma. Short-acting beta2-agonists: It is the treatment of choice for the relief of acute symptoms and prevention of Exercise Induced Asthma. Anticholinergics: Ipratropium bromide may provide some additive benefit to inhaled beta2-agonists in severe exacerbations. Systemic corticosteroids: Used in moderate-to-severe exacerbations to speed recovery and prevent recurrence of exacerbations. Q U I C K - R E L I E F M E D I C AT I O N S Name/Products Indications Short-Acting Inhaled Beta2-Agonists Albuterol Bitolterol Pirbuterol Terbutaline Anticholinergics Ipratropium bromide -Relief of acute symptoms; quick-relief medication. -Preventive treatment prior to exercise for exercise-induced bronchospasm.
-Relief of acute bronchospasm. -For moderate-to-severe exacerbations to prevent progression of exacerbation, reverse inflammation, speed recovery, and reduce rate of relapse.
Systemic Corticosteroids: Methylprednisolone Prednisolone Prednisone
Potential Adverse Effects -Tachycardia, skeletal muscle tremor, hypokalemia, increased lactic acid, headache, hyperglycemia. Inhaled route, in general, causes few systemic adverse effects. -Drying of mouth and respiratory secretions, and increased wheezing in some individuals. -Short-term use: reversible abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, HTN, peptic ulcer, and rarely aseptic necrosis of femur.
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Stepwise Approach for Management of Asthma:
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Step Down Therapy: This involves gradual reduction of long-term control medications after a long period of control of persistent asthma. Inhaled steroids may be reduced by about 25% every 3 months until the lowest dose required to treat is reached. If the patient is on chronic systemic steroid therapy, continuous attempts should be made to reduce the dosage. Step Up Therapy: This involves increasing therapy in response to indicators of poor asthma control. A short course of systemic steroids may be necessary to rapidly alleviate the symptoms and regain control of the asthma. It is necessary to explore possible causes of the deterioration of the patients condition (e.g. non-compliance with medications, infections, or exposure to triggering factors).
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Strength of Recommendation Label Key clinical recommendations B Inhaled corticosteroids are more effective than cromolyn, nedocromil, theophylline, and leukotriene modifiers for the long-term control of asthma. Inhaled corticosteroids are recommended as first-line treatment in children with acute asthma. The combination of a beta agonist and an inhaled corticosteroid is superior to the addition of a leukotriene modifier.
2
Adding an antibiotic to usual care is not recommended in patients with asthma.
Managing Exercise Induced Asthma: With this entity, patients will present with a history of wheezing, shortness of breath, chest tightness, or cough spells in response to activity. Generally it begins at the start of exercise, peaks 5 to 10 minutes later and usually resolves in another 20 to 30 minutes. Diagnosis may be confirmed by measuring a 15% decrease in peak flow readings or FEV1 after vigorous exercise. Pharmacotherapy: Two to four puffs of short-acting beta2-agonist 5 to 60 minutes before exercise (effects last 2-3 hours). Use of long-acting beta2-agonist (effects last 10-12 hours) Cromolyn or nedocromil can also be used before exercise (effects last 1-2 hours) Montelukast may be used for this purpose if taken daily. A 6-10 minute warm-up period before exercise may be beneficial to the patient. Increase in long-term control medication, if appropriate. Follow-up: Follow up for proper management and monitoring of asthma is as follows: Every 2-6 weeks while gaining control of symptoms. Every 1-6 months to monitor maintenance of sufficient control. Every 3 months to assess for step down in therapy.
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During the follow up visit a history of their asthma symptoms should be obtained to ascertain proper asthma control. The following is an example of such a questionnaire: 1) In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? 2) During the past 4 weeks, how often have you had shortness of breath? 3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5) How would you rate your asthma control during the past 4 weeks? A thorough physical exam should be performed with a special attention to the lung examination. A verification of the asthma severity should be made and medications altered accordingly. Steps for Correct use of an Inhaler: 1. Remove the cap and hold inhaler upright. 2. Shake the inhaler. 3. Tilt your head back slightly and breathe out slowly. 4. Position the inhaler into mouth as directed. 5. Press down on the inhaler to release medication as you start to breathe in slowly. 6. Breathe in slowly (3 to 5 seconds). 7. Hold your breath for 10 seconds to allow the medicine to reach deeply into your lungs. 8. Repeat puff as directed. Waiting 1 minute between puffs may permit second puff to penetrate your lungs better. 9. Spacers/holding chambers are useful for all patients. They are particularly recommended for young children and older adults and for use with inhaled corticosteroids. Avoid common inhaler mistakes. Follow these inhaler tips: Breathe out before pressing your inhaler. Inhale slowly. Breathe in through your mouth, not your nose. Press down on your inhaler at the start of inhalation (or within the first second of inhalation). Keep inhaling as you press down on inhaler. Press your inhaler only once while you are inhaling (one breath for each puff). Make sure you breathe in evenly and deeply.
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Management of Asthma Exacerbation at Home:

Assess Severity Measure PEF: Value <40% personal best or predicted suggests severe exacerbation. Note signs and symptoms: Degrees of cough, breathlessness, wheeze, and chest tightness correlate imperfectly with severity of exacerbation. Accessory muscle use and suprasternal retractions suggest severe exacerbation.
Initial Treatment Inhaled short-acting beta2-agonist: up to three treatments of 2-4 puffs by MDI at 20-minute intervals or single nebulizer treatment.
Good Response Mild Exacerbation -PEF >70% predicted of personal best -No wheezing or shortness of breath -Response to beta2-agonist sustained for 4 hours May continue beta2agonist every 3-4 hr for 2448 hours. For patients on inhaled corticosteroids, double dose for 7-10 days.
Incomplete Response Moderate Exacerbation -PEF 40-70% predicted of personal best -Persistent wheezing and shortness of breath Add oral corticosteroid. Continue beta2-agonist.
Poor Response Severe Exacerbation PEF <40% predicted of personal best Marked wheezing and shortness of breath Add oral corticosteroid. Repeat beta2-agonist immediately. If distress is severe and nonresponsive, call your doctor and proceed to emergency department; consider calling 911. Proceed to emergency department.
Contact clinician for follow-up instructions.
Contact clinician urgently (this day) for instructions.
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Supplemental Material: http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm http://www.aafp.org/fpm/20041000/asthmaencounterform.pdf Resources for Patients: http://www.aaaai.org/patients/publicedmat/tips/asthmatriggersandmgmt.stm http://www.aaaai.org/patients/publicedmat/tips/childhoodasthma.stm http://www.aaaai.org/patients/publicedmat/tips/exerciseinducedasthma.stm References: National Institutes of Health (NIH) guidelines
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Chest Pain
780.5x Definition: A complaint based diagnosis which refers to any of a number of conditions associated with discomfort between the clavicles and the xyphoid process that cause a patient to seek evaluation.
General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of chest pain 2. Obtain adequate information to develop a working diagnosis in an efficient manner 3. Arrange for definitive care of identified specific causes of chest pain at time of presentation or with appropriate follow-up 4. Allay fears of patient and family regarding symptom if cause is benign 5. Provide symptomatic relief of patient complaints 6. Avoid ordering unnecessary tests on low risk patients
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Rules of Thumb:
Age Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) 1-10 Common Chest wall pain Asthma Functional GE reflux 11- 25 Common Chest wall pain Functional Asthma GE reflux Acute chest (sickle cell) Cardiac conditions Pulmonary embolism Cocaine and other substances History of heart disease, History of recent cancer treatment Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam 25-40 Common Chest wall pain GE reflux Panic disorder Peptic ulcer disease Atypical chest pain Unstable angina Pulmonary embolism Pneumonia Acute chest (sickle cell) Cocaine and other substances Male sex, History of CAD, diaphoresis, radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam Based on clinical suspicion, consider ECG and if severe cardiac markers Disease dependent Based on diagnosis 40-65 Common Chest wall pain GE reflux Atypical chest pain Typical angina >65 Common Atypical chest pain Typical angina GE reflux Chest wall pain
Life threatening diseases to consider
Asthma Acute chest (sickle cell) Cardiac conditions
Unstable angina Pulmonary embolism Aortic aneurysm
Unstable angina Pulmonary embolism Valvular disease Aortic aneurysm History of CAD, diaphoresis, severity and radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam ECG, consider cardiac markers, others based on clinical suspicion Disease dependent Based on diagnosis
Key worrisome features (history)
History of heart disease, History of recent cancer treatment Respiratory rate, Palpation of chest wall Cardiopulmonary exam None, consider CXR
Male sex, History of CAD, diaphoresis, severity and radiation of pain Respiratory rate, Pulse, Palpation of chest wall Cardiopulmonary exam
Key elements of exam
Key diagnostic study
None, consider CXR
ECG, consider cardiac markers, others based on clinical suspicion Disease dependent Based on diagnosis
Common Treatment Functional limitations
NSAIDS, asthma meds Usually none, especially if asthma controlled
Disease dependent Based on diagnosis
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Overview: Chest pain is a common reason for patients and parents of patients to seek care. In a large part because of public attention regarding ischemic heart disease, 50% of adolescents presenting with chest pain were worried about heart disease, despite the fact that heart disease rarely causes chest pain in this age group (less than 5%)1. Even in adults, the most common etiology is chest wall pain although a cardiac etiology is much more likely than in children and adolescents (ranging from 16% in an office setting to 50% in an emergency department setting). 2,3 The role of the physician is to evaluate and quickly assess the likelihood of the complaint being one of several life threatening conditions. The reality is that often these conditions can be eliminated on the basis of history in the office setting, and then the clinicians main task is one of reassurance. Because of patient and family concern, it is important to quickly reach a decision about whether the symptom warrants intensive evaluation or can be evaluated in a more leisurely fashion (or even be treated symptomatically until it resolves with no further evaluation). Complaints related to an acute onset of symptoms (under 48 hours) are associated with more severe illness but this is not always the case. These complaints always tend to be of more concern to the patient than do more persistent symptoms (some people will have had symptoms for as long as 6 months or more before seeking evaluation). There is no single reassuring finding that can eliminate life-threatening diagnoses from consideration. The most common of these in adults, though, have had evidence based decision rules developed which allow clinicians to comfortably triage patients into appropriate settings for diagnostic tests and definitive treatment. The clinician can take advantage of these decision support tools either by accessing them electronically or using traditional resources and completing calculations by hand or approximating risk and using the support tools to develop rules-of-thumb. Chief Complaint: Typically the complaint is Chest Pain Vitals: Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse, respiratory rate, basal metabolic index (BMI) and pulse oximeter if applicable should be noted. In addition, in patients over 20, cardiovascular risk factors (tobacco use, diabetes, hypertension, hyperlipidemia, obesity, known CAD, strong family history) should be identified through chart review prior to entering the room as well. General approach to history: The history for chest pain is primarily to establish risk of the symptom being caused by a life threatening condition. This is done by characterizing and documenting the nature of the pain experienced by the patient, the time course of the pain, aggravating and alleviating symptoms, and noting pertinent past medical history. Because pain histories tend to be subjective and patients tend to ruminate over time, it is useful to re-evaluate or even seek out other people to retake the history if it is confusing or does not easily fit into an identifiable pattern.
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Location Where does your chest hurt? (Can ask patient to indicate with hand the place of most severe pain) Timing When did the pain begin? What were you doing when you first noticed it? What activities are you engaged in when you notice the pain? Are there activities that reliably bring on the pain? Quality What kind of pain is it? (Sharp, dull, aching, stabbing, burning, pressure, etc) Severity How bad is the pain on a scale of 1-10? Aggravating/Relieving factors Does anything make it better? (Stopping, sitting, lying down, shallow breathing, certain positions, certain medications) Does anything make it worse? (Exertion, cough, movement, etc) Associated symptoms Are any other symptoms associated with the chest pain? (Diaphoresis, nausea, vomiting, radiation to arm, radiation to jaw, radiation to other sites, acid brash)
Age Specific Concerns in the history: Infants, School Aged Children, Adolescents: Key Question Content Acute onset, decreased breath sounds Genetic predisposition to heart disease (Marfans, etc) Trauma Hyperventilation, school stressors Breast growth Night cough Cough, fever Acid brash History of sickle cell disease History of cancer treatment (recent or ongoing) History of sympathomimetic ingestion (pseudoephedrine, cocaine, etc) History of pain on exertion, with syncope, with dizziness, or with palpitations History of congenital heart disease Further investigation if positive Consider pneumothorax Disease dependant Consider fracture Consider functional, explore stressors Consider puberty Consider asthma Consider bronchitis, pneumonia Consider reflux Consider acute chest Consider PTE Consider as cause Consider cardiac cause Consider as cause
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Adults: Questions For Adults From 25 to 65 (Older adults (>65): The questions below are pertinent but the incidence of native cardiac disease is so high that any complaint of chest pain should lead to concern about a cardiac etiology) Key Question Content Further Investigation If Positive Trauma Consider fracture Positional, worsening with movements Consider musculoskelatal Hyperventilation, panic symptoms Consider functional, explore stressors Cough, fever Consider bronchitis, pneumonia Acid brash Consider reflux History of recent or ongoing cancer treatment, Consider PTE immobilization, injury to lower extremity History of sympathomimetic ingestion Consider as cause (cocaine, pseudoephedrine, etc) Risk factor assessment: Tobacco use (amount and years) Hypertension (years and level of control) Family history of premature CAD (age and relation) Upon confirmation that chest pain is Hypercholesterolemia (years and control) potentially cardiac in nature based on Diabetes mellitus (years and control) characterization of pain Known heart disease Documented angina Known CAD Prior myocardial infarction Known congestive heart failure
Physical: The physical exam is targeted primarily at confirming clinical suspicion from history and risk factor assessment Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure General Does the patient appear comfortable or in obvious pain? How is the patient sitting? HEENT n/c Neck probably normal but observe for JVD, auscultate for bruit Chest wall Palpate for reproduction of pain, note if positive Heart Note rate and rhythm, palpate for PMI, auscultate for gallop, rub Lungs Auscultate for rales, wheezes Abdomen (adults) Probably low yield but consider percussion and palpatation for organomegaly or aneurysm, auscultation for bruits Extremities palpate for edema Neuro n/c Musculoskeletal See chest wall Diagnostic studies (see Figures 1&2)
General Guidelines
Patients under 25: The overwhelming majority of these patients with chest pain do not have a cardiac etiology. (SOR - A) 1, 4 There are no evidence based decision rules at this time to assist with diagnosis o Initial evaluation should include sufficient data to rapidly determine need for evaluation in hospital setting. This would include heart rate, respirations, pulse oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature and severity of pain (SOR - C). Patients who make an appointment for this complaint over the phone should be offered a prompt appointment (SOR - C). Patients with a recent history of cancer, ongoing cancer treatment, or sickle cell disease and this complaint should receive expeditious evaluation (SOR - C). o Musculoskelatal pain can be diagnosed on the basis of history and physical exam alone without additional studies. A chest x-ray should be obtained for persistent pain or excessive parental concern. (SOR - C). o Functional pain can be diagnosed on the basis of history and physical alone. A chest x-ray should be obtained for persistent pain or excessive parental concern. (SOR - C). Unexplained pain that has worrisome features or is associated with excessive parental concern should be referred for subspecialty evaluation before assigning to functional category (SOR - C). Upon determining that the pain is functional in nature, further work-up should be limited (SOR - C). o Pain of a pulmonary etiology should be assessed on the basis of history and physical with a chest x-ray and pulse oximetry being obtained almost as a matter of course (SOR - C). For those patients at risk for a deep venous thrombosis and pulmonary thromboembolism, a d-dimer or equivalent study should be obtained. A negative study effectively rules out thromboembolic disease. A positive study should lead to further imaging using high resolution CT scanning or nuclear imaging in an emergency department setting (SOR - B). Presumed infectious causes should be evaluated with a chest x-ray if the patient reports significant discomfort, or is febrile, tachypneic, tachycardic, or the diagnosis is unclear in any way. A complete blood count with differential should be obtained on patients with fevers, in particular if the diagnosis is in doubt. In addition, a blood culture should be obtained if broad spectrum antibiotics are being initiated (SOR - B). Possible masses or pneumothorax should be evaluated with chest x-ray (SOR - B). o Pain felt to be of GI origin may be treated empirically, with relief of symptoms serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure should be referred for subspecialty evaluation (SOR - C). o Initial evaluation of cardiac pain should include a measurement of oxygen saturation. If based on history and physical a congenital problem or rhythm disturbance is suspected then a chest x-ray should be performed. Rhythm disturbances should additionally be investigated with an EKG. Suspected structural problems should be investigated with an echocardiogram (SOR - C). If the pain is predictably exertional, or associated with syncope, or with lightheadedness then the patient should be referred to a cardiologist for additional evaluation (SOR - C).
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o Over the counter stimulants can cause pain and palpitations. These include cough and cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of abstinence should result in resolution of symptoms (SOR - C). Cocaine or methamphetamine related chest pain may be difficult to diagnose due to the patients being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR - C). If the pain is ongoing, further evaluation should occur in the hospital setting (SOR - B). If the pain is remote, screening and treatment for addiction is warranted (SOR - B).
Patients over 25: The majority of these patients with chest pain do not have a cardiac etiology, although more so than in the younger age group. (SOR A) 5,6 At any given age, women are less likely to have heart disease than men, although that advantage is reduced following hysterectomy and menopause (SOR - C). Patients above age 65 are more likely to have cardiac disease, a dissecting aneurysm, and herpes zoster as a cause of chest pain (SOR - C).7 o Initial evaluation should include sufficient data to rapidly determine need for evaluation in hospital setting. This would include heart rate, respirations, pulse oximetry for suspected pulmonary or cardiac pain, and a brief assessment of nature and severity of pain (SOR - C). Patients who make an appointment for this complaint over the phone should be offered a prompt appointment (SOR - C). Patients with a recent history of cancer, ongoing cancer treatment, or known coronary artery disease and this complaint should receive expeditious evaluation (SOR - C). o Musculoskeletal pain can be diagnosed on the basis of history and physical exam alone without additional studies. A chest x-ray should be obtained for persistent pain or excessive concern. (SOR - C). Patients with multiple risk factors should have very close follow-up and possibly an EKG at the time of the visit. If the pain is persistent or clinical suspicion is heightened for any other reason, then an evaluation with a gaited stress test or by a cardiology subspecialist is warranted (SOR - C). A therapeutic trial of NSAIDS can be offered if not contra-indicated (SOR - C). Herpes zoster can present as pain before the rash occurs. o Pain felt to be of GI origin may be treated empirically, with relief of symptoms serving to confirm the diagnosis (SOR - C). Persistent pain or treatment failure should be referred for subspecialty evaluation, as should those people at risk for esophageal cancer (history of long-term alcohol use, cigarette smoking, family history of esophageal cancer (SOR - C). o Evaluation of chest pain in the adult patient is based on certainty of diagnosis, identification of risk factors and application of decision rules. For example, if the pain is characteristic of angina (substernal pain, exertional in nature, and relieved by nitroglycerin) and the patient is a male over 50 the chance of the pain being ischemic cardiac pain is very high and should be expeditiously evaluated. In contrast, a 25 year old woman with exertional pain likely does not have ischemic coronary disease. One such diagnostic decision cascade would be the following (SOR - C): Obtain EKG High risk: New bundle branch block, transient elevation with pain, or sustained V-tach
Intermediate risk: ST T wave inversions > 0.2 mV or pathologic Q waves Low risk: Normal or unchanged, especially during pain Characterize the pain based on known characteristics of angina (quality, aggravating and alleviating factors) High risk: Substernal, on exertion, relieved with NTG Intermediate risk: 2 of three Low risk: 1 of three Identify presence of high risk pre-existing disease Recent MI Recent CABG Recent PCI or stent placement Quickly assess whether patient has known heart disease or diabetes from chart review or patient history. Presence of either puts them at increased risk.
Assess and transfer if ischemia suspected If the EKG and/or the pain history are high risk and there is a good chance that the patient has disease based on risk factors, then the patient is given an aspirin and sent to a hospital for further evaluation in a monitored setting. High risk for unstable angina includes age over 65, characteristic pain for 20 minutes, ST-T wave changes, or pulmonary edema If the clinical suspicion remains low, continue evaluation in office Quickly assess other risk factors from chart review or additional history (Age, Male sex, Presence of diagnosed hypertension, DM or hyperlipidemia, Presence of tobacco use, Family history of early CAD) Higher risk: Male over 50, Woman over 60 Higher risk: Longstanding hypertension, hyperlipidemia, tobacco use Higher risk: Family history of disease in a first degree relative at the patients age or younger Obtain clarifying labs Lipid profile CBC Blood glucose (consider full chemistry) Consider thyroid studies based on clinical suspicion Assess left ventricular function For any concomitant signs of LV dysfunction (particularly dyspnea on exertion), obtain echogardiogram as part of work-up Consider possibility of aortic aneurysm In patients with Marfan body habitus or with history of long time tobacco use and other risk factors such as age and hypertension, aortic aneurysm should be considered as a cause of chest pain. If there is reasonable clinical suspicion, an x-ray and/or CT of the chest should be obtained. A normal mediastinum rules out the diagnosis
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Make a clinical assessment of the likelihood of the coronary artery disease. One such model is seen below (SOR B):
Another more comprehensive model can be found at (SOR B)

http://www.emedicine.com/splash/etools.asp?file=coronary_disease_score&prog=edecision
If the pretest probability is less than 30%, then further testing should be pursued only with the understanding that the risk of a false positive test is high and that a negative test does not rule out disease. If the pretest probability is greater than 30% but less than 60% then further non-invasive testing is indicated. If the pre-test probability is greater than 60% then non-invasive testing should not be pursued and cardiac catheterization would be the next step. The diagnostic testing decision is as follows: Intermediate probability of CAD, EKG with less than 1 mm ST depression and/or RBBB, able to exercise - Dynamic exercise testing Intermediate probability of CAD or remote history of CAD, EKG with greater than 1 mm ST depression, pre-excitation (WPW), paced rhythm, LBBB, able to exercise - Dynamic exercise testing with additional imaging Intermediate probability of CAD, EKG with or without less than 1 mm ST depression, unable to exercise - Adenosine or dipyridamole myocardial perfusion study It is unclear where the multi-slice CT scanner will fit into the diagnostic algorithm for these patients at this time If after the clinical assessment or after non-invasive testing there is a high probability of left main or 3 vessel disease, uncertain diagnosis after non-invasive testing, or suspected non-atherosclerotic etiology Referral for possible cardiac catheterization If after the clinical assessment or after non-invasive testing there is a low probability of left main or 3 vessel disease Work on risk factor modification
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o Pain of a pulmonary etiology should be assessed on the basis of history and physical with a chest x-ray and pulse oximetry being obtained almost as a matter of course (SOR - C). If clinically the diagnosis of DVT is entertained, elements of the history, physical exam suggest PTE then a clinical decision should be made as to whether or not a PTE is likely. Use of a validated decision rule such as the one below can assist with this decision (SOR - B).
For those patients at risk for a deep venous thrombosis and pulmonary thromboembolism, a d-dimer or equivalent study should be obtained. A negative study effectively rules out thromboembolic disease. A positive study should lead to further imaging using high resolution CT scanning or nuclear imaging in an emergency department setting (SOR - B). If the DUniversity of South Alabama, Department of Family Medicine June 30, 2008 39
dimer is positive but the clinical suspicion is relatively low and the imaging study is negative then a venous doppler should be obtained and if negative repeated in a week. If the suspicion is high, then pulmonary artery catheterization would be indicated. Presumed infectious causes should be evaluated with a chest x-ray if the patient reports significant discomfort, is febrile, tachypneic, tachycardic, or the diagnosis is unclear in any way. A complete blood count with differential should be obtained on patients with fevers, in particular if the diagnosis is in doubt. In addition, a blood culture should be obtained if broad spectrum antibiotics are being initiated (SOR - B). If a chest x-ray is inconvenient to obtain, a validated clinical rule can be used to determined the urgency with which an x-ray is needed (SOR - B).
Complaints suggestive of masses or pneumothorax should be evaluated with chest x-ray (SOR - B). o Symptoms consistent with panic disorder should be evaluated with the following two questions:
In the past six months, did you ever have a spell or an attack when all of a
sudden you felt frightened, anxious, or very uneasy? In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you couldnt catch your breath? A yes on either question is considered a positive screen but the screen is neither sensitive nor specific enough in a population with a high prevalence of coronary artery disease to predict a lack of cardiac disease. Thus, in patients at significant risk, a cardiac etiology should be pursued prior to attributing the pain to panic disorder. o Over the counter stimulants can cause pain and palpitations. These include cough and cold remedies, nicotine, and caffeine. If suspected to be the cause, a trial of abstinence should result in resolution of symptoms (SOR - C). Cocaine or methamphetamine related chest pain may be difficult to diagnose due to the patients being less than forthcoming (SOR - B). If suspected, obtain a urine drug screen (SOR - C). If the pain is ongoing, further evaluation should occur in the hospital setting (SOR - B). If the pain is remote, screening and treatment for addiction is warranted (SOR - B). o Functional pain is typically a diagnosis of exclusion in adults. Particularly in patients with risk factors for another disease, diagnostic testing should be pursued. At a minimum a chest x-ray should be obtained for persistent pain or concern and a cardiac work-up should be pursued in patients who are at risk (SOR - C). Unusual diagnoses such as recurrent PTE should be entertained over time. Unexplained pain that has worrisome features or is associated with concern should be referred for subspecialty evaluation before assigning to functional category (SOR - C). Once comfortable that the pain is functional in nature, further work-up should be limited (SOR - C). Office Based Management: Musculoskeletal Pain: Non pharmacologic Patients with acute chest wall pain require only conservative management (SOR - C). Patients should be instructed to resume their normal activities as tolerated. Any aggravating factors should be eliminated to the extent possible. Bed rest is not indicated. (SOR A) Pharmacologic (SOR - C) NSAIDS (see Appendix) relieve chest wall pain through their analgesic properties and also reduce inflammation. Instruct patients to take NSAID regularly until pain resolves. Acetaminophen is an alternative medications in patients for whom NSAIDs are contraindicated. A short course of narcotic pain relievers can be used if the pain is severe until NSAIDs can take effect but should not be used for recurrent pain. Herpes zoster (SOR B) 7 - The treatment of herpes zoster has three major objectives: (1) treatment of the acute viral infection, (2) treatment of the acute pain associated with herpes zoster and (3) prevention of postherpetic neuralgia. Antiviral agents, oral
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corticosteroids and adjunctive individualized pain-management modalities are used to achieve these objectives. Antivirals - Antiviral agents have been shown to decrease the duration of herpes zoster rash and the severity of pain associated with the rash. However, these benefits have only been demonstrated in patients who received antiviral agents within 72 hours after the onset of rash. Antiviral agents may be beneficial as long as new lesions are actively being formed, but they are unlikely to be helpful after lesions have crusted. The 50-50-50 rule has been proposed to identify who would most benefit from antivirals, that is those who have had the symptoms for under 50 hours, and are over 50 or have more than 50 lesions. (SOR-C) Acylovir (Zovirax) therapy appears to produce a moderate reduction in the development of postherpetic neuralgia in these patients. Other antiviral agents, specifically valacyclovir (Valtrex) and famciclovir (Famvir), appear to be at least as effective as acyclovir. Dosages are available from commonly available references Corticosteroids - Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain in patients more than 50 years of age and is useful for reducing symptoms for zoster involving the facial nerve. The dose in adults is generally 30 mg orally twice daily on days 1 through 7; then 15 mg twice daily on days 8 through 14; then 7.5 mg twice daily on days 15 through 21 Analgesics - The pain associated with herpes zoster ranges from mild to excruciating. Patients with mild to moderate pain may respond to over-the-counter analgesics. Patients with more severe pain may require the addition of a narcotic medication. When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control, and less anxiety, than "as-needed" dosing. Panic disorder See Depression chapter Pneumonia - See Pneumonia chapter Gastroesophageal reflux disease: 8 Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down immediately after eating (up to 3 hours). They should also be counseled that acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and should be withdrawn initially; they can be added back as symptoms permit. Reducing dietary fat should improve symptoms as should weight loss. Medications known to cause reflux should be withdrawn if possible. These include calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain sedatives. The head of the bed should be elevated 4 8 inches. Tight clothing should be avoided as should tobacco use. Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a proton pump inhibitor. The choice is based on previous effective and
ineffective therapy and cost to patient. (see appendix for choices and dosages) If the H2 blocker was used initially but is only partially effective, it may be necessary to switch to a PPI. Once symptoms resolve, reduce dose to the lowest required to maintain patient symptom free. Antacids may be added for additional symptom relief, especially early on or when symptoms flair. Chest pain with cardiac risk factors - Those patients who following diagnostic testing are found to be of low immediate risk of having significant coronary artery disease should reduce their risk factors if possible. The sex, age, and family history cannot obviously be change. On the other hand patients can quit the use of tobacco products, reduce their blood pressure, monitor and control their lipids and blood pressure, increase their physical activity and reduce their weight. The stages of change model identifies the likelihood of a patient making a significant lifestyle change. Physicians are most likely to make a difference when the patient is in the contemplation stage (by eliciting commitment) and in the preparation stage (by offering assistance) Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action. Risk Factor Smoking Hypertension Hyperlipidemia (LDL) Diabetes (A1c) Target (no CAD) Abstinence 140/85 130 (2 Risk factors) n/a Target (CAD or diabetes) Abstinence 130/80 100 (consider 70) 7.0
Urgent referral to emergency department for evaluation under controlled conditions and possible admission (SOR - B): Suspected PTE based on history and risk factors Pain associated with hypoxia, regardless of etiology Suspected acute cardiac event Pneumothorax Referral to specialist (SOR - C): Suspected congenital heart disease Pain associated with syncope, exertion, or lightheadedness in child or adolescent
Suspected cardiac ischemic pain in an adult Gastroesophageal reflux associated with dysphagia, early satiety, iron deficiency anemia, odynophagia, vomiting, weight loss or if not improved in reasonable time with conservative measures. Consider referral if at risk for Barretts esophagus (i.e. white male age >45 with long history of symptoms, history of long-term alcohol use, cigarette smoking, family history of esophageal cancer. Consider referral if etiology needs to be made clear and cardiology work-up non revealing) Pain associated with cocaine use Mass in chest Follow-up (SOR - C): Patients who are at risk for potentially life threatening disease should follow through on recommended consultations and follow-up when problem has been evaluated. For patients with musculoskeletal pain, schedule follow-up for two to four weeks but if the pain resolves and the patient is not at risk for ischemic heart disease they may elect to cancel the appointment. For patients with pain from herpes zoster, they should follow-up for infection or non-resolution in 2 4 weeks Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms within 4 weeks and resolution within 8 weeks Patients felt to be symptomatic from stimulant use, a visit following a week of abstinence is usually sufficient. At that visit, counseling regarding excessive stimulant use should be provided. For patients with multiple cardiac risk factors, aggressive risk factor modification should begin when patient is amenable to change. The follow-up visit soon after a negative stress test will often present itself as an opportunity for the physician to facilitate change. This follow-up should occur within a week of the negative stress test.
Suggested for further reading: Chapter 23 Chest Pain in Current Diagnosis & Treatment in Family Medicine. Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at http://www.accessmedicine.com/home.aspx Pnaju A, Hemmerlarn B, Guyatt G, Simel D. Is this patient having a myocardial infarction? JAMA, 1998; 280: 1256 - 1268. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, ORourke RA, Pasternak RC,Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. Available at www.acc.org/clinical/guidelines/stable/stable.pdf .
Resources for patients: Chest pain, acute accessed on Familydoctor.org at http://familydoctor.org/x2587.xml Chest pain, chronic accessed on Familydoctor.org at http://familydoctor.org/524.xml Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at http://familydoctor.org/087.xml Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at http://familydoctor.org/161.xml References: 1. Pantell R, Goodman B. Adolescent chest pain: a prospective study. Pediatrics 1983 Jun;71(6):881-7. 2. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract 1994;38:345-52. 3. Cayley W. Diagnosing the Cause of Chest Pain Am Fam Physician 2005;72:2012-21. 4. Evangelista, JA, Parsons, M, Renneburg, AK. Chest pain in children: diagnosis through history and physical examination. J Pediatr Health Care 2000; 14:3. 5. Marsan R, Shaver K, Sease K, et al. Evaluation of a clinical decision rule for young adult patients with chest pain. Academic Emergency Medicine 2005; 12: 26 32. 6. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, ORourke RA, Pasternak RC,Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. 7. Stankus S, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia Am Fam Physician 2000;61:2437-44,2447-8. 8. DeVault K and Castell D. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterology 2005; 100:190-200.
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Appendix
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Cough
786.2 Definition: Cough A rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material; also called tussis. General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of cough. 2. Arrange for definitive care of identified specific causes of cough at time of presentation or with appropriate follow-up. 3. Provide symptomatic relief of patient complaints.
Age Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) Life threatening diseases to consider 0-2 years Very Common URI GERD Croup Asthma 2-14 years Common URI Postnasal drip Asthma Croup GERD Pneumonia Foreign Body Aspiration Malignancy Fever Shortness of Breath ENT Lung Based on history and physical Disease dependent Based on diagnosis 15-65 years Common URI Postnasal drip Asthma GERD Medication side effect Pneumonia Malignancy >65 years Common URI Postnasal drip Asthma GERD Medication side effect Pneumonia Malignancy
Key elements of exam Key diagnostic study Common Treatment Functional limitations
Pneumonia Congenital malformations Foreign body aspiration Fever Cyanosis Respiratory Distress ENT Lung Based on history and physical Disease dependent Based on diagnosis
Fever Shortness of breath ENT Lung Based on history and physical Disease dependent Based on diagnosis
Fever, shortness of breath, orthopnea, PND ENT Lung Cardiac Based on history and physical Disease dependent Based on diagnosis
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Overview: Cough is a very common complaint experienced by all age groups. Cough is a normal mechanism of the body that clears secretions from the bronchial tree and trachea. Cough is an involuntary reflex mediated through the vagal afferents. There is some degree of voluntary control over this reflex. Voluntary control is manifested as cough inhibition (holding back a cough) or voluntary cough. Involuntary cough is triggered by vagus nerve stimulation in the back of the throat and bronchial tree. A large number of common diseases including asthma, GERD, bronchitis, and post-nasal drip can cause cough through airway irritation. In addition, there are life-threatening ailments like pneumonia and lung cancer that may present with cough as a chief complaint. A thorough history and physical exam is important in determining the cause of cough. Chief Complaint: Typically the complaint is Cough Vitals: Age, respiratory rate, pulse, temperature and weight should be noted prior to going into the room through chart review and review of vital signs. Fever and/or tachypnea may suggest pneumonia or other systemic illness. General approach to history: The history for cough is primarily to identify underlying causes of cough. Questions are directed at determining the nature of the cough (productive vs. nonproductive), time course and modifying factors. Timing How long have you been coughing? Is it getting better, staying the same, or getting worse? When do you cough the most (night, day, etc)? Nighttime cough suggests asthma or GERD. Quality Are you coughing anything up? If so, what color is it? Green or yellow sputum was once thought to be suggestive of bacterial infection, although this remains controversial. Severity How much are you coughing? Are you coughing so much that you vomit? Aggravating/Relieving factors Does anything make it better or worse? (Eating, lying down, going outside, pollen exposure, etc) Associated symptoms Are any other symptoms associated with the cough? (Chest pain, dyspnea, acid brash, wheezing) Symptom Review Targeted at common causes of cough for patients age. See tables and flowcharts.
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Physical: The physical exam is targeted primarily at identifying underlying causes of cough and ruling out serious pathology (i.e. pneumonia, severe COPD exacerbation) General Watch out for respiratory distress (labored breathing, accessory muscle use) HEENT Look for pharyngeal erythema (present with many causes of cough), Nasal drainage (upper airway cough syndrome) Neck n/c Heart Listen for murmurs and arrhythmias particularly in older patients. Lungs Listen for wheezes (asthma), crackles (pneumonia) and rhonchi (bronchitis) Abdomen Assess for epigastric tenderness (GERD), although, most patients with GERD will not have epigastric tenderness. Extremities n/c Neuro n/c Musculoskeletal n/c Disease Specific Indicators: Infants ages 0 2 years:
Disease
URI GERD
Suggestive findings on history and physical

Daycare attendance. Sick contacts. Duration of cough <2 weeks. Nasal congestion. Spitting up after feeding. Poor weight gain. Duration of cough >2 weeks. Nighttime cough. Wheezing. Cough worsened by environmental exposure or change. Asthma, Allergies or Eczema in siblings or parents. Coughing for >1 week with most URIs. Barking cough, inspiratory stridor, abrupt onset. Low grade fever. Productive cough, tachypnea, fever, ill appearance, crackles on physical exam. SpO2 <95%
Asthma
Croup (age 0-6 years) Pneumonia
Children Ages 2-14 years:

Disease
URI
Suggestive findings on history and physical

Daycare attendance. Sick contacts. Duration of cough <2 weeks. Nasal congestion. Sore throat. Nighttime cough. Wheezing. Cough and/or dyspnea on exertion. Family or personal history of asthma, allergies or eczema. Coughing for >1 week with most URIs. Bad taste in mouth, worsening symptoms after eating acid or spicy foods, abdominal or chest pain after eating acid or spicy foods. Duration >2 weeks or recurrent. Productive cough, fever, shortness of breath, crackles on physical exam. SpO2 <95%. Productive cough, no fever, no shortness of breath. Duration >2 weeks. Runny nose, watery eyes, post-nasal drip. Sore throat that is worse in morning and better throughout the day. (This sore throat comes from post nasal drainage irritating the back of the throat) June 30, 2008 51
Asthma
GERD Pneumonia Bronchitis UACS (Upper Airway Cough Syndrome)
Adults >15 years:

Disease URI Suggestive findings on history and physical Sick contacts. Duration of cough <2 weeks. Sore throat. Nasal congestion Nighttime cough. Wheezing. Cough and/or dyspnea on exertion. Family or personal history of asthma, allergies or eczema. Coughing for >1 week with most URIs. Beta blocker use may worsen asthma. Bad taste in mouth, worsening symptoms after eating acid or spicy foods, abdominal or chest pain after eating acid or spicy foods. Duration >2 weeks or recurrent. Productive cough, fever, shortness of breath, crackles on physical exam. SpO2 <95%. See Diehr Rule Table below. Productive cough, no fever, no shortness of breath. Duration >2 weeks. Runny nose, watery eyes, post-nasal drip. Sore throat that is worse in morning and better throughout the day. (This sore throat comes from post nasal drainage irritating the back of the throat) Pt taking ACEI. Duration of cough >2 weeks. May or may not correspond to starting or increasing ACEI. Patient continues to smoke (regardless of amount). Weight loss, fatigue, hemoptysis, current or former smoker
Asthma
GERD
Pneumonia Bronchitis
UACS (Upper Airway Cough Syndrome)
ACEI Smoking Lung Cancer
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Diagnostic studies:
General guidelines
Types of diagnostic studies will depend upon clinical suspicion of underlying cause. In some cases a therapeutic trial may be used as a diagnostic study (i.e. trial of proton pump inhibitors for cough secondary to GERD).
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Suspected cause Asthma
Study to order Spirometry
Asthma GERD GERD GERD Pneumonia UACS Croup Lung Cancer
Chest X-ray Barium swallow H.Pylori Endoscopy (GI referral) Chest X-ray Allergy testing Soft-tissue film of neck Chest X-ray
When to order In patients >6 years old to make diagnosis and follow disease. Initial presentation or dramatic change in asthma pattern Infants Adults who do not respond to standard therapy Patients who fail standard therapy All patients in whom pneumonia is suspected Patients who fail standard therapy All children in whom croup is suspected. All patients in whom lung cancer is suspected.
Office Based Management: URI See URI handout Non pharmacologic Continue normal activity as tolerated. Hot showers (breathing warm, moist air) and humidifiers may help clear the nasal passages. Hot soups and liquids such as tea may also help clear nasal passages by a vapor action. Pharmacologic Cough suppressants. Combination products are available to target specific constellations of symptoms and can be chosen on the basis of patient complaints. Antihistamines are useful for runny nose and post-nasal drip. Decongestants are useful for nasal congestion and sinus pressure. Cough suppressants and decongestants are not recommended for patients less than 2 years of age. Most systemic cough suppressants suppress cough by action on the central nervous system. Cough drops, numbing lozenges and OTC throat sprays are all useful for symptom relief. Follow-up Patients should be told that most URIs resolve within 7 days, but cough can persist for several weeks after an upper respiratory infection. Patients should return for respiratory difficulty, persistent high fever, or in 2 weeks if not better. Asthma See asthma chapter
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GERD: Nonpharmacologic Infants - Reduce amount given at each feed and increase frequency of feeding (i.e. If currently taking 4 oz every 4 hrs, give 2 oz every 2 hrs). This will maintain adequate calories, but limit gastric distention and pressure. Also keeping child upright after feeding can minimize symptoms. Children and adults - Limit intake of foods that provoke symptoms. Avoid lying down for at least 30 minutes after eating. Pharmacologic - A trial of H2 blockers or Proton Pump Inhibitors is often diagnostic and therapeutic. In adults these are often started empirically and a response to the treatment is considered diagnostic of GERD. Follow-up - Cough secondary to GERD may persist for several weeks after initiating therapy. Patients should follow up in 1 month if cough has not resolved or sooner for problems. Upper Airway Cough Syndrome (UACS): Non-pharmacologic - Avoid allergens. Formal allergy testing may be useful in identifying allergic triggers. Pets (especially house cats and dogs) are common offenders as is thick carpeting that tends to retain dust and other allergens. Removal of these offenders may dramatically improve symptoms. Pharmacologic - Antihistamines have traditionally been the mainstay of therapy. They are effective, inexpensive and available OTC as well as by prescription. Inhaled nasal steroids are very effective in treating post-nasal drip and UACS. They are not effective acutely, but if used regularly will prevent most allergic mediated postnasal drip. Anticholinergics may be tried if patients do not tolerate antihistamines and inhaled nasal steroids. Leukotriene modifiers are approved for allergic rhinitis and may be considered although their role remains unclear. Follow-up - UACS may persist for 1-2 weeks after treating post-nasal drip and allergic rhinitis. Patients should return in 1 month if not better, sooner for problems. Croup: Non-pharmacologic Cool humidified air may help with symptoms but no studies prove this. Pharmacologic Nebulized racemic epinephrine may help relieve symptoms temporarily. Systemic steroids have been shown to prevent hospitalization and hasten recovery. Otherwise, pharmacologic therapy is targeted toward symptoms.
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Follow-up - Patients should follow up in 1 week if not better and sooner for increasing work of breathing. Croup is generally a self-limited illness, but occasionally children do require intubation due to subglottic stenosis from croup. Parents should also be informed that symptoms are likely to be worse at night than during the day. Pneumonia: Non pharmacologic Relative rest can help with symptoms of dyspnea. Sitting up for at least 20 minutes per day may help with clearing pulmonary secretions. Frequent voluntary coughing may aid in clearing secretions. Chest physical therapy may also be useful to loosen pulmonary secretions. Pharmacologic Systemic antibiotics for 10-14 days. If patient is hypoxic or appears ill, hospitalization and IV antibiotics are recommended. Supplemental O2 is given to keep O2 Sats >90%. After patient is afebrile for 24 hrs, antibiotics may be changed to PO. Patients may be discharged home when they are no longer oxygen requiring and are able to tolerate PO antibiotics. See http://www.aafp.org/fpm/20060400/pneumoniaseverityindex.pdf for pneumonia severity index to aid in decision whether to admit to hospital or treat as an outpatient. Follow-up Patients should follow up in 1 week if not better and sooner for worsening shortness of breath or if still running fever for more than 72 hrs after starting antibiotics. ACE Inhibitor induced cough: ACE inhibitors are commonly used for treating HTN and nephropathy in diabetes. Cough is a common side effect of these drugs thought to be mediated by elevations in the levels of bradykinin. ACE inhibitors block the enzyme responsible for degrading bradykinin. Bradykinin is thought to stimulate the cough centers directly. The cough may start anytime after initiating ACE inhibitors but often begins about 1 month after starting the drug. Discontinuing the drug will result in resolution of the cough within 2 weeks if this is the cause of the cough. ACE inhibitors should be stopped in all patients with unexplained cough. Angiotensin receptor blockers have a similar effect on blood pressure but do not result in bradykinin elevations and may be used instead of ACE inhibitors in most patients. Smokers cough: Non pharmacologic - Smoking is a common cause of chronic cough. All patients who continue to smoke should be advised to stop smoking, both for their health and as a diagnostic tool. Pharmacologic There are numerous pharmacologic aids to smoking cessation including nicotine replacement and selected antidepressants. Patients should be offered pharmacologic intervention if they are unable to stop smoking on their own. Follow-up - In most smokers who present with a cough, the cough is secondary to smoking and will resolve when smoking ceases or is reduced significantly. If the cough does not resolve within 1 month of smoking cessation, other causes should be investigated.
Lung Cancer: Nonpharmacologic Stop smoking. Potentially, lung or partial lung resections depending on extent and type of cancer. Pharmacologic Depends on type of cancer. Numerous regimens are used by oncologists. These patients will be co-managed with an oncologist. When to refer to a specialist for further evaluation: Asthma Severe persistent asthma or asthma that does not respond to conventional therapy. GERD Symptoms that do not respond to PPI and H. Pylori eradication (if infection is present) Lung Cancer All patients with lung cancer should be seen by an oncologist. Supplemental materials: Free on-line resource covering diagnosis and management of cough on FP Notebook http://www.fpnotebook.com/search.asp?QU=cough&CT=d%3A%5Cusers%5Csmoses%5Cdb Suggested for further reading: Chest Journal: Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines, http://www.chestjournal.org/content/vol129/1_suppl/ Resources for patients: Chronic Cough Handout from Familydoctor.org - http://familydoctor.org/237.xml References: 1. Irwin, R. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest 129: 1S-129S
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Major Depression
(Adult >16 y.o. ) ICD 9 311 Definition: Major Depression Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria discussed below. DSM-IV Criteria for Major Depressive Episode A. Five or more of the following symptoms have been present and documented during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. B. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-congruent delusions or hallucinations. 1.depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2.markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 3.significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day 4.insomnia or hypersomnia nearly every day 5.psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6.fatigue or loss of energy nearly every day 7.feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8.diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9.recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide C. The symptoms do not meet criteria for a mixed episode. D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). F. psychotic symptoms, or psychomotor retardation.
The symptoms are not better accounted for by bereavement ( i.e., after the loss of a loved one), the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, Dysthymic Disorder Chronic (>2 years) and frequent low mood, often experienced as emptiness or sadness, often accompanied with lethargy and self-criticism, and requiring a least 2 other symptoms of depression. Atypical Depression Depressive symptoms not meeting criteria for another mood disorder. General approach to the patient: Goals: 1. Identify patients a risk of developing major depression. 2. Identify patients who have signs and symptoms consistent with major depression. 3. Identify patients with risk of suicide. 4. Initiate appropriate therapy. 5. Continue surveillance for improvement or worsening. Overview: Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major depression. Up to 50 percent of depressed patients are not recognized. The lifetime risk of major depression in the community is 7 to 12 percent in men and 20 to 25 percent in women. "Normal depression" occurs in the course of any active, eventful life. The most important single marker of pathologic depression is that it interferes with the person's ordinary expectable function. This expectable function can apply to self care, the maintenance of important relationships, the performance of work-related tasks, and economic self-support. It is difficult to make a case for a major depression, regardless of symptom severity, without observable interference with function. The three subgroups of depressive disorder according to (DSM-IV) are major depression, dysthymia, and atypical depression or depression not otherwise specified (NOS). A number of medical conditions may present with depression, including stroke, diabetes, dementia, cancer, hypothyroidism, chronic fatigue syndrome, fibromyalgia, systemic lupus erythematosus, coronary heart disease, anxiety and panic disorders and some medications. Patients with medical illnesses such as diabetes and heart disease have higher prevalences of major depression, with estimates between 10 and 20 percent. Several depression screening instruments are available; most instruments have relatively good sensitivity (80 percent to 90 percent) but only fair specificity (70 percent to 85 percent). Treatment may include antidepressants or specific psychotherapeutic approaches (eg, cognitive behavioral therapy or brief psychosocial counseling), alone or in combination. In most patients major depression is a relapsing, remitting illness. After a first episode there is a greater than 40
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percent rate of recurrence over a two-year period; after two episodes, the risk of recurrence within five years is approximately 75 percent. Contributory or predisposing factors Older age Physical illness, particularly if debilitating, painful, or life-threatening. Multiple sclerosis, HIV/AIDS, and cancer carry an especially high risk. Physical illness is the main precipitant of depression in later life Some medically prescribed drugs including alpha-methyldopa, beta-blockers (research has shown no significant correlation), L-dopa, and interferon Drug and alcohol misuse Stress, especially recent adverse events, notably divorce or marital adversity. Vulnerability to adverse events is increased by social isolation and by increasing age Poverty and unemployment Patients with other psychiatric diagnoses (e.g. personality disorders) also have a higher risk of major depressive disorder Patients encountered in the primary care setting with the following characteristics are at risk for depression:

Personal or family history of depression Multiple medical problems Unexplained physical complaints Chronic pain Overutilization of medical services
Clinical presentation: Symptoms Depressed mood may have to be elicited by specific questioning. A patient may complain initially of physical problems (e.g. persistent lethargy) Anhedonia (loss of interest and pleasure in usual activities) is usually present to some degree Weight loss, or weight gain, is commonly associated with depression Disturbed sleep pattern with early morning waking is common; some patients can present with hypersomnia Suicidality is the primary concern, and should be queried by direct questioning, such as 'Have you ever thought that life is not worth living?' or 'Have you ever thought of harming yourself?' There is no evidence that such questions can put the idea of suicide into a patient's mind for the first time. Feelings of guilt and/or unworthiness are common; these can be of delusional intensity in that patients may feel that others are avoiding them, or that they have committed some crime, or have delusions of poverty Physical symptoms, often without clear medical basis, may be a presenting feature. Preoccupation with bodily function is common, especially with bowel function; these feelings may be of delusional intensity (e.g. 'my bowels are stopped up'). But genuine constipation is also common in depression, especially in older patients
Signs

Weight loss is common. Malnutrition is a particular risk in the elderly Activity disturbance may be a feature of severe depression. Psychomotor retardation is common, with both slowed speech and movement. The voice may be toneless, the face expressionless. Or agitation, reflected both in thinking and in bodily movement, may be predominant. Both patterns can occur at different times in the same patient
Differential diagnosis There are several medical conditions, such as hypothyroidism, which produce depressionlike symptoms that resolve when the underlying medical condition is treated.
Cardio vascular CHF Metabolic/ Nutritional Cushings Addisons PheoChromo cytoma Thyroid Disease Parathyroid Dz DM Hypo glycemia Electrolyte imbalance Carcinoid Ovarian failure Testicular failure Renal failure Heavy metal poisoning Hematology/ Neurology Oncology Pernicious anemia malignancies CVA
Medication AntiHypertensives
Infections Hepatitis HIV/ AIDS Mono nucleosis Syphilis TB Lyme disease Encephalitis Influenza
Misc. COPD
Cardio Reglan myopathy M.I. H2 blockers Illicit drugs Chemotheraputic Antiparkinson Antiepileptics Psychotropics NSAIDS OCPS
Huntingtons Hepatic Chorea failure Multiple sclerosis Parkinsons disease Alzheimers disease Narcolepsy Wilsons disease
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Chief Complaint: Some patients present to their primary care physician with a chief complaint of depressed mood. Others may not readily offer such a history, often because they do not recognize that they are depressed, and sometimes because they are reluctant to acknowledge a psychological basis for their symptoms. History of present illness: Determine history of present illness including: - Onset may be gradual over months or years or may be abrupt. - Severity of symptoms and degree of functional impairment. - People diagnosed with major depression have a heterogeneous course from selflimiting to life-threatening. Predictors of poor outcome include severity at initial assessment, lack of reduction of social difficulties at follow-up and low educational level. Categorize severity of symptoms and degree of functional impairment as follows: o Mild: few, if any, symptoms in excess of those required to make the diagnosis and only minor impairment in occupational and/or social functioning o Moderate: symptoms or functional impairment between mild and severe o Severe: several symptoms in excess of those necessary to make the diagnosis and marked interference with occupational and/or social functioning
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Number and severity of previous episodes, treatment responses and suicide attempts. Ask about concurrent psychiatric conditions. Obtaining a past psychiatric history is important in terms of understanding prognosis and risk factors. For example, knowledge of past episodes of major depression, past co-occurring mental/behavioral health conditions, and past self-harm attempts is important for establishing risk and need to involve other mental health professionals. Psychosocial stressors (significant loss, conflict, financial difficulties, life change, abuse).
Pertinent medical history that may complicate treatment includes: prostatism, cardiac conduction abnormalities, and impaired hepatic function. A past medical history and brief review of systems is generally sufficient to rule out medical disorders causing major depression. Unlike younger persons with depression, elderly persons with depression usually have a medical comorbidity. Major depression is more common in medically ill patients who are older than 70 years and hospitalized or institutionalized. Severe or chronic diseases associated with high rates of depression include stroke (30 to 60%), coronary heart disease (8 to 44%), cancer (1 to 40%), Parkinson's disease (40%), Alzheimer's disease (20 to 40%), and dementia (17 to 31%). Physical: Perform a routine physical examination to rule out physical causes of depression and pay particular attention to: Evidence of self-neglect, including weight loss Signs of self-harm, such as scars on wrists or arms Drug injection sites Injuries (e.g. bruises resulting from falls) that might be the result of alcohol or drug misuse Restlessness, agitation, and psychomotor retardation Self-administered or professionally administered depression screening tools are useful adjuncts to the clinical interview. Examples are: Patient Health Questionnaire (PHQ-9), the Deck Depression Inventory, the Hamilton Rating Scale for Depression, Geriatric Depression Scale for the elderly and the Quality Improvement for Depression scale. Two-Item Screening Tool: 1. During the past month, have you felt down, depressed or hopeless? 2. During the past month, have you felt little interest or pleasure in doing things? Five-Item Geriatric Depression Scale: Are you basically satisfied with your life? Do you often get bored? Do you often feel helpless? Do you prefer to stay at home rather than going out and doing new things? Do you feel pretty worthless the way you are now?
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BATHE Mnemonic can assist in identifying signs and symptoms of depression. Background: What is going on in your life? Affect: How do you feel about it? Trouble: What troubles you most about the situation? Handle: What helps you handle the situation? Empathy: This is a tough situation to be in. Anybody would feel as you do. Your reaction makes sense to me. SIG E CAPS Mnemonic may be helpful for remembering the symptoms of major depression. Sleep disorder (increased or decreased) Interest deficit (anhedonia) Guilt (worthlessness, hoplessness regret) Energy deficit Concentration deficit Appetite disorder (increased or decreased) Psychomotor retardation or agitation Suicidality
Suicidal risk assessment: The evaluation of a patient who may be suicidal includes an assessment of ideation, plan, and intent. Components of an evaluation for suicide risk include the following: Presence of suicidal or homicidal ideation, intent, or plan Access to means for suicide and the lethality of those means Presence of psychotic symptoms, command hallucinations, or severe anxiety Presence of alcohol or substance use History and seriousness of previous attempts Family history of or recent exposure to suicide Immediate psychiatric services, usually including hospitalization, are necessary in patients felt to be at imminent risk for self-harm. Substance abuse assessment: Current alcohol or other drug problems can be assessed by the CAGE or CAGE(AID) screen. CAGE(AID) questions are modified with text in parentheses. CAGE or CAGE(AID) questions should be preceded by two questions: 1. Do you drink alcohol? 2. Have you experimented with drugs?
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CAGE Questions: Have you ever: C felt you ought to cut down on you drinking (or drug use)? A had people annoy you by criticizing you drinking (or drug use)? G felt bad or guilty about your drinking (or drug use) E had a drink (or drug use) as an eye opener first thing in the morning to steady your nerves or get rid of a hangover or to get the day started? Each affirmative response earns one point. One point indicates a possible problem. Two points indicate a probable problem. Treatments: Goals:

To protect the patient from the frequent and hazardous complications of depressive illness - especially self-harm, self-neglect, malnutrition, substance misuse To relieve the depressive illness To relieve any disorders in addition to, or resulting from the, e.g. malnutrition, substance misuse To restore the patient to former levels of social and occupational functioning To prevent recurrence of the depression To prevent cardiovascular risks associated with depression
Depression is often most successfully treated with a combination of therapies, for example, medication combined with some form of psychotherapy. There are four main treatment choices: Psychotherapy: Some forms of psychotherapy may be more or as effective as medication in major depression. There is also good evidence that psychotherapy enhances the effect of medication in depression. Psychotherapy can be a useful alternative for patients who will not take or cannot tolerate medication, or who have a history of overdose. The forms of psychotherapy best proven in depression are:

Cognitive behavior therapy (CBT), which is directed towards altering negative belief systems and dysfunctional thinking and behavior Brief psychotherapy, especially interpersonal therapy (IPT), which focuses on relationships and how they affect functioning and self-esteem Psychodynamic psychotherapy: longer-term treatment, with many US adherents; less convincing evidence-based studies of its effectiveness to date Counseling. A very broad category, from practical advice given by professionals to trained volunteers. Generally, this takes a problem-solving approach, with a focus on the present Several self-help groups exist for people with depression. They are typically free of charge and are facilitated by lay persons; they offer support and encouragement from other persons with depression. Can be a useful adjunct to pharmacotherapy
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Non pharmacologic: Can take 8-10 weeks to show improvement. Pharmocologic: (See Below Chart)
Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line therapy for depression because of established efficacy, a favorable adverse effect profile, and their relative safety in overdose. No single SSRI has an efficacy advantage over another. Dropout rates in patients taking SSRIs are generally two thirds to one half those of patients taking tricyclic antidepressants. The potential for a fatal overdose is significantly lower with SSRIs than with tricyclic antidepressants. SSRIs cost more than most other antidepressant agents, but this disadvantage is offset by a decreased need for inpatient and outpatient care. SSRIs have been proved to be as effective as tricyclic antidepressants in controlled clinical trials, with about 70 to 75 percent of patients responding to treatment. Slight improvements in a patient's symptoms may be detected within several days of starting treatment, but two to three months of therapy are necessary to achieve the full benefit of treatment. Dual mechanism antidepressants (venlafaxine, bupropion, and duloxetine) are also considered first-line therapy for depression, with efficacy comparable to SSRIs Mirtazapine may be especially useful in depression with comorbid anxiety, but should be reserved for nonresponders of first-line therapy because of the potentially bothersome adverse effects of weight gain and sedation Tricyclic antidepressants (TCAs) have established efficacy comparable to SSRIs, but are considered second-line therapy because of their associated adverse effects and potential lethality in overdose. Secondary amine TCAs (i.e. desipramine) generally have equal efficacy and fewer adverse effects than the parent tertiary amines (i.e. amitriptyline, imipramine) Monoamine oxidase inhibitors (MAOIs) are reserved for patients who do not respond to first or second-line therapies because of the numerous and potentially severe interactions with other medications. They may be particularly useful in patients with depression with atypical features Trazodone is structurally related to nefazadone. Due to its sedating effects, its use is primarily reserved for patients with insomnia or anxiety. Nefazodone is not widely used due to risk of hepatic damage and failure St John's Wort is a herbal extract that is widely used over-the-counter in the treatment of depression, and is efficacious in the treatment of mild-to-moderate depression Transdermal selegilene is approved for the treatment of adults with major depressive orders; however, its place in therapy is yet to be established S-adenosyl-methionine (SAM) is involved in the methylation of neurotransmitters, monoamines, and phospholipids. SAM synthesis is impaired in depressed patients, so that supplementation results in increased levels of serotonin, dopamine, and phosphatides and clinical improvement in depressive symptoms. Currently SAM is not widely used in the practice setting
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A patients response to antidepressant treatment should be evaluated between 4 and 6 weeks. If there is less than a 25% reduction in symptoms when evaluated, switch to a different medication. If there is a partial response and there are no side effects, increase the dose. First episode treatment duration 6 to 12 months Second episode treatment duration 3 years Second episode with complicating factors lifetime treatment duration Third episode lifetime treatment duration Complicating factors are those situations where there are higher rates of recurrence after stopping antidepressants and include: Pre-existing dysthymia Recurrence Inability to achieve remission of symptoms in response to previously attempted lowering dose or discontinuation.
Referral to a behavioral health or substance abuse provider if there are personality disorders and/or substance abuse issues present. Physical treatments:
Electroconvulsive therapy (ECT) remains a valuable treatment, especially in the urgent treatment of a patient who is acutely suicidal or severely malnourished Electroconvulsive therapy (ECT) is a first-line option in patients with depression and psychotic features who have not responded to antipsychotic and antidepressant medications, and patients with severe nonpsychotic depression who have not responded to adequate trials of two antidepressants. ECT is used most often in patients older than age 60. Patients with delusions, psychomotor retardation, early morning awakening, and a family history of depression are most likely to benefit from ECT. ECT may reverse the memory loss and confusion associated with pseudodementia. Contraindications include recent myocardial infarction, brain tumor, cerebral aneurysm, and uncontrolled heart failure. ECT is an effective short-term therapy but has higher relapse rates over six to 12 months; patients with a history of medication resistance have higher relapse rates following ECT. Transcranial magnetic nerve stimulation (TMS) is not yet clinically available, but is being evaluated as an alternative to ECT Phototherapy may be effective for seasonal depression (seasonal affective disorder) Vagus nerve stimulation electrically stimulates the left vagus nerve at the cervical level. The device is surgically implanted, and received FDA approval in July 2005 for the treatment of treatment-resistant depression for individuals who have failed four other treatment trials. Its efficacy remains to be fully evaluated
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Consider consult Suicide and homicidal risk Severe mental confusion, raising the question of dementia Severe delusions or hallucinations that do not have a clear depressive content, suggesting schizophrenia or similar psychosis (or severe depression) Alcohol or drug abuse Bipolar disorder or question of bipolar disorder Depression that has not responded to typical measures Depression associated with any psychotic symptoms
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Pharmacologic:
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Diabetes
Diabetes mellitus type 2: 250.xx Definition: Symptoms of diabetes and a casual (regardless of relationship to meals) plasma glucose of 200mg/dl. Symptoms are polyuria, poldipsia, and unexplained weight loss. OR Fasting plasma glucose of 126 mg/dl. This would be obtain following abstinence from caloric intake for 8 hours. OR 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. This chapter does not include patients with Type 1 diabetes, diabetes from genetic disorders or chemically induced diabetes (such as from certain medications used to treat AIDS) although many of the principles are the same. It also does not include gestational diabetes. (N.B. Impaired fasting plasma glucose (IPG - FPG 100 mg/dl to 125 mg/dl) and impaired glucose tolerance 2-h plasma glucose (IGT - 140 mg/dl to 199 mg/dl) are considered risk factors for future diabetes and cardiovascular disease. Patients with this finding should be monitored closely for development of frank diabetes and should have counseling regarding optimizing weight and exercise regimen)
Overview: Diabetes mellitus is a disease characterized by hyperglycemia. Type 2 diabetes mellitus is the most common form of this disease and is both due to an under secretion of insulin as well as inadequate activity of the endogenous circulating insulin. It affects over 15 million people in the United States and accounts for over 15% of all healthcare costs. The mortality rate in patients with the disease is higher by a factor of 10. Patients with diabetes are much more likely to suffer from blindness, renal failure, and have a lower extremity amputation. 1 The recommendations in this chapter are from the Standards of Medical Care in Diabetes - 2008. 2 This report provides an evidence-based approach to the prevention and management of diabetes mellitus, as well as prevention and management of complications. The American Diabetes Association has worked on an ongoing basis to monitor evidence from English language, peer reviewed articles published between 1988 and 2006. The professional practice committee of the American Diabetes Association updates the recommendations and publishes them annually in this report.
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Goals of the care process: 1. Identify patients at risk of developing diabetes and implement risk factor modification strategies to prevent diabetes from manifesting. 2. Identify patients who have developed clinical diabetes prior to development of end-organ damage. a. Detect and treat secondary causes. b. Offer counseling to assist with correction through diet and exercise. c. Offer counseling to reduce or eliminate concomitant lifestyle risk factors such as tobacco abuse or obesity. 3. Initiate treatment using medication known to be effective in combinations known to be effective for all components of the metabolic syndrome including achieving glycemic control, blood pressure control, and lipid reduction. 4. Monitor for reduction in and maintenance of blood sugar, blood pressure, and lipids at physiologic levels that are associated with elimination of end-organ damage. 5. Continue surveillance for concomitant conditions which magnify untoward effects of diabetes. Screening Rules of Thumb: Age <18
Frequency of impaired Glucose tolerance Rare in people with BMI < 85th percentile without 2 risk factors Family history of type 2 diabetes in first or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS) Maternal history of diabetes or GDM Obesity with 2 risk factors
18-29
Rare in people with BMI < 25 without risk factors
30-45
Uncommon in people with BMI > 25, more common with risk factors
45-and above
Common in people with BMI > 25
Previous plus: Previous impaired glucose tolerance
All of Previous plus: Inactivity High risk ethnic group Delivery of baby > 9 lbs History of gestational diabetes Hypertension HDL < 35 Triglyceride > 250 History of vascular disease
All of Previous
Risk factors
Recommendation for screening
Indicated for BMI > 25 with 1 risk factor
Indicated for BMI > 25 with 1 risk factor
Indicated Regardless of risk factors
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Prevention/Delay in high risk patients, particularly those with IPG or IGT
Make patients aware of benefits of weight loss and physical activity Patients with Impaired Fasting Glucose or Impaired Glucose Tolerance should be strongly encouraged to lose weight and exercise Follow-up visits should be scheduled with attention to risk factor reduction Glucose screening should occur every 2 years if impairment detected until diabetes diagnosed, otherwise should occur periodically Other risk factors should be attended to Medication not recommended
If tests are normal, repeat testing should be carried out at least at 3 year intervals (SOR - E)
Approach to the Patient: Chief Complaint: Typically the condition is detected via lab result following complaint of symptoms or when end organ damage has occurred. The symptom based complaint (polydipsia, polyuria, or weight loss) leads to testing, following which the disease is diagnosed and management is initiated. The visit should be an initial or follow-up for diabetes and management. Outcomes should improve as more screening of asymptomatic individuals either in the community or in the office setting occurs. Because of the complex nature of the disease, care should be taken to avoid casual initiation of therapy. Vitals: Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures, current blood pressure (with confirmation in opposite arm if warranted) should be noted and compared to age related norms prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be queried regarding disease. Patient should then be queried regarding major risk factors for cardiovascular disease; should be reassessed periodically. (SOR - C)
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Specific areas to be addressed:

AREA OF CONCERN Symptoms of diabetes and control CONTENT Symptoms Previous control DATA COLLECTION Presence of polyuria, polydipsia, weight loss A1C, blood sugar log Document current meds, previous meds, meal history, beliefs and attitudes regarding disease and treatment Frequency and severity of ketoacidosis and hyperglycemia Prior or current infections, particularly skin, foot, dental, and genitourinary infections Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function; heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes Current eating patterns, nutritional status, weight history, growth history if adolescent Exercise history and current activity Age appropriate depression screen
Current and previous treatments
Complications
Complications of control Infectious complications
End organ damage
Lifestyle modification
Possibility of reducing dietary caloric intake Possibility of increasing exercise
Comorbid illness which affect treatment
Screening for depression Medication review for medicines associated with hyperglycemia Risk of pregnancy
Contraception and reproductive and sexual history Family history of endocrine disorders, diabetes Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes Alcohol, and/or controlled substance use Ask, advise, assess, assist, arrange Screen for Psycho-Social problems, depression, anxiety, eating disorder, cognitive impairment June 30, 2008 75
Pertinent family, social history
Family history
Social history
Use of substances which might affect diabetes Use of tobacco Attitudes about the illness, Expectations of medical management, outcomes, quality of life and resources
Psycho-Social assessment and care
History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about self management goals and progress towards achievement. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors and/or target organ questions approximately every 12 to 24 months, more frequently if poor control If previously under control but no longer or resistant (SOR - C): Further investigation if Possible cause Key Question Content positive
Drug use: Prescription Herbal OTC Illicit/recreational Foods Environmental exposure Frequency of alcohol use Inquire in non-judgemental way Encourage patient to bring in all medications Correlate use with blood pressure measurements
Drug induced
Alcohol use
Stages of change model Establish office systems to facilitate adherence Educate patient about treatment Collaborate with other health professionals Individualize regimen Promote social support Minimize economic barriers
Lack of adherence
Some people have trouble taking medications. Do you?
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Target organ surveillance (SOR - B): Complication Key risk factor Recommendations
Hypertension, blood pressure control Target <130 systolic,< 80 diastolic Measure blood pressure at each visit If SBP between 130 and 139 and DBP 80-89, and not at target after 3 months of diet, add ACEI or ARB If 140 systolic, and DBP 90 treat with drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors, ARBs, B-blockers, diuretics, Thiazide diuretic if GFR 50 ml/min and loop diuretic if GFR 50 ml/min and calcium channel blockers) with ACEI being initial choice If renal insufficiency and macroalbuminuria develops, ARB delays progression Elderly should have blood pressure reduced slowly Initiate lifestyle modification focusing on weight loss and increased activity, reduction of saturated fat, trans fat, cholesterol intake Begin statin if they have Coronary vascular disease (CVD), or over the age of 40 If under age 40, begin statin if lifestyle modifications in-effective and LDL >100 or in those with multiple CVD risk factors May consider adding fibrate to improve HDL and triglycerides but combination with statins not tested Statin contraindicated in pregnancy Indications Known CAD Increased CAD risk (age >40, family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). Not indicated in under 21 Indicated with clopidrogel or other agent if disease severe or progressive If allergic, bleeding, on coumadin, or otherwise not a candidate; consider other agents All patients advised abstinence Cessation counseling and other forms of treatment should be offered to all smokers In asymptomatic patients, evaluate risk factors to stratify patients by 10-year risk, and treat risk factors accordingly. (B) In patients with known CVD, ACE inhibitor, aspirin, and statin therapy (if not contraindicated) should be used to reduce the risk of cardiovascular events. (A) Add B-blocker if prior MI to reduce mortality. In patients >40 years of age with another cardiovascular risk factor, ACE inhibitor, aspirin, and statin therapy (if not contraindicated) should be used to reduce the risk of cardiovascular events. (B) Use caution with hypoglycemics if patient has CHF, Metformin and TZD are contraindicated in patients with treated CHF (C)
Heart
Dyslipidemia Target HDL 40 in men and 50 in women Triglycerides < 150 Target without CAD LDL < 100 Target with CAD LDL < 70
Antiplatelet Target ASA (75 162 mg/day)
Smoking cessation
CHD screening and treatment
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Complication
Key risk factor

Prevention of disease Detection of disease
Recommendations
Optimize blood sugar control Optimize blood pressure control Screening for microalbuminuria and measure serum creatinine atleast annually ACEI and ARB used if any evidence of albuminuria (micro or macro) unless contraindicated ARB has been shown to delay progression of nephropathy in patients with type 1 DM with hypertension and microalbuminuria One can substitute for intolerance If disease develops, avoid excess protein Refer to nephrologist when GFR falls below 60, blood pressure or hyperkalemia difficult to control Optimize blood sugar control Optimize blood pressure control Aspirin therapy for cardioprotection does not increase the risk of retinal hemorrhage Should have dilated eye exam upon diagnosis and annually, exam is required more frequently if retinopathy is progressing. Should have eye exam prior to pregnancy Laser therapy is effective and patients with disease detected should be referred for treatment Optimize blood sugar control Educate patients regarding self care Annually screen using monofilament and 128 Hz tuning fork Referral to specialized center indicated for patients with insensate feet Manage autonomic neuropathy symptomatically (tricyclic drugs, gabapentim, duloxitine) Optimize blood sugar control Surveillance for resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, pseudomotor dysfunction, impaired neurovascular function, brittle diabetes, and hypoglycemic autonomic failure Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder Optimize blood sugar control Treat symptoms Optimize blood sugar control Perform comprehensive annual foot exam. Educate patients about general foot care Use monofilament, tuning fork, palpation, visual exam Screen for peripheral artery disease with claudication history and pedal pulse palpitation Consider ABIs for any symptoms or if high risk Refer patients with prior lower extremity complications to specialized center Refer for claudication or positive ABI for definitive repair
Kidney
Treatment to prevent progression
Prevention of disease
Eye
Detection of disease Treatment to prevent progression Prevention of disease
Neuropathy
Detection of disease Treatment to prevent progression Prevention of disease
Autonomic neuropathy
Detection of disease
Foot care
Prevention of disease
Detection of disease
Foot Care cont.

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Complication Preconception/ Pregnancy care
Key risk factor

Prevention of complications and poor outcomes
Recommendations
HGB A1c should be normal < 7% prior to conception Pregnancies should be planned. Educate about the need for good glucose control Medications should be reviewed prior to conception Tight glycemic control should be considered in relatively healthy patients whose life expectancy is > 10 years Screening for diabetic complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. (E) Polypharmacy, depression, cognitive impairment all may dictate less aggressive care Evidence is strongest for blood pressure control, less strong for blood sugar and lipid control All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E)
Geriatric care
Diabetes care in the hospital
All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
Physical: The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. Complete exam should be performed initially and elements repeated periodically as indicated General General body habitus. Sexual maturation stage (if pubertal), HEENT Fundi - Visualize looking for vascular disease Oral Visualize for potential dental problems, gum disease Thyroid Palpate for nodule if thyroid disease suspected Neck Auscultate for bruits Heart Auscultate for valvular disease and evidence of failure Lungs Auscultate for evidence of failure Abdomen - Palpate abdomen looking for hepatosplenomegaly Extremities Palpate femoral, pedal pulses periodically, check for pedal edema Neuro Complete exam of extremities including 10 g monofilament and 128 Hz tuning fork vibration test Musculoskeletal Hand/finger exam, particularly if using glucometer requiring finger sampling Skin Injection site problems and acanthosis nigricans
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Lab Testing (SOR - B): Lab test Reason

Hemoglobin A1c Urinalysis Electro-cardiogram Potassium Thyroid stimulating hormone Creatinine Lipid profile HDL-C LDL-C Triglyceride Urinary albumin excretion Assess blood sugar control End-organ damage End-organ damage Monitoring for medication effect, particularly ACEI and ARB Common symptom complex Estimate GFR
Initial
Yes Yes Yes Yes (Chem 8) No Yes
Follow-up
Point of care if possible, biannual if at goal, quarterly if not Annual if normal For symptoms and periodic Every 6 to 12 months and when medication change dictates For symptoms Every 6 to 12 months and when medication change dictates If at target (LDL < 100 mg/dl, HDL> 50 mg/dl, Triglycerides < 150) repeat every 2 years Annual
Cardiovascular risk factor Detect early nephropathy, monitor disease
Yes
Yes
Office Based Management: Therapeutic goals should be individualized with the following being the ideal: Achieve glycemic control as measured by o Hemoglobin A1c < 7.0 (key target) o Preprandial capillary plasma glucose 90 130 mg/dl o Peak postprandial CPG (if measured) < 180 mg/dl Achieve blood pressure control o Blood pressure consistently below 130/80 Achieve lipid control as measured by o LDL < 100 mg/dl o Triglycerides < 150 mg/dl o HDL >50 mg/dl Take into account the special requirements of children, pregnant women, and elderly when setting targets Tighter control (Hgb A1c < 6)may be attempted to reduce complications but it may be at a cost of increased hypoglycemia
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Non-pharmacological (SOR - B) Disease Self Reason Management
Management
Reach agreement with patient on frequency and timing based on hypoglycemic medication and therapeutic goals 3 or more times daily for patients using multiple insulin injections or insulin pump Perform initially and then twice a year if 7% or under or quarterly in patients whose therapy was changed, or if A1C over 7%. Using point of care testing allows for timely decision on therapy change when needed. Goal of 7% is optimal for most patients but highly motivated patients can attempt to achieve euglycemia (< 6%) and the very young or very old may require less stringent goals
Follow-up
Self monitoring of blood glucose (SMBG)
Has been shown to assist with tight control
Monitor at each visit
Confirm self reported blood glucose with hemoglobin A1c
Identifies average level of blood glucose over past 3 months (see appendix)
Negotiate and set glycemic goal
HgbA1c at 7% or below has been shown to reduce microvascular and neuropathic complications and possibly macrovascular disease
Encourage patient to become educated through Diabetic Self Management Education classes
Educated patient more likely to be compliant
Arrange for classes, encourage compliance
Lifestyle Modification
Reason
Moderate weight loss of 7% body weight improves glyemic control, and prevents development of disease in those at risk
Management
Exercise increase, 150 min per week of moderate intensity aerobic physical activity (50 to 70% of max heart rate), calorie reduction, referral to dietician for Medical Nutritional Therapy.
Follow up
Have patient bring values to office at frequent intervals.
Weight loss to achieve BMI 18.5 -24.9 kg/m2
Monitor types and sources of calories, select foods low in calories and only 45 65% of intake should be carbohydrate
Improves blood sugar control, faclitates weight loss
Individualized eating plan
Encourage enhanced non-pharmacologic care or change medication regimen if not at target
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Reducing protein if renal insufficiency a concern
Reduces rate of progression
Limit to 10% total calories (0.8 g/kg/day)
If patient not at target, negotiate a combination of enhanced compliance, enhanced self monitoring to identify problem, and medication change Offer repeat as needed
Reduce saturated fat, minimize trans fats Encourage use of reduced calorie sweeteners
Reduces rate of progression of heart disease Substitutes for empty calories
Limit to < 7% total calories Diet beverages should be substituted for sugar based drinks Regular moderateintensity physical activity; at least 30 min of continuous/intermittent (preferably 60 min) 5 d/wk, but preferably daily Inquire regarding intake on diagnosis. Periodically inquire. Employ stages of change model Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Administer pneumovax once and again at 65, administer influenza annually Diet beverages should be substituted for sugar based drinks
Increase aerobic activity
Weight loss, glycemic control
Monitor weight at each visit, inquire about diet and exercise, encourage referral and compliance with recommendations
Limit alcohol
Reduction to 1 oz (1 drinks/day) in men or 0.5 oz ( 0.5 drink/day) in women shown to reduce BP Additional risk factor reduction Illness leads to more severe illness and death in diabetic patients Substitutes for empty calories
Encourage at every visit
Eliminate tobacco
Immunize against influenza and pneumonia Encourage use of reduced calorie sweeteners
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Pharmacologic Treatment: Hypoglycemic agents: Indication: Failure of lifestyle modifications to achieve goal (SOR - A) Class Of Medication Mechanism Of Action Cautions
Oral sulfonylurea Thiazolidinediones Biguanides Glinides Glucagon-like peptide 1 agonist Amylin agonist Alpha-glucosidase inhibitors Stimulates pancrease to make more insulin Sensitize the body to insulin and/or control hepatic glucose production Sensitize the body to insulin and/or control hepatic glucose production Stimulates pancrease to make more insulin, short acting Stimulates pancrease to make more insulin, administered sub-Q Slows gastric emptying, inhibits glucagon production, administered sub-Q Slow the absorption of starches Caution in renal insufficiency Contraindicated with abnormal LFTs and CHF Contraindicated for creatinine > 1.4 in women or 1.5 in men or CHF (lactic acidosis)
High frequency of nausea (and weight loss) High incidence of nausea, must be used with insulin Contraindicated in inflammatory bowel disease or cirrhosis
Commercial combinations Any class of drug (including insulin) can be used in combination with any other class but the following are available commercially: Sulfonylurea + Biguainide As above As above
Thiazolidinedione + Biguanide
As above
As above
Strategy for instituting hypoglycemic agents 1-3 Give interventions adequate time before reassessing; if not at goal, reassessment should incorporate evaluation of compliance and frank discussion of medication use. Once goal has been achieved, continually reassess regarding medication reduction and compliance. Lifestyle modifications and metformin IF A1c not at goal reassess and THEN Combination with sulfonylurea OR glitazone OR Insulin IF A1c not at goal reassess and THEN Combination of two hypoglycemic or add or intensify insulin IF A1c not at goal reassess and THEN add or intensify insulin Ultimately combination may include insulin, metformin with or without a glitazone Other meds can be used as adjunct or when patient is intolerant of above meds.
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Insulin therapy: 3 Indication: Failure of lifestyle modifications and oral agents to achieve goal Insulin Category Type Onset/Peak/Duration 15 min/1 hour/ 2-5 hours Immediate Acting Insulin lispro solution
Insulin aspart solution 15 min/1.5 hour/ 3-5 hours 45 min/3 hour/ 8-12 hours 75 min/6 hour/ 12-16 hours 120 min/8 hour/ 24 hours 120 min/11 hour/ 24 hours 360 min/20 hours/ 30 hours 60 min/5 hours/24 hours
Rapid-Acting Intermediate-Acting Long-Acting
Regular Prompt insulin zinc solution Isophane insulin suspension NPH Lente Ultralente Lantus
Strategy for instituting insulin agents: Give interventions adequate time before reassessing; if not at goal, reassessment should incorporate evaluation of compliance and frank discussion of medication use. Insulin is routinely subcutaneous though occasionally insulin pumps are used. Newer delivery systems via inhalation will be available soon. Once goal has been achieved, continually reassess regarding medication reduction and compliance. Begin with combination of hypoglycemics AND Insulin o Single dose of intermediate or long acting in the evening (10 units or 0.2 units/kg) o Check fasting daily and increase dose every 3 days until at target o Reduce by 10% if hypoglycemic IF A1c not at goal at 2-3 months reassess and THEN o If fasting at target check during day, add fast acting IF A1c not at goal reassess and THEN o Check 2 hour post-prandial Glycemic goals for adults with diabetes A1C: Preprandial capillary plasma glucose: Peak postprandial capillary plasma glucose: Hypoglycemia: Recommendations Glucose (1520 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. (E) <7.0% 70130 mg/dl (3.97.2 mmol/l) <180 mg/dl (<10.0 mmol/l)
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Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals. (E) Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. (B)
Antihypertensive agents: 4 Indication: Failure of lifestyle modifications to achieve goal

See Hypertension Chapter For Implementation Strategy
Indication
Initial therapy If not at target, add MI, CAD or high risk for CAD Kidney disease
Medication
ACEI or ARB Thiazide-type diuretic, if GFR 50ml/min and loop diuretic if GFR 50ml/min Add BB, Aspirin, statin ACEI and/or ARB
Notes
Aim for <130 mmHg for systolic DCCB do not delay progression of kidney disease Goal: Below 130/80
Lipid lowering agents: 5 Indication: Failure of lifestyle modifications to achieve goal See hyperlipidemia chapter for in-depth discussion of meds and implementation strategy Indication Medication Notes
Expensive and effective. Statin should be started, in addition to life style therapy regardless of baseline lipid levels for patients with CVD and for patients over the age of 40 and has 1 or more risk factor Less expensive and less effective Inexpensive and much less effective Expensive and much, much less effective Inexpensive and somewhat effective Expensive and less effective Expensive and much less effective Not indicated Expensive and effective Inexpensive and somewhat effective Expensive and much less effective Not indicated
Statin LDL not at target Bile acid sequestrants Nicotinic acid Fibric acid Nicotinic acid Fibric acid Statin Bile acid sequestrants Fibric acid Nicotinic acid Statin Bile acid sequestrants
HDL not at target
Triglycerides not at target
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Strategy for instituting anti-hyperlipidemic agents: Give interventions adequate time before reassessing, if not at goal, reassessment should incorporate evaluation of compliance, frank discussion of medication use. When goal achieve, continually reassess regarding medication reduction and compliance Lifestyle modifications and blood sugar control IF profile not at goal reassess and THEN Initiate statin therapy IF profile not at goal reassess and THEN Consider combination of two classes of medications o Patient should be apprised of risk of myopathy and rhabdomyolisis Additional agents: 2 Indication
Prevention of MI Smoking cessation assistance
Medication
ASA, clopidigrel for failure or allergy Nicotine delivery via various methods, bupropion
Notes
Aggranox third choice Remember stages of change Side effects include oily spotting on underwear, flatulence, urgent bowel movements, fatty or oily stools, increased number of bowel movements
Weight loss
Orlistat
Situations requiring urgent attention (SOR - B): Pregnant patient Suspected or diagnosed diabetic ketoacidosis as diagnosed by hyperglycemia and ketonuria or ketonemia. Suspected or diagnosed hyperosmolar state as diagnosed by profound hyperglycemia, and symptoms of polyuria, polydipsia, mental confusion, etc, and/or lab evidence of excess serum osmolarity Evidence of rapidly progressing end organ damage such as acute coronary syndrome, retinal hemorrhage, renal failure, or transient ischemic attack
Return visit (SOR-C) Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with end-organ damage
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Post-visit Assessment
Normal Blood Sugar
Concern
Interval development of disease
Periodicity
Recheck every 3 years. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Recheck every 1year. Encourage lifestyle modifications. Reduce or eliminate modifiable risk factors. Weight loss of 5-10% of body weight, Exercise 150 min per week. Encourage participation in community screening opportunities. Follow-up q 3-6 months, monitor lifestyle changes and A1c until no longer at risk of progression or until decision is made to begin medication. Reduce or eliminate modifiable risk factors. Facilitate lifestyle modifications. Suggest self-monitoring. Particular attention to surveillance Follow-up q 3months, monitor lifestyle changes and A1c until no longer at risk of progression. If no progress in 3 months consider medication. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Attention to self-monitoring. Particular attention to surveillance Follow-up q 3months, monitor lifestyle changes, A1c until no longer at risk of progression. If no progress on glucose in 3 months consider medication. Facilitate lifestyle modifications. Work on blood pressure and lipid reduction at each visit. Attention to selfmonitoring. Particular attention to surveillance Follow-up q 2-4 months, monitor lifestyle changes and A1c (q 3 m) until reduced. If no rapid progress consider medication. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Particular attention to surveillance Follow-up q 2-4 months, monitor lifestyle changes A1c (q 3 m), blood pressure, lipids until reduced. If no rapid progress consider medication. Particular attention to surveillance and drug SE. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors. Office visit every 3 4 months, labs every 6 12 months, control other risk factors and comorbidities as needed. Particular attention to surveillance and drug SE. Facilitate lifestyle modifications. Reduce or eliminate modifiable risk factors.
Impaired Glucose Tolerance
Progression
Diabetes diagnosed, A1c < 7
Progression
Diabetes diagnosed, A1c 7 8, blood pressure or lipids not at goal
Progression, long term sequelae
Diabetes diagnosed, A1c < 8,
Progression, long term sequelae
Diabetes diagnosed, A1c >8, lipids and blood pressure controlled
Assess efficacy, monitor for compliance
Diabetes diagnosed, A1c >8, or lipids and blood pressure not controlled
Blood pressure, lipids, and glucose controlled with medications
Monitor for side effects, progression
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Supplemental Materials: On-line resource outlining a series on encounters with patients with chronic illnesses www.fammed.usouthal.edu/clerkship/video/back American diabetes association resources for health professionals http://care.diabetesjournals.org/content/vol29/suppl_1/#INTRODUCTION Suggested for further reading: The Standards of medical care in diabetes 2008accessed at
http://care.diabetesjournals.org/cgi/content/full/31
Management of Hyperglycemia in Type 2 Diabetes: A consensus algorithm for the initiation and adjustment of therapy Diabetes Care (2006) 29: 1963-1972 accessed at http://care.diabetesjournals.org/cgi/content/full/29/8/1963?ijkey=421676ae7a0905af338028d499 6e0a875089f3a6&keytype2=tf_ipsecsha on 5/14/2007 Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician 2005;71:469-76. Accessed at http://www.aafp.org/afp/20050201/469.html U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003 accessed at http://www.ahrq.gov/clinic/uspstf/uspshype.htm Onusko E. Diagnosing secondary hypertension Am Fam Physician 2003;67:67-74. accessed at http://www.aafp.org/afp/20030101/67.html Resources for patients: Diabetes patient handout http://www.aafp.org/afp/20001215/2645ph.html Diabetes and Diet http://www.diabetes.org/nutrition-and-recipes/nutrition/overview.jsp Exercise Prescription on the Net http://www.exrx.net/index.html References: Florence J, Yeager B. Treatment of Type 2 Diabetes American Family Physician1999. 58(10) 2835 2846 2. American Diabetes Association. Standards of Medical Care in Diabetes 2006. Diabetes Care 2006. 29, (S 1): S4 S43 3. Schoof M, Ehlers K. Short-acting insulin analogues vs. human insulin for diabetes. American Family Physician 72 (5): 805
1.
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4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report [Published erratum in JAMA 2003;290: 197]. JAMA 2003;289:2560-72. accessed at http://www.nhlbi.nih.gov/ on 2/06/06 5. Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am Fam Physician. 2000 Jun 1;61(11):3371-82.
Appendix:
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Appendix 2
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Hyperlipidemia
mixed (Adult >20) 272.4 Definition Adult: Total cholesterol, LDL, HDL, triglycerides not at risk factor specific goal on a validated lab This chapter does not cover all necessary information for children or patients with diabetic dyslipidemia, (see diabetes chapter), very high LDL cholesterol, or markedly elevated triglycerides. This chapter does include information regarding patients with concomitant hypertension. General Approach to the patient Goals of the care process 1. Identify patients who are at significant risk to develop complication from hyperlipidemia and implement risk factor modification strategies to meet lipid goals. 2. Identify patients who are at risk of a major cardiac event (20%) and implement intensive lipid lowering therapy a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. Initiate treatment using medication known to be effective. 3. Identify patients who are at a reduced risk of a major cardiac event (10% 20%) and implement lipid lowering activities a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. Initiate treatment using medication known to be effective in combinations known to be effective should lifestyle modifications not be effective 4. Identify patients who are at a low risk of a major cardiac event (<10%) and implement lipid lowering activities and medication when necessary a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity d. After adequate trial of lifestyle and risk factor modification, initiate treatment using medication known to be effective in combinations known to be effective.
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Rules of Thumb
Age
Frequency of hyperlipidemia Frequency of ischemic cardiac disease Risk factors
20-35 (men) 20-45 (women) Common Rare
35-45 (men) 45-55 (women) Common Rare but can progress rapidly
45-65 (men) 55-65 (women) Common Common
>65 Common Common
Cigarette Cigarette smoking smoking Hypertension Hypertension Low HDL Low HDL Fm Hx in first Fm Hx in first degree relative degree relative Every 5 years Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride)
Recommendation Every 5 years if > 1 RF for screening Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride) LDL goal
Cigarette smoking Hypertension Low HDL Fm Hx in first degree relative Every 5 years Fasting lipid profile (total cholesterol, LDL, HDL, triglyceride)
CHD and CHD CHD and CHD risk equiv <100 risk equiv Multiple <100 (2+) risk Multiple factors (2+) risk <130 factors Zero to one risk <130 factor <160 Zero to one risk factor <160
Current level likely consistent with previous levels, risk factors same as to younger patients Screening interval uncertain if not already elevated, No screen if life expectancy < 10 years CHD and CHD CHD and CHD risk equival risk equival <100 <100 Addition Addition al risk al risk factors factors <130 <130 Zero risk factor Zero risk factor <160 <160
CHD risk equivalents: Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease); Diabetes Multiple risk factors that confer a 10-year risk for CHD >20%. CHD and CHD risk equivalents give a >20% risk of a CHD event within 10 years.
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Overview Coronary heart disease (CHD) is the single leading cause of death in the United States, accounting for more than one in five deaths each year, or approximately 900,000 fatalities. It is the leading cause of death in women at this time as well. An estimated $403 billion is spent annually to care for patients with CHD. 1, 2 Consistent evidence from long-term, prospective studies indicates that high levels of total cholesterol and LDL and low levels of HDL are important risk factors for coronary heart disease, the leading cause of morbidity and mortality in the United States. The risk for coronary heart disease increases with increasing levels of total cholesterol and LDL, and declining levels of HDL, in a continuous and graded fashion with no clear threshold of risk. According to National Center for Health Statistics data from 1988 to 1994, 17.5 percent of men and 20 percent of women 20 to 74 years of age had high levels of total cholesterol (240 mg per dL [6.20 mmol per L] or higher).3 The following recommendations are from the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). 2 This report provides an evidence-based approach to the prevention and management of the most common variants of hyperlipidemia, with emphasis on primary and secondary prevention of coronary artery disease. It makes extensive use of population based evidence such as the Framingham projections to assist the clinician with identification of persons in need of more intensive treatment. Evidence from peer reviewed articles published between 1995 and 2000 was selected and graded by the ATP III working group and was used to formulate a set of recommendations which formed the basis for the guideline. These were updated to reflect the results from large randomized controlled trials completed in the early 2000s in 2004. The working group focused on Patient-oriented outcomes, primarily reduction in myocardial events. The reduction in morbidity as well as mortality from this disease is reflected in the following recommendations. Because the therapy is considered relatively innocuous, little attention was paid to other patient factors, such as well being, for these recommendations. These recommendations may not be appropriate for patients who suffer from unrelated diseases that may limit lifespan to less than 10 years or patients who find medication use onerous. In addition, patients who must make choices regarding medications because of cost should be made aware that the medications used to treat this condition are expensive and should be strongly encouraged to manage the condition with lifestyle modifications initially and perhaps offered extra time to do so.
The Encounter Chief Complaint: Typically the condition is detected through screening of asymptomatic individuals either in the community or in the office setting. The complaint is typically regarding the evaluation or followup of hyperlipidemia although it may be that the initiation of treatment occurs with an incidental finding the patient has multiple risk factors or the level is markedly elevated. A complaint of
chest pain that is assessed as non-cardiac will often generate a serum lipid profile that may indicate the patient is at an elevated risk of cardiac disease. Vitals Initial and subsequent visits: Age, gender, weight/height (BMI), blood pressure, (previous and current) should be noted prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be encouraged to identify what concerns exist. Patient should then be queried regarding major risk factors for cardiovascular disease. Should be reassessed periodically. (SOR - B) Presence of CAD Known or suspected CAD (Risk 100%) Key Question Content Anginal type chest pain, previous MI, coronary stent placement, CABG History of peripheral artery disease, abdominal aortic aneurysm, angina, claudication Current status of blood sugar (if known) Further investigation if positive Evaluate chest pain, obtain records, communicate with cardiologist, aggressive RF reduction Obtain records, communicate with cardiologist, investigate based on suspicion, aggressive RF reduction Assess blood sugar, if diabetes need stricter control (See diabetes mellitus chapter), aggressive RF reduction Further investigation if positive Counsel regarding cessation, assess stage of change Measure blood pressure at each visit If above140 and not at target after 3 months of diet and exercise add drug in class demonstrated to reduce CVD events
Other ASCVD (Risk 100%)
Diabetes (Risk > 20%)
Major Risk Factor Tobacco use
Key Question Content Current use of tobacco Past use of tobacco Use of antihypertensives, results of previous screenings
Hypertension, blood pressure control Target 140 systolic, 90 diastolic
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Low HDL cholesterol (< 40 mg/dL) Family history of premature CHD
Results of previous screenings CHD in male first degree relative <55 years; CHD in female first degree relative <65 years men >45 years; women >55 years
Diet, exercise, consider addition of fibrate if unsuccessful Aggressive modifiable RF reductions as indicated by additional risk factors Aggressive modifiable RF reductions as indicated by additional risk factors
Age
Risk analysis based on major risk factor inventory 0-1 risk factor, 10 year risk < 10% > 2 risk factors, risk analysis based on Framingham risk scores found in ATP III or at http://hp2010.nhlbihin.net/atpiii/calculator.asp o Risk assigned as <10%, 10% - 20%, or > 20% Life habit risk factors Obesity Current weight (from vitals) Calculate BMI Physical inactivity Athrogenic diet Emerging risk factors lipoprotein (a), homocysteine, prothrombotic and proinflammatory factors, impaired fasting glucose, and evidence of subclinical atherosclerotic disease. Assess for metabolic syndrome Current physical activity Past physical activity Current diet Past diet Familial history, body habitus, unusual symptoms Counsel regarding activity, assess stage of change Counsel regarding diet, assess stage of change Investigate as indicated by history, clinical suspicion, refer to specialist if concerned following initial investigation, consider use of aspirin and aggressive statin use Abdominal Obesity* Waist Circumference Men >102 cm (>40 in) Women >88 cm (>35 in) Triglycerides 150 mg/dL HDL cholesterol Men <40 mg/dL Women <50 mg/dL Blood pressure >130/85 Fasting glucose >110 mg/dL
Truncal obesity, weight gain, elevated blood pressure
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Red Flags Secondary hyperlipidemia considered when suggested by age, history, physical, severity, or lab findings (SOR - C) Secondary cause Key signs or symptoms Further investigation if positive Diabetes Polyuria, polydipsia, Fasting or random blood obesity, weight changes sugar Hypothyroidism Weight gain, cold T4, TSH intolerance Obstructive liver disease Right upper quadrant pain, Liver associated enzymes, jaundice coagulation studies Chronic renal failure History of hypertension or Serum BUN and creatinine diabetes, oliguria Drug induced History of progestin, Abstinance and repeat anabolic steroid or studies corticosteroid use LDL cholesterol goals and strategies (SOR - A) Risk category LDL goal LDL level to institute therapeutic lifestyle change > 100 (consider > 70) > 130 (consider > 100) LDL level to consider drug Therapy
10 year risk > 20%
<100
10 year risk between < 130 (consider < 10% and 20% 100)
10 year risk < 10%
< 160
> 160
> 100 concurrent with lifestyle changes > 130 concurrent with lifestyle changes but can initiate between 100 and 129 by choice > 190 (160 189 optional after lifestyle changes ineffective)
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History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about changes in status, focusing on possible development of cardiac disease. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors approximately every 12 to 24 months, more frequently if poor control. If previously under control but no longer or resistant (SOR - C) Possible cause Key Question Content Further investigation if positive Drug induced Drug use Inquire in non-judgemental way Progestin Encourage patient to bring in Anabolic steroid all medications Corticosteroid use Correlate use with lipid measurements Lack of adherence Some people have trouble taking medications. Do you? Establish office systems to facilitate adherence Educate patient about treatment Collaborate with other health professionals Individualize regimen Promote social support Minimize economic barriers
Physical The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. General Look for evidence of tobacco use, general body habitus looking for truncal obesity, acanthosis nigricans. HEENT Fundi N/A Neck Ausculate for carotid bruits initially and periodically Thyroid Palpate for nodule if thyroid disease suspected Heart Auscultate for valvular disease and evidence of failure Lungs Auscultate for evidence of failure Abdomen Listen for abdominal bruits initially and periodically and (adults over 40) palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Extremities Palpate femoral, pedal pulses periodically, check for capillary refill initially and periodically Neuro N/A Musculoskeletal N/A Skin Observe for xanthomas
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Lab Testing (SOR - C) Lab test Reason Lipid profile Monitor effect of HDL-C therapy, progression of LDL-C disease Triglyceride Electrocardiogram Cardiac disease Dynamic cardiac testing
Initial Yes
No No
Glucose
BUN, creatinine
Additional risk factor, identify metabolic syndrome Additional risk factor, monitor for side effect
Yes
Follow-up Every 6 weeks until at goal if at medium or high risk, then every 6 months. For symptoms of possible angina For symptoms of possible angina When moving from sedentary to more active lifestyle Follow USPSTF guidelines Chem 8 may be useful if on meds that affect kidneys or if suspicion of occult disease Upon initiation of statins or nicotinic acid, or medication change
No
Liver associated enzymes
Monitor effect of meds
Optional
Office Based Management

Non pharmacologic (SOR - B) Lifestyle Reason Modification Weight loss to Loss of as little as achieve BMI 18.5 - 10 lbs reduces or 24.9 kg/m2 prevents hyperlipidemia Reduce saturated Improves lipid fats, dietary control, facilitates cholesterol, Increase weight loss fiber intake Increase aerobic Weight loss, BP activity reduction Eliminate tobacco Additional risk factor reduction Management Exercise increase, calorie reduction Follow-up Encourage at every visit
Therapeutic lifestyle Encourage at every changes (TLC) visit eating plan 30 minutes on most days Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Encourage at every visit Per stages of change model
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Pharmacologic treatment General Principles 4 Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering. TLC Features: TLC diet: Saturated fat <7% of calories, cholesterol <200 mg/day. Consider increased viscous (soluble) fiber (10-20 g/day) and plant stanols/sterols (2gm/day) as therapeutic options to enhance LDL lowering. Weight management Increased physical activity In high-risk persons, the recommended LDL-C goal is 100 mg/dL. o An LDL-C goal of < 70 mg/dL is a therapeutic option especially for patients at very high risk. o If LDL-C is >100 mg/dL, an LDL-lowering drug is indicated simultaneously with lifestyle changes. o If baseline LDL-C is < 100 mg/dL, institution of an LDL-lowering drug to achieve an LDL-C level 70 mg/dL is optional on the basis of available clinical trial evidence. o If a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are > 200 mg/dL, non-HDL-C is a secondary target of therapy, with a goal 30 mg/dL higher than the identified LDL-C goal. For moderately high-risk persons (2 risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is < 130 mg/dL; an LDL-C goal < 100 mg/dL is optional. o When LDL-C level is between 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level 100 mg/dL is optional. Any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level. When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, intensity of therapy should be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. For people in lower-risk categories, the recommended LDL-C goal is 160 mg/dL. o When LDL-C level is > 190 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level 160 mg/dL is an option. o When LDL-C level is between 160 to 189 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level <160 mg/dL is an option.
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Lipid lowering agents 5 Indication: Failure of lifestyle modifications to achieve goal Indication LDL not at target Medication Statin Bile acid sequestrants Nicotinic acid Fibric acid HDL not at target Nicotinic acid Fibric acid Statin Bile acid sequestrants Fibric acid Nicotinic acid Statin Bile acid sequestrants Notes Expensive and effective Less expensive and less effective Inexpensive and much less effective Expensive and much, much less effective Inexpensive and somewhat effective Expensive and less effective Expensive and much less effective Not indicated Expensive and effective Inexpensive and somewhat effective Expensive and much less effective Not indicated
Triglycerides not at target
Strategy for instituting anti-hyperlipidemic agents Give interventions adequate time before reassessing, if not at goal, reassessment should incorporate evaluation of compliance, frank discussion of medication use. When goal achieved, continually reassess regarding medication reduction and compliance and encourage maintenance of lifestyle modifications Lifestyle therapies o Emphasize reduction of saturated fat and cholesterol o Encourage physical activity o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Intensify LDL-lowering therapy o Reinforce reduction in saturated fats and cholesterol o Consider adding plant stanols o Increase fiber o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Consider initiation of statin, bile acid sequestrant, or nicotinic acid therapy o Monitor and offer therapy for metabolic syndrome o Intensify weight and physical activity counseling o Dietary counseling IF profile not at goal in 6 weeks reassess and THEN Consider intensification of statin, bile acid sequestrant, or nicotinic acid therapy
IF profile not at goal in 6 weeks reassess and THEN Consider combination of two classes of medications o Patient should be apprised of risk of myopathy and rhabdomyolisis Consider referral to lipid specialist Situations requiring urgent attention (SOR - B) Triglyceride > 1000 mg/dl because of association with acute pancreatitis requires urgent treatment beyond the scope of this discussion LDL > 220 mg/dl because of association with accelerated cardiovascular disease requires urgent treatment Follow-up (SOR - B) Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with endorgan damage (see following table)
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Post-visit assessment Normal lipids (lipids at target)
Concern Progression
Metabolic syndrome
Progression
Lipids above target but not at treatment threshold in low risk patient. Lipids above target but not at treatment threshold in medium risk patient. Lipids above target but not at treatment threshold in low risk patient with a single severe risk factor (heavy smoking, uncontrolled hypertension, etc), multiple life habit measures or 10 year risk approaching 10% Lipids above target but not at treatment threshold in medium risk patient with severe risk factor(s) (heavy smoking, uncontrolled hypertension, etc), multiple life habit measures or 10 year risk approaching 20% Lipids above treatment threshold.
Progression
Progression
Progression, development of cardiac disease
Periodicity Recheck 5 years. Screen for metabolic syndrome. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Follow-up six months to one year. Encourage lifestyle modifications, weight reduction. Monitor glucose, lipids, consider aspirin. Follow-up every 6-12 months until reduced or until decision is made to begin therapy. Encourage lifestyle modifications. Follow-up every 6 weeks to 3 months until reduced. Strongly consider medication therapy. Encourage lifestyle modifications. Follow-up every 3 - 6 months until reduced. Strongly consider medication therapy if unable to reach goal. Encourage lifestyle modifications.
Progression, development of cardiac disease
Follow-up every 6 weeks until reduced. Strongly consider medication therapy if unable to reach goal. Encourage lifestyle modifications.
Progression, development of cardiac disease Monitor for side effects, progression
Controlled lipids
Follow-up every 6 weeks until reduced. Strongly consider medication therapy after 3 months if unable to reach goal. Encourage lifestyle modifications. Office visit every 3 6 months, lipids annually, additional labs on medication change or periodically, monitor and control other risk factors and comorbidities as needed. Consider low dose aspirin. Encourage lifestyle modifications.
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Supplemental materials On-line resource outlining a series on encounters with patients with chronic illnesses www.fammed.usouthal.edu/clerkship/video/back Suggested for further reading Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Executive Summary accessed at
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp_iii.htm
Lockman A, Tribastone A, Knight K, Franko J . Treatment of Cholesterol Abnormalities. Am Fam Physician 2005;71:1137-1142. Accessed at http://www.aafp.org/afp/20050315/1137.pdf U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults. Release date July 2001 accessed at http://www.ahrq.gov/clinic/uspstf/uspschol.htm Safeer R, Ugalat P. Cholesterol Treatment Guidelines Update Am Fam Physician 2002;65:87180. accessed at http://www.aafp.org/afp/20020301/871.pdf Resources for patients Cholesterol patient handout
What should I know about cholesterol? - Patient Information Handout http://www.aafp.org/afp/20050315/1147ph.html - March 15, 2005 10 year risk calculator
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub Live Healthier, Live Longer (NHLBI) http://www.nhlbi.nih.gov/chd/index.htm Introduction to the TLC diet http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi Be Heart Smart! Eat Foods Lower in Saturated Fat and Cholesterol http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/smart1.htm Exercise Prescription on the Net http://www.exrx.net/index.html
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References
6. American Heart Association. Heart disease and stroke statistics update. Accessed online June
2006, at: http://www.americanheart.org/presenter.jhtml?identifier=1928.

7.
National Cholesterol Education Program. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Accessed online June 2006, at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.
8.
Berg AO. Screening adults for lipid disorders. Recommendations and rationale. Am J Prev Med 2001;20(3 suppl):73-6. Grundy S, Cleeman J, Merz N, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004;110:227-239. Accessed June 2006 at http://www.circulationaha.org.
9.
10. Safeer R, Lacivita C. Choosing drug therapy for patients with hyperlipidemia. Am Fam Physician. 2000 Jun 1;61(11):3371-82.
Appendix
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Drugs, trade name, and type

Advicor Altoprev Antara Caduet cholestyramine Colestid Crestor gemfibrozil Lescol Lescol XL Lipitor Lipofen Lofibra capsules Lofibra tablets Lopid lovastatin Mevacor niacin Niaspan nicotinic acid Omacor Pravachol pravastatin Pravigard PAC Questran Slo-Niacin Tricor Triglide Vytorin WelChol Zetia Zocor lovastatin/niacin lovastatin fenofibrate micronized Statin/niacin combo 20/500,20/750,20/1000 SR) statin (10,20,40,60 SR) fibric acid(43,130)
amlodipine/atorvastatin CCB/Statin cholestyramine colestipol rosuvastatin gemfibrozil fluvistatin fluvistatin atorvastatin fenofibrate fenofibrate micronized fenofibrate gemfibrozil lovastatin lovastatin niacin niacin niacin binding agent (pwdr) binding agent (1 g tabs; 5 g granule packets) statin (5,10,20,40) binding agent (600) statin statin statin (20,40) (80SR) (10,20,4080)
(2.5/10,2.5/20,2.5/40,5/10,5/20,5/40,5/80,10/10,10/20,10/40,10/80)
fibric acid (50, 100, 150) fibric acid(67, 134, 200) fibric acid (54, 160) fibric acid (600) statin (10,20,40) statin (10,20,40)
nicotinic acid (50,100,250,500; IM; IV) nicotinic acid (500,750,1000 SR) nicotinic acid (50,100,250,500; IM; IV)
statin (10,20,40,80) statin (10,20,40)
omega-3-acid ethyl esters (1 g) pravastatin pravastatin
aspirin, buffered/pravastatin (81/20,81/40,81/80,325/20,325/40,325/80) cholestyramine niacin fenofibrate fenofibrate ezetimibe/simvastatin colesevelam ezetimibe simvastatin binding agent (pwdr)
nicotinic acid (250,500,750 SR)

fibric acid (48, 145) fibric acid (48, 145) statin/binding (10/10, 10/20, 10/40, 10/80) binding agent binding agent statin (5,10,20,40,80)
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Essential Hypertension
(Adult >16) 401.1 Definition: Adult Hypertension > 140/90 on at least two separate readings Stage 1 140 159/90-99 Stage 2 >160 /100 Normal blood pressure <120/80 Prehypertension 120-139/80-89 This chapter does not pertain to patients with diabetes mellitus or known coronary artery disease. This chapter does include patients with concomitant hyperlipidemia (272.4) (N.B. Pediatric hypertension is a growing problem (associated with obesity and genetic factors) and should be identified and managed appropriately. In that population hypertension is identified as blood pressure > 95th percentile on 3 separate occasions) General Approach to the patient: Goals of the care process 1. Identify patients at risk of developing hypertension and implement risk factor modification strategies to prevent hypertension from manifesting 2. Identify patients who have developed clinical hypertension prior to development of end-organ damage a. Detect and treat secondary causes b. Offer counseling to assist with correction through diet and exercise c. Offer counseling to reduce or eliminate concomitant risk factors such as tobacco abuse or obesity 3. Initiate treatment using medication known to be effective in combinations known to be effective 4. Monitor for reduction in and maintenance of blood pressure at physiologic levels that are associated with elimination of end-organ damage 5. Continue surveillance for concomitant conditions which magnify untoward effects of hypertension Rules of Thumb:
Age Frequency of pre-hypertension Frequency of hypertension Most common cause of refractory hypertension 18-29 Common Uncommon Noncooperation, Alcohol, Oral contraceptives (in women) 30-39 Common Common Non-cooperation, Alcohol, Oral contraceptives (in women) 40-59 Common Common Noncooperation, Alcohol, Oral contraceptives (in women) 60-69 Common Very common Noncooperation, Thyroid disease >70 Uncommon Approaches 90% Non-cooperation, Thyroid disease, Atherosclerotic renal artery stenosis
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Red Flags: Secondary Hypertension (considered when suggested by 1) age, history, physical, severity, or lab findings 2) Poor response to drug therapy 3) An increase after initial period of good control 4) Sudden onset (SOR - C)
Secondary Cause Key Signs or Symptoms Labile hypertension and/or Paroxysmal hypertension associated with headache, palpitatons, pallor, perspiration Further Investigation if Positive 24 hour urine for metanephrines and normetanephrines Suspected fibromuscular dysplasia: (Women between 15 and 50) digital subtraction angiography Suspected atherosclerosis Renal function normal High risk: angiogram Moderate risk: CT, MR, or US Low risk: No study Renal insufficiency US Doppler or MRA CT angiogram Serum K+, 24 hour urine for aldosterone or other mineralocorticoids Sleep study Intact PTH, ionized calcium T4, TSH T4, TSH
Pheochromocytoma
Renovascular hypertension
Elevated serum creatinine with use of ACEI or ARB, Known atherosclerosis, flash pulmonary edema, abdominal bruit
Coarctation of aorta Cushings syndrome/ other mineralocorticoid excess Sleep apnea Hyperparathyroidism Hyperthyroidism Hypothyroidism
Diminished lower extremity pulses and/or delayed or absent femoral pulses Truncal obesity, glucose intolerance, purple striae History of snoring, daytime somnolence, neck over 17 inches Hypercalcemia, nonspecific pains, fatigue, kidney stones Palpitations, weight loss, sweats Weight gain, cold intolerance
Overview: Hypertension (high blood pressure) is a disorder characterized by an elevated blood pressure over that of the normal population that if left untreated is associated with damage to kidneys, heart, and blood vessels of the extremities and eyes. It is a disease of rising prevalence with 50 million Americans potentially in need of treatment. It is the most common diagnosis given to patients over 65 following an office visit. Unfortunately estimates are that 30% of the population is unaware that they suffer from hypertension, 40% of those who have a diagnosis of hypertension are not being treated and of those that are being treated 66% are not controlled. Hypertension as a finding increases with patient age, patient weight, and a patient diet that is high in sodium and low in fresh fruits and vegetables. The lifetime risk, in fact, approaches 90% by age 90.1 Reduction of systolic blood pressure by 5 mm Hg over the entire population will result in a 14% overall reduction in mortality from stroke, a 9% reduction in death from CAD, and a 7% decrease in all-cause mortality.2 In addition in clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (averaging 3540 percent); myocardial infarction (averaging 2025 percent); and heart failure (averaging >50 percent).3
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The following recommendations are from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). (5) This report provides an evidence-based approach to the prevention and management of hypertension. Evidence from English language, peer reviewed articles published between 1997 and 2003 was selected and graded by the JNC7 working group and was used to formulate a set of recommendations which formed the basis for the guideline. They focused on Patient-oriented outcomes that included not only mortality but also other outcomes that affect patients lives and well-being, such as sexual function, ability to maintain family and social roles, ability to work, and ability to carry out daily living activities. As these outcomes are strongly affected by nonfatal stroke, HF, CHD, and renal disease, this morbidity as well as mortality from these diseases is reflected in the following recommendations. The Encounter Chief Complaint: Typically the condition is detected through screening of asymptomatic individuals either in the community or in the office setting. The complaint is typically regarding the evaluation or followup of hypertension although it may be that the initiation of treatment occurs with an incidental finding if it is Stage 2 or greater. A complaint of headache, epistaxis, (not harbingers of hypertension) will often generate a blood pressure reading that may indicate pre-hypertension or hypertension. Vitals: Initial and subsequent visits: Age, gender, weight/height (BMI), pulse, previous blood pressures, current blood pressure (with confirmation in opposite arm if warranted) should be noted prior to going into the room through chart review and review of vital signs. History of Present Illness (new evaluation): Patient should be encouraged to identify what concerns exist. Patient should then be queried regarding major risk factors for cardiovascular disease. Patient should be reassessed periodically. (SOR - B)
Risk Factor Tobacco use Oral contraceptive use Obesity Physical inactivity Dyslipidemia Diabetes mellitus Reduced kidney function Family history of premature cardiovascular disease or death Key Question Content Current use of tobacco Past use of tobacco Use of oral contraception Current weight (from vitals) Current physical activity Past physical activity Current lipid status (if known) Current status of blood sugar (if known) Current kidney function (if known) First degree relatives and age of CV disease or death Further Investigation if Positive Counsel regarding cessation, assess stage of change Actual risk 41/10,000 use years, either need to discontinue or continue combined with antihypertensive therapy if no other contraception method appropriate Calculate BMI Counsel regarding activity, assess stage of change Assess lipids, counsel regarding activity and diet, assess stage of change Assess blood sugar, if diabetes need stricter control (See diabetes mellitus chapter) Assess kidney function (serum and urine), if reduced function for age need stricter control If strong family history consider stricter control
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All patients with newly identified hypertension should have an investigation via history, physical exam, and laboratory to identify possible target organ damage Questions that assess potential target organ damage (SOR - B):
Target Organ Heart Carotid arteries Other peripheral arteries Kidneys Eyes Key Question Content Dyspnea, chest pain (especially on exertion), Episodic unilateral weakness Claudication Length of time from disease onset, control of blood pressure Vision changes Further Investigation if Positive Stress test, ECHO Carotid dopplers Peripheral artery dopplers Serum creatinine, urine for microalbuminuria Dilated eye exam
History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. Inquire about changes in status. Inquire about side effects of medications. Inquire about status of lifestyle modification. Consider review of Risk Factors and/or target organ questions approximately every 12 to 24 months, more frequently if poor control If previously under control but no longer or resistant (SOR - C):
Possible Cause Key Question Content Drug use Prescription Herbal OTC Illicit/recreational Foods Environmental Frequency of alcohol use Frequency of NSAID use Further Investigation if Positive -Inquire in non-judgemental way -Encourage patient to bring in all medications -Correlate use with blood pressure measurements exposure -Stages of change model -Substitute acetaminophen -Establish office systems to facilitate adherence -Educate patient about treatment -Collaborate with other health professionals -Individualize regimen -Promote social support -Minimize economic barriers
Drug induced
Alcohol use NSAID use
Lack of adherence
Some people have trouble taking medications. Do you?
Physical: The physical exam is targeted at identification of risk factors or target organ damage, and progress in modification or elimination of risk factors. General Look for evidence of tobacco use, general body habitus looking for striae, moon facies. Observe for neurologic asymmetry suggestive of cerebrovascular damage, determine whether cuff size was correct. HEENT Fundi - Visualize looking for vascular disease initially and periodically Neck Ausculate for carotid bruits initially and periodically Thyroid Palpate for nodule if thyroid disease suspected Heart Auscultate for valvular disease and evidence of failure
Lungs Auscultate for evidence of failure Abdomen Listen for abdominal bruitsinitially and periodically and (adults over 40) palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Extremities Palpate femoral, pedal pulses periodically, check for pedal edema initially and periodically Neuro N/A Musculoskeletal N/A Lab Testing (SOR - B):
Lab Test Urinalysis Electrocardiogram Potassium Calcium Creatinine Glucose Hematocrit Lipid profile HDL-C LDL-C Triglyceride Urinary albumin excretion Reason End-organ damage End-organ damage Secondary cause, monitoring for effect of medication Secondary cause Estimate GFR Additional risk factor Secondary cause Additional risk factor Additional risk factor, monitor disease progression Initial Yes Yes Yes (Chem 8) Yes Yes Yes (Chem 8) Yes Yes Follow-up Annual if normal For symptoms and periodic Every 6 to 12 months and when medication change dictates For symptoms Every 6 to 12 months and when medication change dictates Follow USPSTF guidelines For symptoms and periodic Follow ATP-III guidelines
Optional
Unknown
Office Based Management: Non pharmacologic (also appropriate for pre-hypertensive patients) (SOR - B):
Lifestyle Modification Weight loss to achieve BMI 18.5 -24.9 kg/m2 Increasing fruits, vegetables, potassium, calcium. Reducing sodium Increase aerobic activity Limit alcohol Reason Loss of as little as 10 lbs reduces or prevents hypertension Improves blood pressure, facilitates weight loss Reduction to 2.4 g per day correlated with reduction in BP Weight loss, BP reduction Reduction to 1 oz (2 drinks/day) in men or 0.5 oz (1 drink/day) in women shown to reduce BP Additional risk factor reduction Management Exercise increase, calorie reduction DASH eating plan DASH eating plan 30 minutes on most days Inquire regarding intake on diagnosis. Periodically inquire. Employ stages of change model Inquire regarding use on diagnosis. Periodically inquire. Employ stages of change model Follow-up Encourage at every visit Encourage at every visit Encourage at every visit Encourage at every visit Per stages of change model Per stages of change model
Eliminate tobacco
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Pharmacologic treatment (Figure): General Principles: Systolic blood pressure target 130 for patients with diabetes or kidney disease, 140 otherwise. Diastolic will follow systolic. The lower without symptoms, the better Lifestyle modifications much more important for long-term, especially in patients on medication For stage 1, a thiazide-type diuretic is a safe, inexpensive first choice For stage 2, dual drug therapy often needed. Many combinations include a thiazide diuretic and are good first choices Pay attention to compelling indications Pay attention to additional risk factors and focus on reduction or elimination In the face of resistance, think non-adherence Self-monitoring can be helpful. This entails monitoring in home, office, or other settings such as drug stores where blood pressure cuffs are maintained. Initiation of therapy, choosing a medication: Initiation of therapy (SOR - A)
Compelling Indication None Heart failure Post myocardial infarction CAD or high risk for CAD Diabetes Chronic kidney disease Recurrent stroke prevention First Line Thiazide-type diuretic Thiazide-type diuretic, ACEI, ARB, BB, aldosterone agonists BB, ACEI, aldosterone agonists Thiazide-type diuretic, ACEI, BB Thiazide-type diuretic, ACEI, ARB, CCB ACEI, ARB Thiazide-type diuretic, ACEI Other Considerations ACEI, ARB, CCB also indicated. BB may not offer equal protection from CVA CCB not indicated If angina not controlled can add long-acting dihydropyridine or nondihydropyridine CCB Follow more stringent diabetic guidelines Goal 130/80 Use caution during ongoing ischemia. BB may not offer equal protection from CVA Maintaining systolic < 160 lowers stroke risk by 33%. BB may not offer equal protection from CVA
Older patient
Thiazide-type diuretic, CCB
Situations requiring urgent attention (SOR - B): Pregnant patient Hypertensive crisis as defined by BP > 180/120 and evidence of impending or progressive organ dysfunction. BP must be immediately reduced to prevent or limit organ damage. Examples of diseases needing urgent attention include hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute LVF with pulmonary edema, unstable angina, dissecting aortic aneurysm, or ecclampsia Hypertensive urgency as defined by severe elevation in blood pressure (above stage II) but lack of end-organ damage. Symptoms might include severe headache, shortness of breath, epistaxis, or severe anxiety
Follow-up (SOR - B): Monitor and comply with age appropriate health maintenance protocols. Attention to acute complaints with particular attention to worrisome symptoms that are consistent with end-organ damage
Post-visit assessment Normal Blood Pressure Progression Concern Periodicity Recheck 2 years. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Follow-up six months to one year. Encourage lifestyle modifications. Encourage participation in community screening opportunities. Follow-up bi-monthly until controlled or until decision is made to begin medication. Encourage lifestyle modifications. Consider suggesting self-monitoring Follow-up monthly until target achieved, obtain labs for monitoring. Encourage lifestyle modifications. Consider suggesting self-monitoring Follow-up monthly or more frequently until target achieved, obtain labs for monitoring. Encourage lifestyle modifications. Consider suggesting self-monitoring Office visit every 3 6 months, Potassium, creatinine every 6 12 months, control other risk factors and co-morbidities as needed. Low dose aspirin when control achieved. Encourage lifestyle modifications. Consider suggesting self-monitoring
Pre-hypertension
Progression
Stage 1 hypertension, pre-treatment
Progression
Stage 1, initiation of treatment
Initiation of treatment, stage 2 hypertension
Assess efficacy
Controlled blood pressure
Monitor for side effects, progression
Supplemental materials: On-line resource outlining a series on encounters with patients with chronic illnesses www.fammed.usouthal.edu/clerkship/video/back Reference card from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf
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Suggested for further reading: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure accessed at http://www.nhlbi.nih.gov/ on 3/06/08 Dickerson L, Gibson M. Management of Hypertension in Older Persons. Am Fam Physician 2005;71:469-76. Accessed at http://www.aafp.org/afp/20050201/469.html U.S. Preventive Services Task Force. High Blood Pressure Screening. Release date July 2003 accessed at http://www.ahrq.gov/clinic/uspstf/uspshype.htm Onusko E. Diagnosing secondary hypertension Am Fam Physician 2003;67:67-74. accessed at http://www.aafp.org/afp/20030101/67.html Moser, Marvin, Setaro, John F.Resistant or Difficult-to-Control Hypertension N Engl J Med 2006 355: 385-392 accessed at http://content.nejm.org/cgi/content/full/355/4/385 (subscription) Resources for patients: Hypertension patient handout http://www.fammed.usouthal.edu/clinicresources/Handouts&old/hypertension.htm DASH Diet http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf Exercise Prescription on the Net http://www.exrx.net/index.html References: National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. Accessed November 2003. http://www.nhlbi.nih.gov/resources/docs/cht-book.htm and 19992000 unpublished data computed by Wolz M and Thom T, National Heart, Lung, and Blood Institute. June 2003. Vasan RS, Larson MG, Leip EP, Evans JC, ODonnell CJ, Kannel WB, et al. Impact of high normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report [Published erratum in JAMA 2003;290: 197]. JAMA 2003;289:2560-72. accessed at http://www.nhlbi.nih.gov/ on 2/06/06 Wiysonge CS, Bradley H, Mayosi BM, Maroney R, Mbewu A, Opie LH, Volmink J.. Betablockers for hypertension. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002003. DOI: 10.1002/14651858.CD002003.pub2 accessed at http://www.cochrane.org/reviews/en/ab002003.html
Modified from JNC VII (5)
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Appendix Antihypertensive drugs (taken from JNC7)
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Joint Pain
719.4x Definition: Joint Pain pain derived from the articulating surfaces of bones and is divided into 3 categories. Monoarticular joint pain Pain in 1 joint Oligoarticular joint pain Pain in 2 4 joints Polyarticular joint pain Pain in more than 4 joints General Approach to the patient: Goals: 1. Identify specific or life-threatening causes of joint pain. 2. Arrange for definitive care of identified specific causes of joint pain at time of presentation or with appropriate follow-up. 3. Provide symptomatic relief of patient complaints. 4. Avoid ordering unnecessary tests on low risk patients. Rules of Thumb:
Age Complaint frequency Commonly diagnosed diseases (in descending order of prevalence) Life threatening diseases to consider Key worrisome features (history) Key elements of exam Key diagnostic study Common Treatment Functional limitations 1-10
Occasional Trauma Infection Avascular necrosis Hemarthrosis
11-16
Common
17-50
Common Overuse Trauma Crystals Arthritis
50-70
Common Trauma Overuse Arthritis Crystals
>70
Common
Overuse Trauma
Osteoarthritis Trauma Crystals
Cancer Infection
Cancer Infection
Cancer Infection
Cancer Infection
Cancer Infection
Fever Vitals Lymph Joint exam X-rays of affected and surrounding joints Disease dependent Based on diagnosis
Fever Vitals Lymph Joint exam X-ray NSAID Alter activities Typically limited by pain
Fever Vitals Lymph Joint exam X-ray
Fever Vitals Lymph Joint exam X-ray
Fever Vitals Lymph Joint exam X-ray Disease dependent Based on diagnosis
NSAID Typically limited by pain
NSAID Typically limited by pain
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Overview: Almost 100% of people experience joint pain at some point in life. Many cases of joint pain are treated without seeing a physician using OTC analgesics, ice packs, heating pads and other home remedies. The differential diagnosis of joint pain is quite broad (see tables) and often presents a diagnostic dilemma. Due to the high prevalence of benign, self-limited conditions and the varied presentations and overlap of different types of inflammatory arthritis, there is no single widely accepted approach for evaluating the patient with joint pain. There are numerous guidelines and rules for interpreting diagnostic tests, but most diagnostic data is based on expert opinion. There is better evidence for diagnosis and treatment of some of the more common diseases such as rheumatoid arthritis that are based on randomized controlled trials. Tests that are available for diagnosing inflammatory arthritis are neither sensitive nor specific and may lead to confusion if ordered indiscriminately. Synovial fluid tests (microscopy, cell counts and culture) can be diagnostic in some cases and are almost always helpful when a joint effusion is present. Chief Complaint: Typically the complaint is Joint pain with or without reference to a specific joint Vitals: Age, gender, temperature, and weight loss or gain should be noted prior to going into the room through chart review and review of vital signs. General approach to history: The history for joint pain is targeted at identifying the cause of joint pain and determining if infection is a potential cause of the joint pain. Timing When did your joint pain begin? What were you doing when you first noticed it? Is your pain worse in the morning or at night? Location Does it hurt in the joint or the skin or muscles around the joint? (Patients sometimes mistake muscular pain or bursitis for joint pain) Have you had pain in any other joints? Quality What kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc) Severity How bad is the pain on a scale of 1-10? Aggravating/Relieving factors Does anything make it better or worse? (Sitting, lying down, lifting, bending over, etc) Is the pain or stiffness worse after you rest for more than 30 minutes? Associated symptoms Are any other symptoms associated with the joint pain? (Recent heavy lifting, trauma, morning stiffness, fevers) Symptom Review Consider asking about fever, weight loss, lymphadenopathy, fatigue
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Age specific concerns: Toddlers and young children: Children will often present with a limp or simply quit using the affected joint rather than complaining directly about the pain. Pediatric limp has a broad differential diagnosis. Septic arthritis and osteomyelitis should always be entertained in the differential, particularly if there is a joint effusion and/or fever present. Nursemaids elbow is a common cause of elbow pain and disuse in young children. This is due to subluxation of the radial head (often occurs after child is lifted by the arm) Adolescents: By far most common causes of joint pain in this age group are trauma and overuse injuries. Fever, joint effusions and lymphadenopathy may suggest joint infections. Ankle sprains are a particularly common cause of joint pain in this age group. Systemic symptoms, involvement of multiple joints, and duration of pain >8 weeks may suggest rheumatologic causes. Adults: Although trauma and overuse are still very common causes of joint pain in this age group, adults are more likely than other age groups to present with rheumatologic diseases that respond to specific interventions. Rheumatologic disorders should be strongly suspected in patients who have joint pain for more than 8 weeks. Older adults: Osteoarthritis is the most common cause of joint pain in the elderly. Occasionally, rheumatologic disorders present in the elderly. Osteoporosis and pathologic fractures are also considerations in this age group. Physical: The physical exam is targeted primarily at identifying joint effusions, palpating for bony tenderness and examining range of motion in the affected joints. General Does the patient appear ill? Are they sitting in an awkward position due to pain? Musculoskeletal Inspect joint for swelling, redness and effusion. Palpate joint for bony tenderness, effusion and warmth. Test active and passive range of motion. True intra-articular processes will limit both types of motion whereas periarticular pathology (bursitis, etc) will limit active range of motion more than passive range of motion due to placing more strain on tendons. This examination can be useful in deciding whether to get an X-ray of the affected joint. If there is suspicion of fracture (bony tenderness or trauma), plain films are indicated. If there is a joint effusion, a therapeutic and diagnostic arthrocentesis is important to rule out infection. Elbow Consider lateral epicondylitis (tennis elbow) patient will have tenderness over lateral epicondyle and pain over lateral epicondyle on resisted extension of wrist.. No pain on passive movement of elbow. Hip Consider trochanteric bursitis (tender to palpation over greater trochanter). No pain on passive movement of hip. Listed below in the tables are some findings that may be present on physical exam to provide clues in the setting of polyarticular joint pain.
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Laboratory Findings:
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Diagnostic Studies: Acute joint pain and no signs of infection Consider X-rays. Acute joint pain and ANY suspicion of septic arthritis Urgent arthrocentesis mandatory. Consider X-rays Chronic joint pain without systemic signs/symptoms X-ray affected joints. Chronic joint pain with systemic signs/symptoms (fever, fatigue, etc) CBC, ESR as an initial screen for inflammatory disorders. Consider ANA and rheumatologic work-up if ESR is elevated. X-ray affected joints. Although there are many more tests that can be ordered in the evaluation of joint pain (as listed in tables above), most of the diseases they detect are rare. It is a waste of health care resources to order an extensive laboratory work-up on all patients presenting with joint pain. Exhaustive work-up should be reserved for those patients with persistent symptoms or symptoms strongly suggestive of rheumatologic disease as listed above. Office Based Management: Sprains/strains Generally diagnosed on basis of history of trauma or overuse and absence of fracture on X-ray. Non-pharmacologic: Rest Relative rest until pain is improving Ice Apply cold compresses for 20 minutes at a time several times a day Compression Ace Bandages may help with swelling Elevation Keeping affected joint elevated may help with swelling Pharmacologic: NSAIDs Help with pain and inflammation. Have patient take medication on a regular basis for several days to one week and then on an as needed basis. Osteoarthritis Generally diagnosed by history and degenerative changes on X-ray. Non pharmacologic: Rest will improve symptoms to some degree. Modify behaviors that exacerbate symptoms (running, repetitive joint movements, etc). Pharmacologic: Tylenol is first-line. NSAIDs may be used but are potentially dangerous if used long term (GI Bleeds). Narcotics may ultimately be needed in older patients if other therapies fail. Corticosteroid injections may be of benefit, but should not be given more than 4 times per year due to systemic effects of corticosteroids and the potential for worsening osteoarthritis if they are overused.
Lateral epicondylitis - Generally diagnosed by history of overuse and physical exam. Non pharmacologic: Rest is the definitive treatment. Special brace that puts pressure over extensor carpii insertion onto lateral epicondyle may be of benefit. Pharmacologic: NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections have been shown to be helpful. Trochanteric Bursitis - Generally diagnosed by history of overuse and physical exam. Non pharmacologic: Rest. Pharmacologic: NSAIDs on a regular basis for 1 week then as needed may help. Local corticosteroid injections have been shown to be helpful. Rheumatologic Disorders: Nonpharmacologic: Rest. Avoid activities that aggravate symptoms. Pharmacologic: Disease dependent. Patients are generally referred to rheumatologist for initiation of disease modifying therapies. Follow-up: Patients should follow up in 1-2 weeks if not improving, sooner for development of any signs of septic arthritis (fever, joint effusion, etc). Suggested for further reading: Sloane, P. Essentials of Family Medicine 4th edition. Chapters 20, 22, and 42.
References: Richie, A.M. et al. Diagnostic Approach to PolyArticular Joint Pain. American Family Physician Sept 15, 2003; Vol 68. No. 6 p.1151-1160. Chokkalinhan, S. Diagnosing Acute Monoarthritis in Adults: A Practical Approach for the Family Physician. American Family Physician July 1, 2003; Vol 68 No. 1 p. 83 90.
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Low Back Pain

724.2 Definition: Acute low back pain: Back pain of <1 month duration, typically under 7 days upon presentation. Subacute low back pain: Back pain of 1-2 months duration. Chronic low back pain: Back pain of >2 months duration. Goals: 1. Identify specific or life-threatening causes of low back pain. 2. Arrange for definitive care of identified specific causes of low back pain at time of presentation or at follow-up. 3. Provide symptomatic relief of patient complaints. 4. Avoid ordering unnecessary tests on low risk patients. Rules of thumb:
Age Complaint frequency Commonly diagnosed diseases Life threatening diseases to consider Key worrisome historical features Key elements of exam Key diagnostic studies Common treatment Functional limitations 1-10 Rare Trauma Infection Functional Cancer Infection 11-16 Rare Functional Trauma Scoliosis Cancer Infection 17-50 Common Functional Disc disease 50-70 Common Functional Fracture >70 Uncommon Osteoarthritis Cancer Fracture Functional Cancer Infection History of cancer History of back surgery Reflexes Straight leg raise Plain films, CBC, ESR, based on clinical suspicion Disease dependent Based on diagnosis
Cancer Infection Bowel or bladder incontinence Reflexes Straight leg raise Typically none indicated unless red flags present NSAID Typically limited by pain
Cancer Infection History of cancer History of back surgery Reflexes Straight leg raise Typically none indicated unless red flags present NSAID Typically limited by pain
Night pain Based on clinical suspicion Based on clinical suspicion Disease dependent Based on diagnosis
Night pain
Spinal curvature Typically none indicated unless red flags present NSAID Alter activities Typically limited by pain
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Overview: Over 90% of people will experience an episode of acute low back pain during life. The overwhelming majority (over 90%) of these episodes of low back pain will be due to nonspecific, functional causes, such as muscle strains and other ill-defined causes. The vast majority of patients will improve regardless of treatment and resume all normal activities within 3 months. In most cases low back pain will be managed conservatively, and can be expected to resolve without specific interventions. Functional low back pain is most common in the middle years of life. It is important to keep in mind when seeing people complaining of low back pain that a small percentage will have severe underlying pathology. It is important to recognize these causes in a timely fashion, especially if they will be responsive to specific interventions. If lifethreatening causes such as cancer, osteomyelitis, or abdominal aortic aneurysm are suspected, then urgent work-up should be initiated. To identify that subset of patients at risk for serious underlying pathology and order appropriate diagnostic studies, red flags have been identified through retrospective studies and meta-analyses of studies on low back pain that are associated with serious causes of low back pain. The most efficient strategy is to screen patients who present with a complaint of back pain using history, physical exam, and a knowledge of disease epidemiology, performing diagnostic studies only on those patients who have an intermediate risk of non-functional pain or a significant risk of life threatening illness. Patients fitting the profile of functional low back pain typically have a benign and self-limiting course, and thus it is important to avoid exposing them to unnecessary tests and procedures. The evidence for diagnosis and management of low back pain is primarily based on consensus and expert opinion, as there are no results from large, high quality, randomized, double blind trials available. Such studies are very difficult to undertake for low back pain, given that the overwhelming majority of patients improve rapidly regardless of treatment. As a result, the available studies for low back pain examine red flags, the identification of ominous signs and symptoms, and their association with pathology. Chief complaint: Typically the complaint is low back pain. Vitals: Age, gender, fever, and weight loss or gain should be noted prior to going into the room, through review of the chart and vital signs.
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General approach to history: The history for low back pain is targeted primarily to identify red flags. If no red flags are present, the history allows the provider to characterize and document the nature of the pain experienced by the patient. This information may be useful if the pain does not spontaneously resolve. TimingWhen did your back pain begin? What were you doing when you first noticed it? LocationWhere does your back hurt? (Ask patient to point with one finger to place of most severe pain.) QualityWhat kind of pain is it? (Sharp, dull, aching, stabbing, burning, etc.) SeverityHow bad is the pain on a scale of 1-10? Aggravating/Relieving factorsDoes anything make it better or worse? (Sitting, lying down, lifting, bending over, etc.) Associated symptomsAre any other symptoms associated with the pain? (Recent heavy lifting, trauma.) Symptom ReviewConsider asking about fever, weight loss, dysuria, hematuria, leg weakness or numbness, bowel or bladder incontinence, groin numbness. Age specific concerns: Infants and school aged children: It is uncommon for children to complain of low back pain of such severity as to occasion a physicians office visit. When children do present with back pain to the office, the history is key in determining whether the complaint is related to a functional problem or a somatic disorder. The younger the patient is, the more likely it is a somatic cause. Conversely, as children approach middle school age, functional low back pain is likely. The pain is commonly a function of book carrying methods or improper footwear. Adolescents: Patients in this age group are more likely to present to the office with a complaint of back pain than younger patients. Suspicion of functional back pain becomes more common with book bags greater than 25% of body weight, improper footwear, overuse or awkward athletic maneuvers, or prolonged sitting or standing. Resolution depends on identification of the underlying cause and correction of the functional problem. Scoliosis is likely to present as back pain in this age group. Questions for parents of children or for adolescents:
Key Question Content Trauma Night pain New onset of severe pain in child who has never had similar complaint Associated with school (both sexes) Associated with school (female) Further Investigation if Positive Consider fracture Consider cancer, infection, rheumatologic Consider cancer, infection, rheumatologic Investigate book bag weight Investigate footwear
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Adults: Functional low back pain is by far the most common cause of low back pain in this age group. Risk stratification is based on red flags. Questions for adult:
Age Any Key Question Content Trauma Radiation in dermatome distribution Previous surgery, history of alcoholism or injection drug use Fever, persistent pain Bowel or bladder dysfunction, saddle anesthesia Inconsistent response, overreaction Physical activity, overuse Night/rest pain Any female over age 14 > 50 > 60 Flank pain, fever, dysuria History of cancer History of uncontrolled hypertension, smoker Further Investigation if Positive Consider fracture Disc herniation, varicella zoster Discitis Discitis, rheumatologic Cauda equine syndrome Malingering, non organic pain None needed, alter activities to protect back Cancer, ankylosing spondylitis, infection Pyelonephritis, PID Metastatic disease Abdominal aortic aneurysm
Physical: The physical exam is targeted primarily at identifying red flags and assessing range of motion. GeneralPosture (Is pain causing patient to sit or move in an awkward fashion?) HEENTN/C NeckN/C HeartN/C LungsN/C Abdomen (adults over 60)Listen for abdominal bruits and palpate abdomen looking for large pulsating mass in abdomen if abdominal aortic aneurysm is suspected. Palpate for suprapubic and CVA tenderness if UTI/pyelonephritis is suspected. PelvicCheck for cervical/urethral discharge and adnexal masses if sexually transmitted disease (PID) is a possibility. ExtremitiesSee neuro exam. NeuroStrength in hip, leg and foot. Assess DTRs in knee and ankle. Perform sensory exam if patient reports numbness. Unilateral numbness or weakness suggests acute disk herniation. MusculoskeletalPalpate spinous processes of lumbar spine (curvature, alignment, tenderness). Palpate paraspinal muscles to assess for tenderness or muscle spasm. Assess range of motion (flexion, extension, rotation, side-to-side bending). Perform straight leg raise test to assess pain when sciatic nerve is stretched.
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Straight-leg-raise test:
Purpose Of Test Maneuver Positive Finding Negative Finding Interpretation of Positive Result Detect sciatic nerve root entrapment Lie patient flat on table. Slowly raise heel while keeping leg straight. Stop when patient reports pain, resistance is felt, or 70 degree angle between bed and leg is reached. Note angle of elevation where patient reports pain. Shooting pain from back to below the knee on the side of leg being raised. No pain, back pain during maneuver, upper leg pain, pain in other leg. Indicates nerve root entrapment. Suggests acute disk herniation.
Diagnostic studies: General guidelines No diagnostic studies are indicated in the absence of red flags. Plain films are indicated in all ages for pain following trauma, pain greater than 4 weeks duration, persistent or severe neurologic deficit, or fever. Cervical swabs and perhaps pelvic ultrasound are indicated if sexually transmitted disease (PID) a possibility. Dip urinalysis is indicated for females with any urinary symptoms or if pyelonephritis is otherwise clinically suspected. OFFICE BASED MANAGEMENT Functional Low Back Pain: NonpharmacologicThere is general agreement among physicians that patients with acute nonspecific lower back pain require only conservative management. Patients should be instructed to resume their normal activities as tolerated. Any aggravating factors should be eliminated to the extent possible. Bed rest is not indicated, and has actually been shown to delay recovery in patients with low back pain. Back pain education booklets provide lots of information to patients, and teach exercises, postures, and lifting techniques that may be useful in preventing back pain. Both physical therapy and chiropractic spinal manipulation have been shown to offer small short-term benefits, but significantly increase the cost of medical care, and do not decrease the recurrence of back pain or change long-term outcomes. PharmacologicNSAIDs relieve low back pain through their analgesic properties and also reduce inflammation. Instruct patients to take the NSAID regularly until back pain resolves. Acetaminophen is an alternative medication in patients for whom NSAIDs are contraindicated. Skeletal muscle relaxants may be useful in low back pain where muscle spasm is identified. They are prescribed to be taken regularly until back pain resolves, but no longer than 4 weeks. Avoid narcotic pain relievers unless pain is severe and not improved with NSAIDs and muscle relaxants.
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Acute disc herniation: NonpharmacologicBed rest for 2-3 days is recommended to avoid aggravating the injury, thereby increasing inflammation and ultimately worsening nerve root impingement. Patients should then gradually resume normal activities as tolerated. Low back exercises and educational booklets may be of some benefit. Most patients with radicular findings (even decreased reflexes and strength) will significantly improve over time with conservative management. Surgical intervention has not been conclusively shown to be of long-term benefit, though more rapid initial recovery may occur. PharmacologicSame as for functional low back pain with one exception. If patient is unable to take NSAIDs, consider a high dose oral corticosteroid for 5-7 days to reduce inflammation, although there are no controlled prospective studies to support corticosteroid use in low back pain. PyelonephritisSee UTI chapter. Referral to specialist for further evaluation and treatment: Possible scoliosis noted on physical exam with or without confirmatory plain films. Urgent referral to specialist for further evaluation and treatment: Possible primary or metastatic cancer as identified on imaging studies. Possible infectious etiology as identified through blood work or on imaging studies. Progressive neurologic deficits involving bowel, bladder, or saddle anesthesia. Possible abdominal aortic aneurysm greater than 4 cm as identified on imaging studies. Follow-up: Patients should follow up if back pain has not resolved in 4 weeks, or sooner for fever, dramatic increase in pain level, or new onset of numbness or weakness. Non-resolution of symptoms should prompt investigation for structural causes, rheumatological causes, as well as reevaluation for the possibility of infection and cancer. If all symptoms resolve with therapy, the patient need follow up only for regularly scheduled health maintenance visits.
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Flow chart:
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Suggested further reading: Chapter 23: Low Back Pain in Current Diagnosis and Treatment in Family Medicine; Jeannette E. South-Paul, Samuel C. Matheny, and Evelyn L. Lewis, editors; accessible by subscription at http://www.accessmedicine.com/home.aspx. Patel, A.T. and A.A. Ogle; Diagnosis and Management of Acute Low Back Pain; Am Fam Physician; 2000 Mar 15;61(6):1779-86, 1789-90; accessible online at http://www.aafp.org/afp/20000315/1779.html. Humphreys, S.C., J.C. Eck, and S.D. Hodges; Neuroimaging in Low Back Pain; Am Fam Physician 2002;65: 2299-306; accessible online at http://www.aafp.org/afp/20020601/2299.html. Resources for patients: Back PainLow; accessed on Medline Plus at http://www.nlm.nih.gov/medlineplus/ency/article/003108.htm. Low Back Pain: Tips on Pain Relief and Prevention; accessed on Familydoctor.org at http://familydoctor.org/117.xml. Relieving Low-Back Pain With Exercise; by Brian Shiple, DO; The Physician and Sportsmedicine;
Vol 25, No. 8, August 97; accessed at
http://www.physsportsmed.com/issues/1997/08aug/shiplepa.htm. References: Frymoyer, J.D.; Back Pain and Sciatica; N Engl J Med 1988;318: 291-300. Carey, T.S., J. Garrett, A. Jackman, C. McLaughlin, J. Fryer, D.R. Smucker DR; The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons: The North Carolina Back Pain Project; N Engl J Med 1995;333:913-917. Malmivaara, A., U. Hakkinen, T. Aro, et al; The Treatment of Acute Low Back Pain: Bed Rest, Exercises, or Ordinary Activity?; N Engl J Med 1995;332:351-355. Cherkin, D.C., R.A. Deyo, M. Battle, J. Street, and W. Barlow; A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain; N Engl J Med 1998:339:1021-1029. Weber, H; Lumbar Disc Herniation: A Controlled, Prospective Study With Ten Years of Observation; Spine 1983;8:131-40. Wheeler, A.H.; Pathophysiology of Chronic Low Back Pain; http://www.emedicine.com/neuro/topic516.htm
Migraine Headaches
346.XX Definition: Migraines are a common form of headaches that are genetically based and occur in 18% of women and 6% of men. They affect either one side or both sides of the head and are widely associated with various gastrointestinal, autonomic and Neurologic symptoms. Goals: 1. Establishing a diagnosis 2. Encourage use of a headache diary to establish frequency of headaches, severity of attacks, and uncover triggers. 3. Establish an individualized treatment regiment based on headache frequency and severity as well as impact on the patients daily routine. 4. Provide education to the patient aimed at reducing migraine frequency through trigger avoidance and life style modifications. Red Flags: The following symptoms and signs warrant investigations (mainly brain imaging) directed towards exclusion of secondary headaches:
Red Flags for a Secondary Headache Disorder A new or different headache "Thunderclap" headache (peak intensity within seconds to minutes) Worst headache ever Focal neurologic signs or symptoms, such as papilledema, motor weakness, memory loss, papillary abnormalities, or sensory loss Change in existing headaches New onset headache after age 50 Headache associated with systemic symptoms (fever, weight loss, jaw claudication)
Overview: Migraine headache patients are frequently encountered in a primary care physicians office. The direct and indirect costs of migraine have been estimated at approximately $17 billion per year. Migraines may present with or without auras (an aura being a wide variety of gastrointestinal, autonomic, or neurologic symptoms). Migraines without auras are the most frequent type, occurring in approximately 80% of migraine patients. They are described as a deep and dull headache if mild or moderate but throbbing in severe ones. They are typically
worsened by rapid head movements, sneezing, or straining and are associated in typical cases with some degree of photophobia and phonophobia. Typical migraines usually last 4 hours or more if left untreated. They are described to be unilateral in 60-70% of cases and bifrontal or global in up to 30% of cases. They are frequently first encountered in the 2nd and 3rd decade of life, but may also be encountered in children as well. Multiple factors are thought to be involved in the etiology of migraines. Some of the factors put forward include a genetic role, a vascular role, as well as a possible role of Serotonin. The Encounter Chief Complaint: The patient may present to the office for an acute migraine attack wanting quick relief of his headache or present with a history of chronic migraine headaches expressing a desire to decrease the frequency and severity of the attacks. Even though, the patient presenting with an acute attack needs quick relief of his medication, a detailed history of his migraines must be elicited with the goal of therapy to decrease his attack rate and severity. History of Present Illness: Acute Migraine Attack: Classical Migraines: Classical migraine patients present with unilateral dull to throbbing headaches that are positional and are exacerbated by loud noises or bright light. Patients tend to seek dark quiet rooms during an acute attack. There attacks usually start in the morning and very rarely does it wake them up from sleep. They are preceded by an aura that is temporary and typically lasts less than an hour. Auras: Neurological symptoms: Visual disturbances (most common) Numbness and/or tingling in the face or fingers. (2nd most common) Autonomic symptoms: Nasal congestion or rhinorrhea Tearing Color and temperature change Changes in pupil size Some patients may report migraine triggers. These triggers commonly include stress, menstruation, lack of sleep, hunger, head trauma, some medication like oral contraceptives and certain foods and beverages. Atypical migraines may present with only some of the above symptoms making it difficult at times to differentiate it from other forms of headaches.
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Key Questions to ask the Patient: How frequent are your headaches? How can you characterize your headaches? Which part of your head is affected during the headache? How long do your headaches last, if left untreated? When do these headaches occur during the day? Have you noticed any triggers to your migraines? When you are having a headache, what makes it worse? What do you do to relieve your headaches? Do you have any other symptoms during the headaches? Can you tell if you are about to have a headache? If yes, what symptoms do you have before the headache starts? Does anyone in your family have similar headaches? Migraine Variants: Hemiplegic Migraines: These migraines are associated with motor and sensory deficits which may last longer that the headaches itself and at times lasting for a few weeks. Basilar type Migraines These are associated with dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, or altered consciousness. Migrainous vertigo This may cause episodes of vertigo that frequently is misdiagnosed.
IHS Criteria for Migraine with Typical Aura:
A At least 2 attacks fulfilling criteria B

B
Aura consisting of at least one of the following, but no motor weakness: Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness) Fully reversible dysphasic speech disturbance At least two of the following: Homonymous visual symptoms and/or unilateral sensory symptoms At least one aura symptom develops gradually 5 minutes or more and/or different aura symptoms occur in succession over 5 or more minutes Headache fulfilling criteria for migraine without aura beginning during the aura or follows the aura within 60 minutes
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IHS Criteria for Migraine without Aura

Headache Descriptions (Any 2) Unilateral Pulsatile quality Moderate to severe pain intensity Aggravation by or causing avoidance of routine physical activity Associated Symptoms (Any 1)
Nausea and/or vomiting Photophobia and phonophobia
Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last 472 hours
Physical Examination: The physical examination in a migraine patient is usually normal; however, a comprehensive neurologic exam is necessary to rule out focal neurological deficits, which are seen in secondary headaches. Lab Testing: Patients with classical migraines do not require any lab testing.
Differential Diagnosis: Tension Type Headaches (TTH): This is the most common type of primary headaches. Unlike migraine headaches they are not as severe and are not described as throbbing. Rapid head movements do not aggravate them. They are very rarely associated with nausea, vomiting, photophobia or phonophobia. Patients with TTH may present with episodic attacks (<15 days/month) or chronic tension type headaches (>15 days/month). Cluster Headaches: Cluster headaches are less frequently encountered in an office than migraine headaches. They are thought to be worse in intensity than any other primary headache. Cluster headaches start more commonly in the 3rd and 4th decade of life. They are associated with symptoms of sympathetic hypofunction and parasympathetic hyperfunction.
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Characteristics of Primary Headache Disorders:

Migraine Location Intensity Duration Quality Associated symptoms Gender Unilateral Moderate/severe 4 to 72 hours Throbbing Yes Female > male Tension-Type* Bilateral Mild/moderate 30 min to 7 days Pressing/tightening No Female > male Cluster Strictly unilateral Severe 15 to 90 min Severe Yes -- autonomic Male > female
Management of Migraine Headaches: Therapy of migraines is divided into treatment of acute attacks as well as preventive therapy targeted to patients with frequent disabling headaches. Acute Treatment: Non-Pharmacologic Therapies: The following therapies may be used in conjunction with pharmacologic therapy: Relaxation Training Thermal biofeedback with relaxation training EMB biofeedback Cognitive-behavioral therapy Pharmacologic Therapy: Concepts of Pharmacologic Therapy: 1) Use NSAIDs in the treatment of mild-to-moderate migraine headaches. 2) Use migraine-specific agents in patients with moderate-to-severe migraines or in patients with mild-to-moderate migraines who fail to respond to NSAIDs. 3) Use of non-oral routes to administer medications in patients with significant nausea or vomiting. (Anti-emetics may play an important role in alleviating these symptoms) 4) Medication-overuse headaches (rebound headache) are caused by frequent use of acute medications. Patients requiring frequent rescue medications should use preventive therapy. Migraine-Specific Medications: Triptans (Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan): Effective and relatively safe in the treatment of Migraine headaches and may be used as the first line therapy in patients with moderate-to-severe headaches. Triptans may be administered via an intranasal or subcutaneous route in patients with significant nausea or vomiting. Ergot Alkaloids and derivatives: Ergotamine PO/PR and caffeine combinations may be considered in the treatment of selected patients with moderate-to-severe migraine. Dihydroergotamine may be administered through an intravenous, intramuscular, subcutaneous, or intranasal route and are reasonable treatment choices in the therapy of moderate-to severe migraines.
Nonspecific Medications: NSAIDs, and other nonopiate analgesics: NSAIDs and combination medications are a reasonable first-line therapy for mild-to-moderate migraine headaches. Acetaminophen alone, however, is not recommended for migraines. Butalbital-containing analgesics: These are effective in the treatment of migraines, however, should be limited and patients should be carefully monitored due to overuse, medication-overuse headaches, and withdrawal concerns. Opiate Analgesics: These are also effective in the treatment of migraine headaches, but, however, carry the risk of overuse and dependence. Non-oral routes play an effective role in the rescue therapy for acute migraine headache resistant to other medications provided the sedation side effect will not put the patient at risk. Preventive Therapy: Goals of Preventive Therapy: 1) Reduce attack frequency, severity, and duration 2) Improve responsiveness to treatment of acute attacks 3) Improve function and reduce disability Indications of Preventive Therapy (one or more of the following): 1) Recurring migraines that significantly interfere with daily routine despite acute treatment. 2) Frequent headaches. 3) Contraindications to or failure or overuse of acute therapy. 4) Adverse effects with acute therapies. 5) Presence of uncommon migraine conditions (migraine variants) mentioned previously. 6) Patient preference
Follow-up Frequent follow up may be necessary initially to assess adequacy of response to therapy. Patients are encouraged to use their headache diary to assist the physician in adjusting the dose and type of medication most appropriate for his/her symptoms. However, when initiating preventive therapy it may take 2-3 months to achieve full therapeutic effect of the medication.
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Acute Therapies
Acute Therapies
Triptans (serotonin1B/1D receptor agonists) Sumatriptan nasal spray Oral triptans Naratriptan Rizatriptan Sumatriptan Zolmitriptan Sumatriptan SC Ergot alkaloids and derivatives DHE IV DHE SC/IM DHE IV plus antiemetics DHE nasal spray Ergotamine Antiemetics Chlorpromazine IM/IV Metoclopramide IM PR/IV Prochlorperazine PR/IM IV NSAIDs and nonopiate analgesics Acetaminophen Ketorolac IM Oral NSAIDS Aspirin Diclofenac K Flurbiprofen Ibuprofen Naproxen Naproxen sodium Combination analgesics Acetaminophen, aspirin, caffeine Barbiturate hypnotics Butalbital, ASA, caffeine Butalbital, ASA, caffeine, codeine Opiate analgesics Butorphanol nasal spray Opiatesoral combinations Acetaminophen, codeine combinations Opiatesparenteral Butorphanol IM Meperidine IM/IV Methadone IM Other medications Corticosteroids IV plus antiemetics Dexamethasone Hydrocortisone Isometheptene compound Lidocaine IN
Quality of evidence
A A A A A A B B B A B C/B B B B B B B A B B A B A A C B A A B
Scientific effect
+++ ++ +++ +++ +++ +++ ++ +++/++ +++ ++ + ++ + +++ +++ 0 + ++ ++ + ++ + ++ +++ ? ++ +++ ++ ++
Adverse effects
Occasional
Frequent Frequent Occasional Frequent Occasional Frequent Mild to moderate Infrequent to occasional Occasional
Infrequent Infrequent Occasional
Infrequent Occasional
Frequent Occasional Frequent
Infrequent
B B
+ ++
Infrequent Frequent
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Preventive Therapies
Preventive Therapies Antiepileptics Carbamazepine Divalproex sodium/sodium valproate Gabapentin Topiramate Antidepressants Tricyclic antidepressants Amitriptyline Nortriptyline Protriptyline Doxepin, imipramine Selective serotonin reuptake inhibitors Fluoxetine Fluvoxamine, paroxetine, sertraline Monoamine oxidase inhibitors Phenelzine Other antidepressants Bupropion, mirtazepine, trazodone, venlafaxine Beta-blockers Atenolol Metoprolol Nadolol Propranolol Timolol Calcium channel blockers Diltiazem Nimodipine Verapamil NSAIDs Aspirin Fenoprofen Flurbiprofen Mefenamic acid Ibuprofen Ketoprofen Naproxen/naproxen sodium Serotonin antagonists Cyproheptadine Methysergide Other Feverfew Magnesium Vitamin B2 Quality of evidence B A B C Scientific effect ++ +++ ++ ? Adverse effects Occasional to frequent Occasional to frequent Occasional to frequent Occasional to frequent
A C C C B C C C
+++ ? ? ? + ? ? ?
Frequent Frequent Frequent Frequent Occasional Occasional Frequent Occasional
B B B A A C B B B
++ ++ + ++ +++ ? + + +
Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent to occasional Infrequent
C B B C A B B B
? + + ? +++ ++ + +++
Infrequent Infrequent Infrequent Frequent Frequent Infrequent Infrequent Infrequent
Adapted from the AAN Evidence-based guidelines for Migraine Headache
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Migraine Algorithm
Initial Visit
Detailed History Diagnostic Screening & Differential Diagnosis Assess illness severity: Attack frequency and duration Pain severity Impact Non-Headache symptoms Patient history and preferences
Intermittent mild-to-moderate migraine
Intermittent moderate-to-severe migraine
Behavioral Therapies Aspirin/NSAID (large dose) Aspirin/acetaminophen + antiemetic

Rescue
Oral/Nasal/SC Triptans or DHE
If Initial Treatment Unsuccessful
Oral Triptan
Alternative oral/Nasal/SC Triptan
If Unsuccessful
Frequent Headaches 4 attacks / month
Consider prophylaxis & acute treatment for breakthrough migraines
If Unsuccessful
Consider Referral
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Supplemental Material http://www.neurology.org/cgi/reprint/63/12/2215.pdf http://www.neurology.org/cgi/reprint/55/6/754.pdf http://www.guideline.gov/algorithm/4002/NGC-4002_3.pdf Resources for Patients: http://www.aan.com/professionals/practice/pdfs/Headache_Peds_Patients.pdf http://www.aan.com/professionals/patient/hakit/pdf/pat_hea_dia.pdf http://www.aan.com/professionals/patient/hakit/pdf/pat_hea_tri.pdf References: American Academy of Neurology Evidence-based guidelines for migraine headache International Headache Society headache classification
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New Onset Headache

784.0, 346.XX, 307.81 Definition: Headache, or cephalalgia, is defined as diffuse pain in various parts of the head General Approach to the patient Overview: Headache is among the most common pain problems encountered in family practice. One epidemiologic study1 found that 95 percent of young women and 91 percent of young men experienced headache during a 12-month period; 18 percent of these women and 15 percent of these men consulted a physician because of their headache. Missed workdays and medical benefits associated with headache cost American industry approximately $50 billion annually.
Chief Complaint: Patients will present complaining of headaches of different descriptions depending on the etiology. Most patients with primary headaches will present after trying OTC remedies. History of Present Illness: A systematic case history should include the following: Age at onset Presence or absence of aura and prodrome Frequency, intensity and duration of attack Time and mode of onset Quality site and radiation of pain Precipitating and relieving factors Associated symptoms and abnormalities Effect of activity on pain Number of headache days per month Family history of migraine Relationship with food/alcohol Response to any previous treatment Any recent change in vision Association with recent trauma Any recent changes in sleep, exercise, weight, or diet State of general health Change in work or lifestyle (disability) Change in method of birth control (women) Possible association with environmental factors Effects of menstrual cycle and exogenous hormones (women)
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Diagnostic instruments: The brief headache screen, adopted by the American Academy of Neurology, appears to be well suited to identify migraine in the primary care setting. This screen includes the following questions: Use the frequency of severe and mild headache and medication use to categorize patients as migraine (i.e.: episodic, severe), daily headache and/or medication overuse.
Q1. How often do you get severe headaches (i.e. without treatment its difficult to function)? This question alone identifies migraine. Any patient with severe headaches which are episodic should be assumed to have migraine. Q2. How often do you get other (milder) headaches? Daily headaches should always be evaluated for "worrisome" features. Patients with daily headaches (at times severe and migrainous) may have "transformed migraine," often due to medication overuse. Q3. How often do you take headache relievers or pain pills? Use of symptomatic medications more than 3 days/week represents medication overuse. The label, "drug rebound headache," should not be applied without a complete evaluation that has considered secondary and "worrisome" headaches. When drug rebound headache is recognized, symptomatic medications must be withdrawn for the patient to improve. Q4. Has there been any recent change in your headaches? The best screening question for "worrisome" headaches. A patient with a stable pattern of headache for 6 months has the same likelihood of an underlying tumor as a patient without headache. Q5. How often do you miss work (or leisure activities) because of headache? Good question for headache-related disability. Q6. Are you satisfied with your current headache medicine? Rapidly assesses acute therapy. Q7. Are you on a preventive medicine for headache? If not, would you like to be?Determines the patient's preference for prophylaxis.
MIGRANES IN A MINUTEMIGRAINE IN A MINUTE Adapted from Morris Maizels, MD, Kaiser Permanente
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Danger signs: Headaches may be the presenting symptom of a space-occupying mass or vascular lesion, infection, metabolic disturbance, or a systemic problem.
Symptom Sudden onset of headache New headache in patients under the age of five or over the age of 50 may suggest underlying pathology. The "first" or "worst" headache of my life A worsening pattern Focal neurologic symptoms other than typical visual or sensory aura Fever associated with headache Change in mental status The rapid onset of headache with strenuous exercise Head pain that spreads into the lower neck and between the shoulders New headache type in a patient with cancer New headache type in a patient with Lyme New headache type in a patient with HIV suggests Headache during pregnancy or postpartum Possible Diagnosis Subarachnoid hemorrhage Cluster headache may sometimes be confused Intracranial hemorrhage, CNS infection, or a space occupying lesion Intracranial hemorrhage or central nervous system (CNS) infection A mass lesion, subdural hematoma, or medication overuse headache A mass lesion, arteriovenous malformation, or collagen vascular disease Intracranial, systemic, or local infection Intracranial hemorrhage, CNS infection, or a space occupying lesion Carotid artery dissection or intracranial hemorrhage Irritation due to either infection or subarachnoid blood Metastasis. Meningoencephalitis Opportunistic infection or tumor Preeclampsia, cortical vein or venous sinus thrombosis, carotid dissection, and pituitary apoplexy
Other features suggesting a specific headache source Chronic nasal stuffiness or chronic respiratory infection suggests a diagnosis of sinusitis. Impaired vision suggests the presence of glaucoma. Visual field defects suggest the presence of a lesion of the optic pathway. The presence of nausea, vomiting, worsening of headache may be caused by a tumor. Sudden, severe, unilateral vision loss suggests the presence of optic neuritis. Headache, fatigue, generalized aches and pain, and night sweats in subjects age 55 years or older suggest the presence of temporal arteritis. Intermittent headaches with high blood pressure are suggestive of pheochromocytoma. Physical: The majority of patients with headache complaints have a completely normal physical and neurologic examination. If a complete and careful history does not point to a primary etiology, further examination is warranted in the following areas: Obtain blood pressure and pulse Listen for bruit at neck Palpate the head, neck, and shoulder regions Check temporal and neck arteries Examine the spine and neck muscles A comprehensive neurologic examination
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Danger Signs on Exam:

Sign Neck stiffness Papilledema Focal neurologic signs Possible Diagnosis Meningitis Intracranial mass lesion, pseudotumor cerebri, encephalitis, or meningitis Intracranial mass lesion, arteriovenous malformation, or collagen vascular disease.
Indications for imaging studies Patients with any of the danger signs noted above need urgent brain imaging: Recent significant change in the pattern, frequency or severity of headaches Progressive worsening of headache despite appropriate therapy Focal neurologic signs or symptoms Onset of headache with exertion, cough, or sexual activity Orbital bruit Onset of headache after age 40 years
NOTE: Neuroimaging is usually not warranted for patients with migraine and a normal neurologic examination.
The data are insufficient to recommend CT or MRI when neuroimaging is necessary. A head CT scan (with and without contrast) is likely to be sufficient in most patients. An MRI along with MRA are indicated when posterior fossa or vascular lesions are suspected. As many as 90 percent of all benign headaches fall under a few categories, including: migraine, tension-type, and cluster headache. While a population-based study found that the one-year prevalence of episodic tension-type headache was 38 percent, most of these people do not present to physicians for care.
Characteristics of Primary Headache Disorders:

Location Intensity Duration Quality Associated symptoms Gender Migraine Unilateral Moderate/severe 4 to 72 hours Throbbing Yes Female > male Tension-Type* Bilateral Mild/moderate 30 min to 7 days Pressing/tightening No Female > male Cluster Strictly unilateral Severe 15 to 90 min Severe Yes -- autonomic Male > female
MIGRAINE HEADACHES See Chapter on Migraines
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TENSION TYPE HEADACHE IHS Criteria for Diagnosis of Tension Type Headaches
Headache Description (Any 2) Pressing or tightening Mild to moderate intensity Bilateral location No worsening with exertion Associated Symptoms (Any 1) No nausea or vomiting Photophobia or phonophobia (1 allowed)
Must have had >10 previous headache episodes and no evidence of a secondary headache disorder
Tension type headache is the most common headache syndrome. Tension type headaches feel like pressure or tightness all around the head and have a tendency to wax and wane in intensity. The revised IHS classification distinguishes three subtypes of tension type headache: Infrequent episodic TTH with headache episodes less than one day a month Frequent episodic TTH with headache episodes 1 to 14 days a month Chronic TTH with headaches 15 or more days a month Treatment: Episodic: Simple analgesics such as acetaminophen, aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) are the drugs of choice for abortive therapy. Combination drugs containing ergotamine, caffeine, butalbital and codeine should be avoided due to the potential for drug dependency and analgesic overuse (rebound) headaches. Chronic headaches: Prophylactic therapy is indicated for patients with chronic headaches requiring daily analgesics. Tricyclic antidepressants, specifically amytriptyline, has shown benefit. Mirtazapine showed positive results in one randomized controled trial. SSRIs have shown mixed results. Biobehavioral techniques ( mind-body therapies) can be useful for managing chronic tension type headaches, either alone or in combination with antidepressant medications. Psychotherapy, relaxation therapy, and biofeedback all may be useful. Physical therapy also may reduce the frequency of headaches in some cases.
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Table 2. Recommended Mind-Body Therapies for Headache

Therapy Migraine headache Behavioral therapy with prophylactic drug therapy Cognitive behavior therapy Combination of progressive muscle relaxation and biofeedback Electromyographic biofeedback Relaxation training Thermal biofeedback (alone or in combination with relaxation training) Tension headache Cognitive behavior therapy Cognitive behavior therapy in children and adolescents with chronic headache Home-based behavioral therapies Muscular biofeedback Progressive muscle relaxation Relaxation training in children and adolescents with chronic headache Stress management training B A B B B A B B A A A A A Evidence rating
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see http://www.aafp.org/afpsort.xml.
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CLUSTER HEADACHES IHS Criteria for the General Diagnosis of Cluster Headache
Headache Description (All 4) Severe headache Unilateral Duration of 15180 min Orbital, periorbital, or temporal location *No evidence of a secondary headache disorder. Autonomic Symptoms (Any 2) Rhinorrhea Lacrimation Facial sweating Miosis Eyelid edema Conjunctival injection Ptosis
CLUSTER HEADACHE Cluster headaches are characterized by repetitive headaches that occur for weeks to months at a time, followed by periods of remission. Cluster headache is relatively uncommon; the prevalence is less than 1 percent. Men are affected more commonly than women, with a peak age of onset of 25 to 50 years. The pain of cluster headache begins quickly without any warning and reaches a crescendo within a few minutes. The headache is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing. The pain usually begins in or around the eye or temple; less commonly it may start in the face, neck, ear, or hemicranium. The pain is always unilateral; it remains on the same side of the head during a single cluster, but can switch sides during the next cluster in a small percentage of patients. Some patients report superimposed paroxysms of stabbing ice pick-like pain in the periorbital region that lasts for a few seconds and occur once or several times in rapid succession. Cluster headaches are associated with ipsilateral lacrimation and redness of the eye, stuffy nose, rhinorrhea, sweating, pallor, and Horner's syndrome. Nausea and vomiting may occur. Photophobia occurs ipsilateral to the pain. Focal neurologic symptoms are rare other than Horner's syndrome. Over 50 percent of sufferers report that alcohol is a potent precipitant of cluster headaches during a cluster bout; this sensitivity to alcohol ceases when the cluster ends. A typical cluster headache lasts from 15 minutes to three hours. The frequency of attacks depends upon the type of cluster: Episodic cluster headaches are most common, occurring in about 80 to 90 percent of patients suffering from this disorder. They are characterized by one to three attacks of periorbital pain per day over a six to twelve week period, followed by an average pain free interval of six months to one year. The remission may last for years. Chronic cluster headaches are characterized by the absence of sustained periods of remission. Either form of cluster headache can transform into the other. Attacks of pain tend to recur at the same hour each day for the duration of a single cluster; attacks occur between 9 pm and 9 am in up to 80 percent. Most patients experience one cluster per year, but this is not predictable.
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Management: Abortive therapy Abortive therapy of cluster headaches can be difficult because of the short duration of each episode. Nevertheless, a number of medications have proven effective Oxygen Acute cluster headaches can be aborted by inhalation of 100 percent oxygen in the majority of patients. Oxygen inhalation should be given for 20 minutes in an upright sitting position. Triptans are helpful in aborting an acute cluster attack. Octreotide appears to be effective and well tolerated in the treatment of acute cluster headaches. DHE Intranasal dihydroergotamine has been shown to relieve the pain of an acute cluster attack. Prophylaxis Prophylactic therapy should be started as soon as possible at the onset of a cluster episode. Verapamil was found to be effective for prophylaxis but there is a four to six week delay before the headaches remit. Prednisone is highly effective for prophylaxis, but should not be used chronically due to side effects. Lithium appears to be particularly effective for the chronic form of cluster headaches. Ergotamine, Cyproheptadine, and Indomethacin have also been shown to be effective. Prophylactic medications can be tapered after the expected duration of the cluster has passed. The drugs can be restarted if symptoms recur at the lowest effective dose.
Strength of Recommendations Key clinical recommendation The first-line treatments for acute cluster headache are oxygen or sumatriptan, or a combination of the two. Less well-studied alternatives for acute treatment include intranasal dihydroergotamine, intranasal lidocaine, and intranasal capsaicin. Verapamil, in a dosage of 360 to 480 mg daily, can effectively reduce the number of attacks during a cluster headache period. Less well-studied alternatives for prophylaxis include prednisone and antiepileptic drugs; they should only be considered if verapamil is not tolerated or not effective. Label A B A B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series.
Surgical Therapy: Patients with chronic cluster headaches that do not respond to medications may be considered for surgical therapy aimed at the trigeminal nerve. A case series found that 15 of 17 patients who underwent complete or partial section of the trigeminal nerve had complete or nearcomplete relief of symptoms.
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Diagnosis and Treatment of Headache Algorithm

Diagnosis algorithm Evaluate type of headache Take a detailed history and assess functional impairment Rule out causes for concern Consider secondary headaches Refer to specialist
Migraine Treatment Categorize and select treatment based on severity and functional impairment Patient education and lifestyle modifications
Tension-type Headache Establish diagnosis Acute treatment Prophylactic treatment Patient education and lifestyle modifications
Cluster Headache Establish diagnosis Acute treatment Prophylactic treatment Patient education and lifestyle modifications
Resources for Patients: http://www.aafp.org/afp/20020901/805ph.html http://www.aafp.org/afp/20051101/1816ph.html http://www.aafp.org/afp/20050215/728ph.html http://www.aafp.org/afp/20041215/2313ph.html References: International Headache Society headache classification American Academy of Neurology Evidence-based guidelines for migraine headache Evaluation of Acute Headaches in Adults; American Family Physician, February 15, 2001 Tension-Type Headache; American Family Physician, September 1, 2002 Management of Cluster Headache; American Family Physician, February 15, 2005 http://www.aafp.org/afp/20071115/1518.html http://www.aafp.org/afp/20070701/bmj.html
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Acute Pharyngitis
034.0 Streptococcal sore throat (GABHS pharyngitis) 462 Acute pharyngitis 465.0 Acute laryngopharyngitis 472.1 Chronic pharyngitis 472.2 Chronic nasopharyngitis
Definition: A complaint of throat discomfort with or without cough or fever.
General Approach to the patient: Goals: 7. Identify specific or life-threatening causes of throat pain 8. Obtain adequate information to develop a working diagnosis in an efficient manner 9. Arrange for definitive care of identified specific causes of throat pain at time of presentation or with appropriate follow-up 10. Detect and treat streptococcal pharyngitis in a timely manner 11. Allay fears of patient and family regarding symptom if cause is benign 12. Provide symptomatic relief of patient complaints 13. Avoid exposure to antibiotics when not indicated
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Rules of Thumb:
Age Complaint frequency 0-18 months Very uncommon Thrush Ulcerative pharyngitis (herpesvirus Herpangina Hand-footmouth Mouth breathing from URI GABHS 18 m- 5 y Uncommon Herpangina Group A B hemolytic strep (GABHS) Allergic rhinitis Hand-footmouth Mouth breathing Ulcerative pharyngitis (herpesvirus) Meningitis Epiglottitis Kawasaki Disease C diphtheriae 5 y-15 y Common 15-45 Uncommon >45 Very Uncommon
Commonly diagnosed diseases (in descending order of prevalence)
GABHS Allergic rhinitis Mouth breathing Infectious mononucleosis Gonococcal pharyngitis
Infectious mononucleosis Allergic rhinitis GABHS Gonococcal pharyngitis
Allergic rhinitis Rhino-sinusitis Viral pharyngitis GABHS
Life threatening diseases to consider
Meningitis Epiglottitis
Meningitis Abcess Palatal Cellulitis C diphtheriae Cancer
Abcess Palatal Cellulitis Meningitis Cancer C diphtheria HIV
Inconsolability Toxic appearance
Drooling Toxic appearance Prolongued febrile illness
Voice changes Dehydration Assess hydration status Visualize pharynx Determine if cough, rhinitis is present Abscense of nuccal rigidity If prior probability for GABHS over 30%, Rapid antigen test If GABHS, PCN If non-GABS, supportive care Out until treated for 24 hrs if GABHS
Key elements of exam
Assess hydration status
Assess hydration status Abscense of nuccal rigidity
Voice changes Dehydration Severe sore throat Assess hydration status Visualize pharynx Determine if cough, rhinitis is present Abscense of nuccal rigidity If prior probability for GABHS over 30%, Rapid antigen test If GABHS, PCN If non-GABS, supportive care Out until treated for 24 hrs if GABHS June 30, 2008
Abcess Palatal Cellulitis Cancer Meningitis HIV Autoimmunie disorder Environmental exposure Voice changes Mental status changes High fevers Ulcerstion Brief mental status exam Abscense of nuccal rigidity Visualize pharynx Assess breath for fetid nature
Key diagnostic study
None
Common Treatment Functional limitations
Depends on clinical situation Depends on clinical situation
Assess prior probability for GABHS. If over 30%, Rapid antigen test If GABHS, PCN If non-GABS, supportive care Out until treated for 24 hrs if GABHS
Depends on clinical situation
Depends on clinical situation Depends on clinical situation 156
Overview: Chief Complaint: Typically the complaint is Sore throat Vitals: Age, gender, and a review of vital signs with attention to the presence or absence of fever, pulse, respiratory rate, and pulse oximeter if applicable should be noted. General approach to history: The history for pharyngitis is primarily to establish risk of the symptom being caused by a life threatening condition and to determine whether the patient has streptococcal pharyngitis. This is done initially by observing the patient for signs of toxicity, and listening to the quality of the patients voice. Following this, the time course of the illness and associated symptoms will give important clues as to whether this is infectious due to bacterial causes, infectious due to viral causes, inflammatory, or related to another disease process (such as Gastroesophageal Reflux Disease) Vocal Quality Location Where does your throat hurt? (Can ask patient to indicate with hand the place of most severe pain) Timing When did the pain begin? Has there been a change over time? What is the relationship of the pain with associated symptoms such as fever? Quality What is the severity of the pain? How would you characterize the pain? (Sharp, dull, aching, stabbing, burning, etc) Severity How bad is the pain? (Consider pain scale) Are you able to swallow liquids? Solids? Aggravating/Relieving factors Does anything make it better? Does anything make it worse? List medications tried for relief. Associated symptoms Are any other symptoms associated with the throat pain? (fevers, rashes, mouth ulcers, cough, coryza, acid brash) Risk Factors (child and adolescent) - Exposure to other children or adults with similar illness (identify diagnosis) Risk Factors (adult) Exposure to tobacco (amount, time of exposure), Exposure to alcohol (amount, time of exposure), Illness contacts
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Age Specific Concerns: Infants, toddlers: Key Question Content Whitish patches in mouth Sores in mouth Lesions on hands, feet as well as in mouth Cough, coryza Toxic appearance Drooling, toxic appearance Household contact with GABHS School Aged Children, Adolescents: Key Question Content Acute onset, lack of cough, coryza, desquamating rash, GABHS in community Acute onset, fever, lack of cough or coryza, GABHS in community Acute onset, lack of cough or coryza, Cough, coryza Sores in mouth Lesions on hands, feet as well as in mouth Toxic appearance Drooling, toxic appearance Household contact with GABHS Prolonged course, adenopathy, GABHS testing negative History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of prolonged illness, desquamating rash, cherry red lips History of non-vaccination Prolonged illness, adenopathy, tests for common infectious illnesses negative Immunocompromised patient
Further investigation if positive Consider thrush Consider primary herpes outbreak, herpangina Consider coxsackie virus Consider viral rhinosinusitis Consider life threatening infection such as meningitis, sepsis, pertusis, diphtheria Consider epiglottitis Consider GABHS
Further investigation if positive Consider very strongly GABHS (pre-test probability >80%) Consider strongly GABHS (pre-test probability >50%) Consider GABHS (pre-test probability between 30 and 50%) Consider viral rhinosinusitis (pre-test probability < 30%) Consider primary herpes outbreak, herpangina Consider coxsackie virus Consider life threatening infection Consider epiglottitis Consider GABHS Consider infectious mononucleosis Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis Consider Kawasaki disease Consider as rubeola, diphtheria, other preventable infectious causes Consider connective tissue disease, hematologic disease, HIV Consider thrush
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Young adults (patients over 15 but younger than 45): Key Question Content Acute onset, fever, lack of cough, coryza, GABHS in community, Household contact with GABHS Cough, coryza with or without fever Toxic appearance Drooling, toxic appearance Prolonged course, adenopathy, GABHS testing negative History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of no or improper vaccination History of dyspnea Prolonged illness, +/- adenopathy, tests for infectious illness negative Immunocompromised patient History of neck tenderness at thyroid Prolonged illness, adenopathy, tests for infectious illness negative, particular if history of exposure to tobacco or alcohol Older adults (patients over 45): Key Question Content Acute onset, fever, lack of cough, coryza, GABHS in community, Household contact with GABHS Cough, coryza with or without fever Toxic appearance Drooling, toxic appearance History of oral-genital contact History acid brash History mouth breathing Ill appearance, neck stiffness History of no or improper vaccination Further investigation if positive Consider GABHS (pre-test probability between 30 and 50%) Consider GABHS Consider viral rhinosinusitis (pre-test probability < 30%) Consider life threatening infection Consider epiglottitis or peritonsillar abcess Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis, sepsis, life-threatening soft tissue infection Consider as rubeola, diphtheria, other preventable infectious causes
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Further investigation if positive Consider GABHS (pre-test probability between 30 and 50%) Consider GABHS Consider viral rhinosinusitis (pre-test probability < 30%) Consider life threatening infection Consider epiglottitis or peritonsillar abcess Consider infectious mononucleosis Consider gonnococcal pharyngitis Consider laryngoesophageal reflux Consider as cause Consider meningitis, sepsis, life-threatening soft tissue infection Consider as rubeola, diphtheria, other preventable infectious causes Consider spontaneous pneumothorax Consider connective tissue disease Consider thrush, HIV Consider thyroiditis Consider hematologic illness
History of dyspnea Tenderness at neck Prolonged illness, +/- adenopathy, tests for infectious illness negative Immunocompromised patient History of neck tenderness at thyroid Prolonged illness, adenopathy, tests for infectious illness negative, particular if history of exposure to tobacco or alcohol Exposure to environmental toxins
Consider spontaneous pneumothorax Consider carotidynia, Consider connective tissue disease Consider thrush, HIV Consider thyroiditis Consider hematologic illness Consider environmental cause
Physical: The physical exam is targeted primarily at confirming an infectious process, identifying lifethreatening causes, and confirming clinical suspicion Vitals - Heart rate, respirations, temperature, weight/height (age below 16), blood pressure General Does the patient appear toxic? How does the patient react to his or her environment? HEENT Sclera and nasal turbinates for coryza, tympanic membranes for fluid, purulence, oropharynx for purulence, lesions, Koplick spots, Neck Check for adenopathy, document presence or absence of rigidity, Heart Note rate and rhythm, presence or absence of murmurs Lungs Auscultate for rales, wheezes Abdomen n/c Extremities n/c Neuro n/c Musculoskeletal n/c Diagnostic studies: General Guidelines 1-7 Patients under 5: The evidence regarding management of febrile infants below the age of 5 who do not have a readily identifiable source of fever has been well established and will not be reviewed here. The likelihood of a child under the age of 3 having GABHS is very small and the clinician should look for sources other than GABHS as the source of the childs fever (SOR - C). Diagnostic studies are dictated by the suspicions generated by the history, the findings on physical exam, and ultimately the clinicians index of suspicion for GABHS or other treatable bacterial or viral illnesses, or the suspicion of a serious bacterial infection requiring urgent evaluation in an urgent care environment. Patients between 5 and 15: The majority of cases of GABHS occur in this age group, although the majority of people in this age group who have symptoms of pharyngitis do not have GABHS. (SOR A) Identifying and appropriately treating those patients with GABHS infections is felt to be important because treatment of GABHS will reduce symptoms by 24 hours when compared to watchful waiting and is believed to prevent rheumatic fever. (SOR C). Testing algorithms include decision making based on symptoms, use of rapid streptococcal antigen (Positive predictive value 86%, negative predictive value 88%, time to result 10 minutes or less) and/or throat culture (Sensitivity 90%, specificity 99% under ideal conditions for presence or absence of GABHS, time to result 24-48 hours).The evidence for optimal use of rapid testing, empiric treatment, or determining the absence of clinically
significant GABHS based on history and physical alone has not been determined but a compilation of the literature with a proposed approach is found in Figure 1. (SOR - C). Additional ambulatory testing for patients where GABHS is not suspected or who are GABHS negative might include a complete blood count and/or monospot (infectious mononucleosis, hematologic concerns) or chocolate agar culture (gonnococcal pharyngitis) or empiric therapy (laryngoesphageal reflux). If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Patients over 15: A number of diseases and conditions can cause symptoms of pharyngitis. As with younger children and adolescents, identifying and appropriately treating patients with GABHS infections is felt to be important because treatment of GABHS will reduce symptoms by 24 hours when compared to watchful waiting and is believed to prevent rheumatic fever. (SOR - C). ?? Because of the lower prevalence, testing algorithms are proposed which include decision making based on symptoms, use of rapid streptococcal and/or throat culture but they are based only on expert opinion. A proposed approach based on existing evidence is found in Figure 2. (SOR - C). Additional ambulatory testing for patients who are GABHS negative might include a complete blood count and/or monospot (infectious mononucleosis, hematologic concerns), chocolate agar culture (gonnococcal pharyngitis), or thyroid function tests (tender thyroid) or empiric therapy (laryngoesphageal reflux).In patients with persistent symptoms, consider immunologic testing for connective tissue diseases. In patients with persistent symptoms and exposure to tobacco and/or alcohol referral for direct visualization might be warranted, particularly of the symptoms are associated with voice changes, weight loss, or other worrisome signs. If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Office Based Management: APPLICABLE TO ALL AGES GABHS pharyngitis Non-pharmacologic (SOR-C) Increased fluid intake is felt to help with symptoms and will help patient to avoid dehydration. Topical anesthetics such as Chlorasceptic spray help patient to tolerate symptoms until infection resolves and assist with maintaining hydration. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient. Clean toothbrushes and other personal items after the infection has been treated. Pharmacologic (SOR B) Treatment with IM penicillin is the gold standard for prevention of non-suppurative and suppurative sequelae. Cure rates with oral regimes dosed anywhere from every 12 to every 6 hours have been found to be equivalent. The failure rate is anywhere from 5 15%. Alternative antibiotics for use with those patients who reprt allergies or have treatment failures are found in the appendix. Antipyretics likely aid in symptom relief and should be offered to patients..
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Other viral and presumed viral causes Non-pharmacologic (SOR-C) Increased fluid intake and humified air are felt to help with symptoms as have topical anesthetics such as Chlorasceptic spray. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient. Pharmacologic (SOR B) Antibiotics are known not to be effective. Decongestants, cough suppressants, and antihistamines are felt to be harmful in children and to have significant side effects with the potential of some symptom relief in adults. Nasal ipatropium was found to help in adults with nasal congestion. Antipyretics likely aid in symptom relief. Allergic rhinitis see allergic rhinitis chapter
INFANTS, TODDLERS, YOUNG CHILDREN Herpes gingivostomatitis Non-pharmacologic (SOR C) - Pain associated with swallowing may limit oral intake of infants and children, placing them at risk for dehydration. Intake should be encouraged through the use of cold beverages, ice cream, and yogurt. Pharmacologic (SOR A) - Oral acyclovir (15 mg/kg/dose 5 times a day PO for 7 days, maximum 1 g/day) started within 72 hr of onset reduces the severity and duration of the illness Thrush: Non pharmacologic The condition may resolve spontaneously without treatment. The aprent can be offered the activity of cleansing the bottle nipples or treatment of the breast of the mother which may be effective Pharmacologic (SOR B) Thrush is traditionally treated with nystatin oral suspension. For neonates, the dose is 100,000 U (1.0 mL) given in each cheek pouch every 6 hours after feedings for at least 7 to 10 days; for pediatric patients, the dose is 1 to 2 million U/day divided every 6 hours until resolution. Fluconazole suspension (3 mg per kg orally once daily for seven days) is possibly more effective based on one small study (SOR B). Gentian Violet is also effective OLDER CHILDREN AND ADOLESCENTS Infectious Mononucleosis Non-pharmacologic (SOR C) Good supportive care is the mainstay of therapy including adequate
hydration; nonsteroidal anti-inflammatory drugs or acetaminophen for fever and myalgias; and throat lozenges or sprays, or gargling with a 2 percent lidocaine (Xylocaine) solution to relieve pharyngeal discomfort. Enforced bed rest has been found to slow recovery and patients should be advised to increase activities as tolerated. Patients should avoid contact sports until asymptomatic
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Pharmacologic (SOR B) Acylclovir has been found to offer no clinical benefit. Corticosteroids may offer some benefit to those patients who suffer from significant edema. Antibiotics should be used for GABHS as well as suspected cellulitis from bacterial causes.
ADOLESCENTS AND ADULTS Gonnococcal pharyngitis Non-Pharmacologic (SOR C) Many patients are asymptomatic. Positive cultures should be reported and contact tracing initiated through public health mechanisms. Persons with gonococcal pharyngitis should be counseled regarding safe sex and should be offered testing for HIV and syphilis. Pharmacologic (SOR B) Recommended first-line antibiotic is a single dose of ceftriaxone A single dose of spectinomycin may be used (if available) in patients who cannot tolerate cephalosporins. However, it is considered unreliable in pharyngeal infections, and so patient should have a pharyngeal culture 3-5 days after treatment to confirm eradication All patients should also be treated for chlamydial infection if it has not been ruled out Gastroesophageal reflux disease: Non-pharmacologic: Patients should be instructed to avoid large meals and should not lie down immediately after eating (up to 3 hours). They should also be counseled that acidic foods, alcohol, caffeinated beverages, chocolate, onions, and garlic may exacerbate symptoms and should be withdrawn initially, they can be added back as symptoms permit. Reducing dietary fat should improve symptoms as does weight loss. Medications known to cause reflux should be withdrawn if possible. These include calcium channel agonists, alpha-adrenergic agents, theophylline, nitrates and certain sedatives. The head of the bed should be elevated 4 8 inches. Tight clothing should be avoided as should tobacco use. Pharmacologic: After making diagnosis, it is reasonable to start with either an H2 blocker or a proton pump inhibitor. The choice is based on previous effective and ineffective therapy and cost to patient. (see appendix for choices and dosages) If the H2 blocker was used initially but is only partially effective, it may be necessary to switch to a PPI. Once symptoms resolve, reduce dose to the lowest required to maintain patient symptom free. Antacids may be added for additional symptom relief, especially early on or when symptoms flair.
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Urgent referral to emergency department for evaluation under controlled conditions and possible admission (SOR - B): Suspected sepsis or other significant invasive soft tissue infection requiring IV antibiotics Suspected Kawasaki Disease Moderate to severe dehydration Pneumothorax Referral to specialist (SOR - C): ENT - The American Academy of OtolaryngologyHead and Neck Surgery states that children with three or more infections of the tonsils or adenoids per year, despite adequate medical therapy, are candidates for tonsillectomy The following criteria are also used: seven documented tonsil infections in any 1 year, five documented tonsil infections in each of 2 consecutive years, and three documented tonsil infections in each of 3 consecutive years. Tonsil infections are defined by three of the following criteria: fever ( > 101_F), dysphagia, cervical adenopathy, positive GABHS culture, and tonsillar exudates. Additionally, suspected malignancy should be urgently referred Gastroenterology Suspected laryngoesophageal reflux that does not respond to conservative therapy should be referred, especially if the patient has a history of tobacco or significant alcohol use. Rheumatology Suspected connective tissue cause of symptoms Follow-up (SOR - C): Patients with GABHS pharyngitis should be free from contagion within 24 hours of beginning antibiotics and can increase activity as tolerated. They should be symptom free within 4 days and should return for re-evaluation if they are not. Patients with other viral, bacterial or fungal causes should be instructed to return for signs or symptoms of dehydration. They otherwise should be symptom free within 2 weeks. Patients with infectious mononucleosis should be informed that they will continue to have symptoms for several weeks to months. They should return for signs or symptoms of dehydration. They may return to full activity (including contact sports) when free of symptoms. If hepatosplenomegaly was detected, ultrasound imaging and follow-up imaging may be warranted. Patients with gastroesophageal reflux disease should be re-evaluated for reduction of symptoms within 4 weeks and resolution within 8 weeks
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Resources for patients: Strept throat - Patient Information Handout accessed at http://www.aafp.org/afp/20010415/1565ph.html Things to know about infectious mononucleosis. - Patient Information Handout accessed at http://www.aafp.org/afp/20041001/1289ph.html - October 1, 2004 Heartburn: Hints on dealing with the discomfort accessed on Familydoctor.org at http://familydoctor.org/087.xml Smoking: Steps to Help You Break the Habit accessed on Familydoctor.org at http://familydoctor.org/161.xml References: 1. Laine Keahey MD Blake Bulloch MD Rose Jacobson RN Milton Tenenbein MD Amin Kabani Diagnostic accuracy of a rapid antigen test for GABHS performed by nurses in a pediatric ED American Journal of Emergency Medicine - Volume 20 (2) 2. Simasek M and , Blandino D, Treatment of the common cold. Am Fam Physician2007;75:515-20, 522 3. Chapter 249. Herpes simplex in Nelsons Textbook of Pediatrics Jeannette E. SouthPaul, Samuel C. Matheny, Evelyn L. Lewis eds Accessible by subscription at http://www.mdconsult.com 4. Hayes C and Williamson H management of Group A Beta-Hemolytic Streptococcal Pharyngitis Am Fam Physician 2001;63:1557-64,1565 5. Perkins A. An approach to diagnosing the acute sore throat. Am Fam Physician 1997;55:131-8,141-2. 6. Ebell M. Epstein Barr Virus Infectious Mononucleosis Am Fam Physician 2004;70:127987,1289-90 7. C.M. Discolo et al. Management of pediatric pharyngitis Pediatr Clin N Am 50 (2003) 445458 8. Bisno A et al Practice guidelines for the diagnosis and management of GABHS Clin Inf Dis 35 (2) Accessible by subscription at http://www.mdconsult.com
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Appendix
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Approach to pharyngitis symptoms (Ages 5-15) History and physical suggest GABHS is likely
Signs and symptoms suggestive of GABHS 1. 2. 3. 4. Lack of cough History of fever Tonsillar exudates Swollen, tender anterior lymph nodes
None or one present
Two or three present
All four present
Household contact with GABHS or patient with scarletinaform rash
Symptomatic treatment, consider other causes, rapid antigen test or culture if clinical uncertainty exists
Rapid antigen test, treat if positive, if negative consider other causes, culture if clinical uncertainty exists or rheumatic fever strain prevalent
Rapid antigen test, treat if positive if negative consider culture and empiric treatment while awaiting result. Can offer empiric treatment without testing if disease highly prevalent or rheumatic fever strain prevalent
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Empiric treatment with antibiotics
For persistent symptoms in face of fatigue if CBC shows 50% lymphocytes and heterophile antibody is +, consider Mono (see following page)
Supportive care
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Approach to pharyngitis symptoms (Ages greater than 15) Complaint of sore throat and not critically ill Finding more suggestive of For persistent symptoms see table throat pain on next page. Consider malignancy if alcohol or tobacco exposure, worrisome physical finding. Consider connective tissue disease Signs and symptoms suggestive of GABHS or other infectious process (No) (Yes) 1. 2. 3. 4. Lack of cough History of fever Tonsillar exudates Swollen, tender anterior lymph nodes
None or one present
Two or three present
All four present
Household contact with GABHS
Probable viral or allergic etiology. Symptomatic treatment, consider other causes, rapid antigen test or culture if clinical uncertainty exists
Rapid antigen test, treat if positive, if negative consider other causes, culture if clinical uncertainty exists or rheumatic fever strain prevalent
Rapid antigen test, treat if positive if negative consider culture and empiric treatment while awaiting result. Can offer empiric treatment without testing if disease highly prevalent or rheumatic fever June 30, 2008 strain prevalent
Empiric treatment with antibiotics
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Preparticipation Sports Physical Evaluation

V70.3 Definition: Preparticipation Sports Physical Evaluation a targeted history and physical performed on patients prior to participation in sports or other strenuous activity intended to detect those patients at high-risk for activity related complications Goals: 1. Identify conditions that predispose the participant to activity related complications (particularly sudden death and musculoskeletal injuries) 3. Arrange for definitive care and/or appropriate follow-up studies for identified problems. 4. Fill out preparticipation form as required by state law 5. Avoid ordering unnecessary tests on low risk patients 6. Use visit as an opportunity to address preventive services for patient Overview: Preparticipation physical examinations (PPE) have become the standard of care for over 6 million high school and college students in the United States prior to participation in organized sports activities. Since 1970, the basic structure of the PPE has been developed, revised, and implemented based primarily on the recommendations and opinions of medical experts in large medical organizations.1 The driving force behind these exams has been a desire to prevent rare but serious events that have occurred in athletes during sports participation. The forms used vary from state to state. Almost all states require a PPE for all high school athletes prior to participate in sports. These visits, in addition to fulfilling state requirements for preparticipation examination, present the physician with an opportunity to address health maintenance issues with patients. Although these examinations are intended to detect serious underlying pathology that places the patient at increased risk of sudden death, they are neither sensitive nor specific. Looking for these abnormalities has been likened to looking for a needle in a haystack. In this chapter, we will review in detail the PPE form used by the State of Alabama and discuss common problems identified and how they are commonly managed. There are no universal guidelines as to whether to give full clearance, restricted clearance or deny clearance. Ultimately the decision is made based on clinical judgement by the physician after completing a history, physical exam and ordering further studies (if indicated) and possibly referring the patient to a specialist if there is uncertainty about the patients ability to participate safely. There is very little evidence to support PPE for preventing sudden cardiac death and PPE does not satisfy the basic requirements for medical screening as described by the USPSTF.1 Chief Complaint: Typically the complaint is Sports Physical or similar.
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Vitals: Age, gender, and past medical history should be noted prior to entering the room. If the preparticipation history has been filled out by parents or patient, it is useful to briefly look over this to identify areas of concern. General approach to history: Patients generally arrive with a PPE form given to them by the school. The history on this form is to be filled out by the patient with the assistance of his/her parents. See appendix. Listed below are all of the questions asked, the reason for asking the question, and how to respond to yes answers. 1. Have you ever been hospitalized? Have you ever had surgery? --Both of these questions seek to identify underlying medical conditions. Some surgeries such as a tonsillectomy may have no bearing on clearance while others such as heart surgery or orthopedic surgery may be referred to a specialist for further evaluation depending on the primary care physicians level of comfort with these conditions. 2. Are you presently taking any medications or pills? --Identifies underlying medical conditions that patient might not otherwise mention (i.e. the patient may know that they take albuterol, but may not identify themselves as having asthma if asked Do you have any medical problems? Some medications such as occasional use of allergy medicines or antacids may have little bearing on clearance, while asthma medications, antihypertensives, diuretics and others may warrant a more detailed history. 3. Do you have any allergies (medicine, bees or other stinging insects)? --These could be important to note if the patient participates in outdoor sports. If patient has a severe allergy to insect bites (anaphylaxis) it would be prudent to have an Epi-Pen available. 4. Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you tire more quickly than your friends during exercise? Have you ever had high blood pressure? Have you ever been told that you have a heart murmur? Have you ever had racing of your heart or skipped heartbeats? Has anyone in your family died of heart problems or a sudden death before age 50? --All of these questions are aimed at identifying underlying cardiac pathology. A positive answer to any of these should prompt further cardiac work-up. See table for most common causes of sudden death in athletes. Generally an EKG and an echocardiogram are performed if there are any cardiac concerns. The presence of an arrhythmia (other than sinus arrhythmia or PVCs that go away during exercise) should prompt referral to a cardiologist. 5. Do you have any skin problems (itching, rashes, acne)?
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6.
7.
8.
9.
--Contact dermatitis, recurrent skin infections and acne may all be identified. Generally these are not a problem for clearance, but can be a concern that patients need to be aware of. Contact dermatitis can be managed with topical steroidal creams for flare-ups. This is mainly a concern because pads and protective gear can irritate skin and exacerbate underlying skin problems. Have you ever had a head injury? Have you ever been knocked out or unconscious? Have you ever had a seizure? Have you ever had a stinger, bumer or pinched nerve? --Concussions are the primary concern being addressed with this question. See Management for discussion of concussions. Seizure disorder if well controlled may not be an absolute contraindication to participation, but most physicians would probably have a patient see their neurologist if they are on anti-seizure medications prior to clearing them for participation in strenuous activities. Strenuous exertion and associated electrolyte disturbances from sweating and dehydration may lower the seizure threshold. At the very least these patients need to stay well hydrated. Febrile seizures as an infant are not a problem. A stinger or burner results from transient nerve compression following an axial load to the spinal column (generally cervical). This can occur after a patient runs or dives head first into an object. This can compromise the neural foramen transiently and pinch the nerve. The patient experiences radicular pain along a dermatome. Any persistent symptoms may prompt spine films and possibly neuroimaging (MRI). Symptoms that resolved spontaneously and have not recurred are generally not worrisome. Have you ever had heat or muscle cramps? Have you ever been dizzy or passed out in the heat? --This identifies patients prone to sweating induced electrolyte disturbances, dehydration and/or exertional hyperthermia. These patients should be encouraged to drink plenty of water and avoid extremely high temperatures while participating. If symptoms are persistent or severe, further investigation with serum chemistries looking for underlying electrolyte or metabolic disturbances may be warranted. Do you have trouble breathing or do you cough during or after activity? --Exercise induced asthma may present as breathing difficulty or cough related to activity. Patients who have these symptoms should undergo spirometry to look for asthma. Patients with exercise induced asthma should use a bronchodilator prior to participation (i.e. albuterol MDI 30 minutes before participation) or may require better control of their asthma prior to participation. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)? --This may identify problem areas specific to the patient not identified by other questions. Generally these are not a problem for clearance unless they bring into focus serious underlying problems not identified elsewhere in the examination. Patients may answer yes to this question as a matter of course (shoulder pads in football, mouth guard in boxing, etc)
10. Have you had any problems with your eyes or vision?
Do you wear glasses or contacts or protective eye wear? --Identifies eye problems. Vision that corrects to 20/20 in both eyes is generally not a concern. Patients that require glasses may require corrective protective lenses for participation in contact sports but generally poses no problem for clearance. Concern may arise however if the patient is to participate in a contact sport and they have low (worse than 20/40 corrected) or no vision in one eye. Eye injuries do occur in sports and damage to a patients only good eye could render them blind. It is important to note and document this concern with the patient and discuss with them the importance of eye protection. 11. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)? --Identifies other problems not discussed elsewhere. Decisions regarding clearance will be made on a disease specific basis and the experience of the physician with these particular illnesses. Some physicians may clear a patient with diabetes, while others may refer them to an endocrinologist, etc. 12. Have you had a medical problem or injury since your last evaluation? --Identifies other condtions. Decisions regarding clearance will be dependent upon the nature of the medical problem or injury. 13. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones or joints Head Back Shoulder Forearm Hand Hip Knee Ankle Neck Chest Elbow Wrist Finger Thigh Shin Foot --Identifies orthopedic problems. Problems with joints will mandate a targeted joint exam for the affected joint including range of motion, strength, palpation and crepitus. X-rays may be ordered for fractures or abnormalities on exam. If any clinical uncertainty persists regarding joint function or stability, referral to an orthopedist or sports medicine physician may be obtained prior to clearing patient. 14. When was your first menstrual period? When was your last menstrual period? What was the longest time between your periods last year? --Identifies proper menstrual function. Female athletes who train very intensely may become amenorrheic. The female athlete triad is eating disorder, amenorrhea, and osteoporosis. Increasing caloric intake and decreasing intensity of training may restore cycles. Estrogen containing oral contraceptives may prevent bone loss but has not been shown to increase bone mass. This question may also identify pregnancy, which would prevent clearance for strenuous activity and contact sports. Other menstrual irregularities may not affect clearance, but warrant further investigation.
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Physical Examination: Height: _________ Weight: _________ B/P: ______/_______ Pulse: ________ Note general appearance. Observe for evidence of excessive long-bone growth (arachnodactyly, arm span>height, pectus excavatum) that suggest Marfan Syndrome. Note vital signs. Height values that are extremes on a growth chart may warrant further investigation, but generally do not pose an obstacle to clearance. Weight extremes also may warrant discussion of eating disorders and/or obesity, but generally pose no obstacle to clearance. Blood pressure that is poorly controlled is a concern. Blood pressure should be well-controlled (<140/90) prior to clearing athletes for participation. Pulse rate is often relatively bradycardic in young, well conditioned athletes. Pulse irregularities should prompt an EKG to assess the type of arrhythmia.
Criteria for Hypertension in Children and Adolescents Age (Years) Percentile for height Blood pressure (mmHg) Girls 6 50 111/73 Girls 6 75 112/73 Boys 6 50 114/74 Boys 6 75 115/75 Girls 12 50 123/80 Girls 12 75 124/81 Boys 12 50 123/81 Boys 12 75 125/82 Girls 17 50 129/84 Girls 17 75 130/85 Boys 17 50 136/87 Boys 17 75 138/88 Reprinted from Update on the task force report on high blood pressure in children and adolescents. Bethesda, Md.: National Institutes of Health, 1997. Publication no. 97-3790. Gender
Vision R 20/______ L 20/ _______ Corrected: Y N Note vision. Vision that is worse than 20/40 corrected in one eye is a big concern. These patients should be evaluated by an ophthalmologist.4 See recommendations below. Cardiovascular Palpate PMI for increased intensity and lateral displacement that suggest hypertrophy and failure Pulses Palpate femoral pulses. Decreased femoral pulses suggest coarctation of aorta. Heart Perform auscultation with patient lying and standing. Also auscultate while having patient strain with Valsalva maneuver. Murmurs that increase with standing or valsalva suggest hypertrophic cardiomyopathy and warrant further investigations. Soft murmurs (<2/6) that decrease or disappear with Valsalva are generally innocent flow murmurs that warrant no further investigation.
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Lungs Observe for accessory muscle use or prolonged expiration and listen for wheezing. Exercise induced asthma will not produce manifestations on a resting examination and requires exercise testing for diagnosis. Skin Evidence of molluscum contagiosum, herpes simplex infection, impetigo, tinea corporis or scabies. E. N. T. Subjective hearing (finger rub) Abdominal Palpate for hepatic or splenic enlargement Genitalia (males) Assess for hernia (palpate inguinal canal with finger while patient coughs, a palapable bulge suggests a hernia), varicocele (venous malformation of testicular veins; will be felt as mass in testicular blood vessels), undescended testicle and solitary testicle. Musculoskeletal General inspection of posture and gait. Test all of the following movements. Follow up for abnormalities will be dependent upon findings, type of sport and physician experience. Neck Shoulder Elbow Extension and flexion of elbows Wrist Pronation and supination, flexion, extension Hand Fist clench and finger spread Back Inspection, extension, flexion and rotation Knee Ankle Foot Having patient squat down and walk like a duck and then stand on toes will test these joints. Other Any problems identified warrant a complete examination of affected joint. Forward flexion, extension, and lateral flexion of neck Resisted shoulder shrug, internal and external rotation of shoulders, resisted shoulder abduction
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Office Based Management: Clearance In general, it is rare for athletes not to be cleared. In an examination of 26,247 athletes only 249 were not cleared. The range of disallowed athletes in the study ranged from 0 to 2.6%. 3 Conditions that may limit participation or require further investigation prior to clearance Cardiovascular disease: Patients with any cardiac abnormalities listed above should undergo EKG and echocardiogram to evaluate for hypertrophic cardiomyopathy, conduction abnormalities (long QT). Patients with hypertrophic cardiomyopathy or an arrhythmia should be seen by a cardiologist before clearing the patient for participation. Mitral valve prolapse generally does not prohibit sports participation. However, if the mitral valve prolapse is associated with repetitive arrythmias, family history of sudden death or severe mitral regurgitation, these patients should be limited to low intensity sports. Sinus bradycardia and occasional PVCs (<6/minute) that resolve with exercise are not a basis for restriction in asymptomatic patients without structural heart disease. Musculoskeletal Injuries: Musculoskeletal findings are the major category of abnormalities leading to restriction from sports activities. Knee injuries are the most common followed by ankle. In knee injuries, the risk of reinjury is high without proper rehabilitation. In order to clear a patient with a joint injury, several criteria must be filled. There should be no joint effusion, decreased range of motion or symptomatic ligament instability and at least 80% normal strength in the affected extremity. Ligament laxity can be a normal finding, but symptomatic instability is pathologic and these patients should not be cleared by a primary care physician. Head and Cervical Spine Injury: Concussions are the most common injuries in football. There is no clear agreement on definitions or classifications of concussion severity, treatment or clearance guidelines. In general, athletes with a history of concussion who have been asymptomatic for at least one week and show no residual neurologic deficits are allowed to participate in sports. Any persistent postconcussive symptoms (headache, dizziness, sensory changes or cognitive disturbance) are a contraindication to contact sports even though they may take weeks to resolve. This may prevent a sometimes fatal second impact syndrome in athletes who have a second concussion while recovering from the first. Burners and stingers should be asymptomatic and patients free of neck pain before returning to the sport. Recurrent stingers require cervical films before clearance.4 Convulsive disorders: Guidelines from American Academy of Pediatrics clear young athletes with well-controlled convulsive disorders for participation in conventional school sponsored sports. Consider neurologic consultation for high risk sports (gymnastics, skiing, high diving). Athletes with poorly controlled seizures should be withheld from contact or collision sports and hazardous non-contact sports (archery, rifling, swimming, weight lifting)
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Exercise-induced Asthma: Status asthmaticus is an extremely rare cause of death in athletes (4/30,000,000). This condition should be treated appropriately (typically beta agonist prior to exercise) and patients allowed to participate. Heat-related Illness: Leading causes of nontraumatic, noncardiac sports death are exertional hyperthermia, followed by exertional rhabdomyolysis and status asthmaticus. Athletes with a history suggestive of heat related illness are usually allowed to participate in sports, but must be cautioned about maintaining adequate hydration and avoiding temperature extremes. Sickle Cell Trait: Patients with sickle cell trait should be allowed to participate without restriction. There is some evidence that patients with sickle trait have increased risk of exertional rhabdomyolysis and should be encouraged to drink plenty of fluids. High exertion and contact or collision sports are generally contraindicated in patients with sickle cell disease even if appropriate hydration can be ensured. Solitary organs: Whether athletes with one paired organ, especially one kidney, should be allowed to play sports is controversial. Patients should be educated on the risks so they can make an informed decision. A single polycystic or abnormal kidney prevents patients from participation in contact or collision sports. Athletes with only one functional eye (worse than 20/40 corrected in one eye) can participate only in sports that permit used of protective eyewear and do not involve projected objects. Wrestling, boxing and martial arts are contraindicated. Athletes with a single testicle should use a protective cup during contact sports and educated about potential for inury and loss of fertility.4 Supplemental materials On-line resource outlining how to do a 2-minute orthopedic exam for a sports physical. http://www.aafp.org/afp/20000501/2696.html References 1. Matheson et al. Preparticipation Physical Examination, 3rd ed. Minneapolis, MN: American Academy of Family Physicians, American Academy of pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. McGraw-Hill: The Physician and Sportsmedicine, 2005. 2. OConnor F. et al. Sudden death in Young Athletes: Screening for the Needle in the Haystack. American Family Physician. Vol 57/No. 11 (June 1998) 3. Mick, T. et al. What kind of physical examination does a young athlete need before participating in sports? Cleveland Clinic Journal of Medicine Volume 71 Number 7 July 2004 p587-597. 4. Kurowski, K. The Preparticipation Athletic Evaluation. American Family Physician. Volume 61/No.9 May 1, 2000.
Somatoform disorders
300.81 Definition: Encompasses elements of somatization disorder (differentiated and undifferentiated), conversion disorder, pain disorder, hypochondriasis, body dysmorphic syndrome, and somatoform disorder NOS as they relate to patients in primary care settings. Specifically, refers to patients with: (1) several (more than three) vague or exaggerated symptoms in, often, different organ systems, and (2) a chronic course (i.e., a history of such symptoms for more than two years). (N.B. This chapter deals with patients in the primary care setting. The strict diagnostic criteria of the DSM-IV are frequently not useful in people with unexplained symptoms, and instead the focus has been placed on the practical aspects of management which have been shown to improve functional activity.) Goals of the care process: 1. Identify patients at risk of developing a physical symptom in response to an emotional stressor or difficult life situation 2. Identify methods to identify patients who have developed a physical symptom in response to an emotional stressor or difficult life situation a. Identify symptom complexes consistent with somatization b. Offer a strategy for evaluating physical complaints which are not clearly related to physical ailments but are serious in nature c. Offer a diagnostic testing strategy which optimizes use of health care resources 3. Initiate treatment using strategies known to be effective 4. Monitor for improvement in function and well-being 5. Continue surveillance for concomitant conditions that are of a serious nature but may be overlooked because of patients previous history of somatization 6. Avoid iatrogenic harm Rules of Thumb:
Age Frequency of somatic symptoms Frequency of multiple symptoms over two years Most common symptom 1-10 Common 11- 25 Common 25-40 Common 40-65 Common >65 Common
Rare
Uncommon Headache Nausea Chest pain Fatigue
Uncommon
Uncommon
Uncommon
Abdominal pain Headache
Joint pain Arm/leg pain Headache Bloating
Arm/leg pain Headache Bloating
Abdominal pain Bloating Palpitations
Overview:
Many people manifest non-physical illness as somatic complaints. Commonly expressed symptoms such as headache, nausea, chest pain or fatigue, are often stress related and in some office settings as many as 80% patients present with complaints that have no physical findings which correlate with symptoms. If a physician spends his or her energy looking for disease where none exists, what results is wasted money, wasted time, and increased frustration 1 Patients who seek care for somatic complaints in a pathologic manner constitute a group which, if considered a single disease, would have a prevalence of 1.2 million Americans potentially afflicted in the general population with as many as 22% of patients in an office waiting room afflicted, including 5% children at the physicians office and a larger number of adolescents. 2 - 4. The care of these patients can cost as much as 9 times as that of caring for patients who are unaffected. Despite using excessive healthcare dollars, these patients report higher levels of disability and suffering than their peer group.5 Physicians do not find care of these patients rewarding, either. They report increased frustration and a decreased sense of job satisfaction when engaged in the care of a disproportionate number of patients reporting multiple unexplained symptoms.1,6,8 There is a paucity of evidence-based recommendations regarding the identification, evaluation, and management of these patients. In part, this is because many people, either prior to seeking physician input or after interpretation by a professional, have the awareness to realize that their symptoms are not related to a serious illness. Logistically, it is difficult to design and investigate interventions targeted at patients lacking this insight. These recommendations are based on anecdotal evidence, limited small studies, and expert opinion. In addition, patients who interpret stressful situations with physical symptoms are not immune to serious illness. This in no way should preclude adequate investigation of worrisome symptoms particularly if they are relatively new or incompletely evaluated by the previous care provider. Chief Complaint: Typically suspicion will be aroused by multiple symptoms, recurrent visits for the same or similar symptoms, or the shear amount of clinical information gathered over time with the dearth of diagnoses made. Additionally complaints regarding food sensitivity, chronic fatigue, or fibromyalgia should trigger concern Vitals: Initial and subsequent visits: At a minimum age, gender, weight/height (BMI) should be obtained. In addition, based on the patients complaint, pulse, temperature, blood pressure, respiratory rate and/or pulse oximetry reading should be noted. Time permitting, through chart review the provider should review the last 6 months worth of visits and any consultation, diagnostic results, or other available data prior to going into the room as well.
History of Present Illness (New complaint): Patient should be allowed to voice symptoms in an open-ended manner, encouraging a description of symptomatology and a discussion of patient fears and concerns. Clarifying questions should lead patient to characterize the complaint in the standard manner (timing, location, radiation, quality, severity, precipitants, and relievers of pain, as well as any associated
symptoms) but care should be avoided not to lead the patient into a description that fits a known diagnosis. Clues include: amplification of common symptoms such as chest pains associated with premature atrial contractions, knowledge that the patient is from a family in stress, knowledge that the patient stands to benefit from secondary gain associated with the illness, and a patient self report of dissociative type symptoms. The clinician should always bear in mind that serious illness can co-exist with somatization. (SOR - C) 1,7
Common Symptomatic Organ System
Common Symptoms Reported Vomiting Abdominal pain Nausea Bloating and excessive gas Diarrhea Food intolerances Diffuse pain (i.e., "I hurt all over.") Pain in extremities Back pain Joint pain Pain during urination Headaches Shortness of breath at rest Palpitations Chest pain Dizziness Amnesia Difficulty swallowing Loss of voice Deafness Double or blurred vision Blindness Fainting Difficulty walking Seizures (pseudoseizures) Muscle weakness Difficulty urinating Burning sensations in sexual organs Dyspareunia Painful menstruation Irregular menstrual cycles Excessive menstrual bleeding Vomiting throughout pregnancy Vague "food allergies" Atypical chest pain Temporomandibular joint syndrome "Hypoglycemia" Chronic fatigue syndrome Fibromyalgia Vague "vitamin deficiency" Premenstrual syndrome Multiple chemical sensitivity
Commonly Ignored Red Flags Requiring Further Clarification Symptoms: Risk factors for pancreatic cancer, weight loss, Signs: Murphys sign,
Gastrointestinal symptoms
Pain symptoms
Symptoms: Risk factors for cancer, weight loss, fevers, Signs: Diminished strengths, physiologic deficits, Speech deficits Symptoms: Risk factors for heart failure, weight loss, fevers Signs: Abnormal cardiac or pulmonary exam
Cardiopulmonary symptoms
Pseudoneurologic symptoms
Symptoms: Risk factors for cancer, weight loss, fevers, Signs: Diplopia, Diminished strengths, physiologic deficits, Speech deficits
Reproductive organ symptoms
Symptoms: Risk factors for sexually acquired infection, weight loss, fevers Signs: Abnormal GU exam
Syndromes
Symptoms: Risk factors for cancer, weight loss, fevers
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Inquire About Risk Factors for Somatization: Consider when suggested by 1) A history of unexplained symptoms 2) Previous unrevealing work-up of serious symptoms 3) a sense by the treating physicians that the symptoms are not reflective of a physical ailment 4) Multiple symptoms seemingly unrelated or 5) presence of risk factor (SOR - C) 1
Risk Factor Disorder of mood (depression) Disorder of affect (anxiety) Obsesive-compulsive disorder Substance abuse Survivor of sexual abuse Key Signs or Symptoms Fatigue, aches and pains, palpitations, dizziness and nausea. Chest pain, palpitations Amplification of bodily imperfections Problems with work Pelvic pain, dyspyrunia Organic Illness of Which to be Mindful Thyroid disorder Thyroid disorder Anorexia and/or bulemia Addiction Pregnancy, infection
Follow organized diagnostic process for suspected somatoform symptoms (SOR - C): 1
Stage of Diagnosis Process Strategy Focus on complaint, use open ended technique, ask clarifying questions Perform physical exam of affected area, no matter how unlikely the complaint is to be manifested in a physical finding Explain findings and likely interpretation to patient Attention to previous evaluations Avoid repetition where possible Reassure patient of the likely benign nature of the illness Focus on simple, inexpensive tests first Avoid repetition Schedule follow-up to discuss results Offer reassurance Offer explanation for symptoms Have patient repeat interpretation back to you prior to leaving Offer intervention to allow improvement Avoid expression Its all in your head
Evaluate for organic medical conditions.
Obtain excellent history and physical
Review previous visits and studies Order limited but appropriate studies
Offer interpretation of symptoms
Stage of Diagnosis
Process
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Evaluate for psychiatric conditions associated with somatic complaints (depression, anxiety disorders, substance abuse/dependence).
Screen for Depression
Screen for Anxiety disorder
Screen for substance abuse
Asking (1) "Over the past two weeks, have you ever felt down, depressed, or hopeless?" and (2) "Have you felt little interest or pleasure in doing things?" may be as effective as any instrument as an initial screen Child: Consider screening instrument such as Reynolds Child Depression Scale or Children's Depression Inventory Adolescent: The Center for Epidemiologic Studies Depression Scale for Children and Beck Depression Inventory are inexpensive and have been shown to be effective Adult: Beck Depression Inventory Scales is commonly used Post-partum: Edinburgh Postnatal Depression Scale Elderly: "Do you often feel sad or depressed?" may be as effective as any scale Children: Pediatric Symptom Checklist may be useful Adolescents and Adults: A validated web-based anxiety screened is available at http://mdao.vcc.com/wb%2Ddat/ A version of the CAGE questionnaire (Cut down on drinking, Annoyance with criticisms about drinking, Guilt about drinking, and using alcohol as an Eye opener.) can be used and modified for use for any drug and any age group. A positive answer should be pursued Avoid Its all in your head Acknowledge severity of illness Offer possibility of improvement Offer to maintain relationship and work with patient over time Discuss meaning of diagnostic label Regular, brief office visits key to successful management Therapeutic goal is to limit unscheduled phone calls and emergency department visits Frequency dictated by severity of condition and may need to be altered over time
Pursue a positive diagnosis of somatization.
Empathize with the patient
Discuss diagnosis
Schedule follow-up
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Return visits: General Principles: Targeted history to demonstrate attention to detail and identify medical/surgical conditions o Agreeing on the diagnostic process o Identify potential red flags in symptom complex, if none focus on function o Monitor changes in function over time Physical examination focused on symptoms Laboratory and imaging studies should be selected based on the history and physical examination. Focus therapy on function o Treat concomitant mental health disorder o Offer suggestions to improve lifestyle o Avoid overmedicalization o Avoid causing harm History of Present Illness (Follow-up visit): Allow patient to verbalize concerns. How have your symptoms interfered with your everyday life? Ask open-ended questions Physical: The physical exam is targeted at area of complaint. Do not underemphasize the power of the therapeutic touch If satisfied that symptoms are not due to physical cause, focus on function (SOR - C) 7 BATHE Technique:
Question Intent Background Affect Trouble Handle Sample Question "What is going on in your life?" "How do you feel about it?" "What troubles you the most about that situation?" "What helps you handle that?" "This is a tough situation to be in. Anybody would feel (down, stressed, etc.). Your reaction makes sense to me...
Empathy
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General Treatment Guidelines (SOR - C): 7,8 Monitor and comply with age appropriate health maintenance protocols. Attention to new complaints with particular attention to worrisome symptoms that are consistent with life threatening illnesses
Therapeutic Goal Treatment of concomitant depression Treatment of concomitant anxiety Treatment SSRI, TCA Notes Start low and go slow Anticipate side-effects Treatment does not affect underlying disorder Start low and go slow Anticipate side-effects Treatment does not affect underlying disorder Avoid long-term benzodiazepine use Reassures patients of likely benign nature and effect of time Have patient repeat interpretation back to you prior to leaving to assure understanding Reduces intensity and improves function in some patients Challenges illness beliefs May be helpful Many patients express concern regarding stigma Helpful with toxic family situation Enhances sense of well-being Creates focus on healthy behavior Should strive for 20 minutes daily and increase as tolerated Encourage pleasurable activities outdoors and with groups Limiting doctor shopping can take focus off of medical model Avoid follow-up prn, schedule visits to give patient permission to visit regardless of symptoms Minimize chronic symptoms, focus on function Use BATHE technique Hot and cold packs Bandages and poultices Lotions and salves Inexpensive nutritional supplements Inexpensive alternative medicine Discuss success or failure at follow-up Problem solve with patient Avoid Its all in your head Avoid excessive diagnostic testing Avoid expensive or potentially harmful treatments Avoid referrals to get patient out of office Avoid excessive attention to symptom
SSRI, newer agents
Treatment of illness beliefs
Offer explanation of symptoms to patient
Psychotherapy
Brief group therapy Family intervention General lifestyle Increase physical activity
Change leisure focus
Avoid overmedicalization of the symptoms
Limit number of physicians, schedule frequent follow-up
Prescribe benign symptom based remedies
Prescribe leisure activity Avoid causing harm Dont disregard symptoms Pursue diagnosis despite evidence that there is no physical cause
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Problem solving (SOR C): 7, 8

Problem Example Potential solution Set out with agenda to inquire about function from outset Use verbal cues to limit time (Ill wash up and do your exam now) Address patients emotions up front Be aware of your own emotions Sit and make eye contact Prepare for the Oh-by-the-way Indicate that visit is over and set plan for next visit Focus on improving function rather than cure Accept new symptom Limited work-up of new symptom Focus on function Follow accepted screening guidelines Work towards cure where possible but continue focus on function Monitor progression of disease using objective measures Focus on normal exam Can allow testing to occur over time for patient well-being Negotiate least invasive test Focus on benign treatments Focus on side effects of opiates Focus on possibility of addiction If opiates are used, move quickly to long acting and limit short acting Focus on physician needs (I need my sleep; I need to take care of others as well) Schedule more frequent visits Limit number of calls Encourage list making Communicate with staff to avoid iaotrogenic illness Have record available to ED staff Shorten visit interval Encourage list making
Fear of uncontrolled visits
Open ended question might extend visit until next day
Unrealistic goals Symptom substitution
Desire for complete resolution of symptoms Fatigue substitute for chest pain after institution of PPI therapy Chronic disease manifests over time or development of illness such as cancer
Presence or development of co-morbid conditions
Desire for diagnostic studies
Request for MRI for cephalgia
Desire for opiate analgesia
Trial of oxycodone from friend was effective
Excessive phone contacts
Calling after hours to discuss symptoms
Frequent ED visits
Multiple ambulance rides for chest pain
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Suggested for further reading: Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care physician. 2d ed. Westport, Conn.: Praeger, 1993. Barsky AJ. A 37-year-old man with multiple somatic complaints. JAMA 1997;278:673-9. Resources for patients: When you have chronic unexplained medical problems http://www.aafp.org/afp/20000301/1431ph.html Chronic pain: How to get relief http://familydoctor.org/551.xml Fibromyalgia: What is it and how to manage it http://familydoctor.org/070.xml Stress: How to cope better with lifes changes http://familydoctor.org/167.xml References: 1. Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: part I. Practical diagnosis. Am Fam Physician 2000;61:1073-8. 2. Allen L, Gara M, Escobar J, Waitzkin H, Silver R. Somatization A debilitating syndrome in primary care. Psychosomatics 2001; 42:63-67 3. Kreipe RE The biopsychosocial approach to adolescents with somatoform disorders. Adolesc Med Clin 2006; 17(1): 1-24 4. Silber TJ, Pao M. Somatization disorders in children and adolescents. Pediatr Rev 2003;24(8): 255 64. 5. Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB. Somatization in the community: relationship to disability and use of services. Am J Public Health 1987;77:837-40. 6. Lin EH, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991;6:241-6. 7. Servan-Schreiber D, Tabas G, Kolb R. Somatizing patients: Part II. Practical Management. Am Fam Physician 2000;61:1423-8,1431-2 8. Lutton ME. Sticking the landing: how to create a clean end to a medical visit. Fam Pract Manag. 2004 Jul-Aug;11(7):51-3. 9. Rief W, Heitmuller AM, Reisberg K, Ruddel H Why reassurance fails in patients with unexplained symptomsAnexperimental investigation of remembered probabilities. PLoS Med 3(8): e269. DOI: 10.1371/journal.pmed.0030269
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Tobacco Dependence: Primary and Secondary Prevention of Tobacco Related Illnesses

Rules of thumb:
Age % daily smokers Evidence supports screening for smoking (USPHSTF) 0-13 <1% No 8% Yes 13-18 23% Yes Ask Advise Assess Assist Arrange For recalcitrant smokers: Relevance, risk, rewards, roadblocks, repetition Risk of smoking initiation plateaus at age 22, 70% of current tobacco users want to quit 18-65 9% Unclear if previously negative Ask Advise Assess Assist Arrange For recalcitrant smokers: Relevance, risk, rewards, roadblocks, repetition Pulmonary benefits detectable in 3 months, cardiac benefits in 1 year >65
Primary preventive measures
Identification of patients at risk Provide information regarding harmful effects Encourage abstinence
Ask Advise Assess Assist Arrange
Justification
Tobacco use in some communities as high as 15% in 3rd grade
15% of 8th graders and 31% of 12th graders report recent smoking
Goals of the primary and secondary prevention process: 1. Identify patients at risk of beginning tobacco use and offer information and guidance regarding harmful effects of tobacco. 2. Identify patients who have begun tobacco use on a regular basis but who are not yet addicted and offer information and guidance regarding harmful effects of tobacco. 3. Identify patients who have used tobacco on a regular basis and who are addicted and assess willingness to quit, offer assistance, and arrange follow-up and support. 4. Monitor for continued abstinence, assist patient when relapse detected. Overview: Cigarette smoking remains the leading preventable cause of death in the United States, accounting for approximately 1 of every 5 deaths (438,000 people) each year. Tobacco use starts early with an estimated 3 percent of male middle school students using smokeless tobacco. The health care system has difficulty competing with the marketing budget for the tobacco industry. In 2005, cigarette companies spent $13.4 billion, or more than $40 million per day, on advertising and promotional expenses. This amounted to more than $50 for every person in the United States, or $320 for each adult smoker. Tobacco industry advertising and promotional expenditures more than doubled since 1998. Specific products are targeted towards members of
racial/minority communities and specific age groups. As an example, Marlboro is the cigarette brand preferred by 49 percent of smokers aged 12 to 17 years, followed by Newport (24 percent) and Camel (10 percent). These are the brands most heavily advertised in the United States. In addition, there is a bit of regional variation in smoking. The highest state estimates for cigarette smoking among men were in Kentucky (29.3 percent), Mississippi (29.1 percent), and Alabama (29 percent); the lowest estimates were in Utah (11.7 percent), California (18.5 percent), and Idaho (19.2 percent). When broken down by educational status, adults with a General Education Development (GED) diploma or 911 years of education have the highest rate of smoking (34 percent). Smoking rates are lowest for adults with an undergraduate college degree (11.7 percent) or a graduate college degree (8 percent). The Surgeon General has identified tobacco use and dependence as a chronic condition which often requires repeated interventions but can be effectively treated. Effective treatment relies upon the stages of change model, where people who must make a behavior change move from having no interest in making the change (precontemplation), to interest (contemplation), to making plans (preparation), to actually doing something (action). Taking advantage of this, even patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit. To do so, consistent identification, documentation, and treatment of every tobacco user seen in a health care setting is essential. The clinician should become comfortable with brief tobacco dependence treatment and should offer it to every patient who uses tobacco. There is a dose-response, and therefore multiple attempts in various settings should be used. In addition to counseling, numerous effective pharmacotherapies for smoking cessation now exist (see appendix). Except in the presence of contraindications, these should be used with all patients attempting to quit smoking. The first-line pharmacotherapies should be used initially but the two second-line pharmacotherapies have been identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective. Remember that relapse rates are high. About 60% will relapse in 3 months and 75% in 6 months, so ongoing monitoring and support is essential. Because it is estimated that 70% of the tobacco users will visit a physicians office at least once in a calendar year, it is important that the clinician become comfortable with assisting the patient to become abstinent of tobacco. Following is the approach recommended by the US Surgeon General. Preventive approach in younger children:
Preventive Strategy Line of Inquiry Initially and periodically Inquire about pre-smoking Inquire about exposure to environmental smoke, document on chart. environment Inquire about patient Begin at age 1012. Inquire about all forms of tobacco. tobacco use Periodically (typically at well child check). See below if tobacco use initiated Review environment Anticipate tobacco use Inquire about poor school performance, low aspirations, alcohol and other drug use, school absences, and anticipated dropping out. Explore the teens knowledge of short-term risks of smoking (such as cough and Assess patients ability to shortness of breath) and chewing tobacco (such as gingivitis and bad breath). resist pressure Clarify misperceptions Reinforce and rehearse refusal skills. Positively identify abstinence as goal. Reward abstinence Encourage parents of at risk children to establish reward. University of South Alabama, Department of Family Medicine June 30, 2008 189
Preventive approach in teens and older:

Action Initially and periodically: Line of Inquiry Do you use tobacco? Or Ask about smoking and tobacco use (if no, inquire periodically; if not started by 22, unlikely to begin) Many people use tobacco, do you? And, if so How much do you use and how often? (quantify) Operationalization Implement an office-wide system that ensures that tobacco-use status is obtained and recorded for every patient at every office visit. Include in collected vital signs data. Place tobacco-use status stickers on patient chart.
Indicate smoking status using computer reminder systems. At every visit if identified as a user and, at a minimum annually, in context of wellness exam: Be clear. (I think it is important for you to quit smoking now, and I will help you.) Speak strongly. (As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.) Personalize your advice. (Youve already had one heart attack.) Mention the impact of smoking on children or others in the household. (You know your children need you.) Assess at every visit and optimally 3 times a year. Assess willingness to quit Are you ready to discuss quitting? If no, offer brief information and repeat at next visit. If yes, offer assistance. Record conversation and patients response in medical record. Use information at next visit to further argument for quitting.
Advise tobacco users to quit
Record conversation and patients response in medical record. Use information at next visit to further argument for quitting.
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If user remains in pre-contemplative phase incorporate portions of this in every visit:

Discussion Topic Line of Inquiry Explore why quitting is personally relevant, being as specific as possible. Relevance Move discussion to patients disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation). Explore potential negative consequences of tobacco use. Suggest and highlight those that seem most relevant to the patient. Emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples of risks are: Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, and increased serum carbon monoxide. Long-term risks: Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability, and need for extended care. Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in children of tobacco users; increased risk for low birth weight, Sudden Infant Death Syndrome, asthma, middle ear disease, and respiratory infections in children of smokers. Ask the patient to identify potential benefits of stopping tobacco use. Suggest and highlight those that seem most relevant to the patient. Examples of rewards: Improved health. Food will taste better. Improved sense of smell. Save money. Feel better about yourself. Home, car, clothing, breath will smell better. Can stop worrying about quitting. Set a good example for children. Have healthier babies and children. Not worry about exposing others to smoke. Feel better physically. Perform better in physical activities. Reduced wrinkling/aging of skin. Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Typical barriers might include: Withdrawal symptoms. Fear of failure. Weight gain. Lack of support. Depression. Enjoyment of tobacco. Repeat elements every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. June 30, 2008 191
Risks
Rewards
Roadblocks
Repetition
When user expresses willingness to move to action (contemplative, preparation phase):

Review previous quit attempts what helped, what led to relapse. Anticipate challenges, particularly during the critical first few weeks, including nicotine withdrawal. Offer advice on successful quitting. Total abstinence. Alcohol is associated with relapse. Others smoking in household pose a problem. When arranging follow-up Identify if intensive support will be necessary. Number of quit attempts Intensity of tobacco use Period of time of use At follow-up visit Congratulate success. Review benefits accrued. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Remind patient that a lapse can be used as a learning experience. Consider multimedia resources for modeling behaviors. Have patient set a quit date, ideally within 2 weeks. Have patient inform friends, family, and coworkers of plans to quit, and ask for support. Have patient remove cigarettes from home, car, and workplace and avoid smoking in these places. Contact patient to remind to quit. Offer access to community resources. Initiate class, assign buddies. Offer pharmacologic assistance (see appendix). Make referral to intensive support if necessary and available to patient.
Assist patient with a quit plan
Arrange follow-up and support
TimingFollow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated. Actions during follow-up contact Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Encourage use of support. Consider use or referral to more intensive treatment.
At every follow-up regularly for the first 6 months and periodically for at least five years, ex-smokers should be assessed for smoking status and counseled to avert relapse:
Line of Inquiry Inquire about support Inquire about withdrawal symptoms Action if Positive If limited support, refer to community resources. If symptoms, consider changing pharmacologic treatment. Encourage physical activity. Reassure that it is temporary. Emphasize healthful choices. Consider pharmacotherapy known to delay weight gain. Refer to intensive program. Reassure these are common feelings. Recommend reward activities. Query about use. Reinforce abstinence. June 30, 2008 192
Inquire about weight gain
Flagging motivation, feel deprived
Components of an intensive intervention:

Assessment Assessments should ensure that tobacco users are willing to make a quit attempt using an intensive treatment program. Other assessments can provide information useful in counseling (e.g., stress level, presence of comorbidity). Multiple types of clinicians are effective and should be used. One counseling strategy would be to have a medical/health care clinician deliver messages about health risks and benefits and deliver pharmacotherapy, and nonmedical clinicians deliver additional psychosocial or behavioral interventions. Because of evidence of a strong dose-response relationship, the intensity of the program should be: Session lengthlonger than 10 minutes. Number of sessions4 or more sessions. Total contact timelonger than 30 minutes. Either individual or group counseling may be used. Proactive telephone counseling also is effective. Use of adjuvant self-help material is optional. Followup assessment intervention procedures should be used. Counseling and behavioral therapies should involve practical counseling (problem solving/skills training) and intra-treatment and extra-treatment social support.
Program clinicians
Program intensity
Program format Type of counseling and behavioral therapies
Every smoker should be encouraged to use pharmacotherapies endorsed in the guideline, except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations (e.g., pregnancy, adolescents). Pharmacotherapy The clinician should explain how these medications increase smoking cessation success and reduce withdrawal symptoms. The first-line pharmacotherapy agents include: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. Intensive intervention programs may be used with all tobacco users willing to participate in Population such efforts. Counseling to Prevent Tobacco Use and Tobacco-Caused Disease U.S. Preventive Services Task Force (USPSTF) This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on counseling to prevent tobacco use and tobacco-caused disease and the supporting scientific evidence, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition.
PHARMACOTHERAPY: The use of pharmacotherapy is a key part of a multicomponent approach to assisting patients with their tobacco dependence. The following tables address the clinical use of pharmacotherapies for tobacco dependence and some of the more common questions and concerns regarding pharmacotherapy.
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Clinical guidelines for prescribing pharmacotherapy for smoking cessation:

Who should receive pharmacotherapy for smoking cessation? What are the first-line pharmacotherapies recommended? What factors should a clinician consider when choosing among the five first-line pharmacotherapies? Are pharmacotherapeutic treatments appropriate for lighter smokers (e.g., 10-15 cigarettes/day)? What second-line pharmacotherapies are recommended? When should second-line agents be used for treating tobacco dependence? Which pharmacotherapies should be considered with patients particularly concerned about weight gain? Are there pharmacotherapies that should be especially considered in patients with a history of depression? Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease? All smokers trying to quit, except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations: those with medical contraindications, those smoking fewer than 10 cigarettes/day, pregnant/breastfeeding women, and adolescent smokers. All six of the FDA-approved pharmacotherapies for smoking cessation are recommended, including varenicline (Chantix), bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. Because of the lack of sufficient data to rank-order these six medications, choice of a specific first-line pharmacotherapy must be guided by factors such as clinician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain). If pharmacotherapy is used with lighter smokers, clinicians should consider reducing the dose of first-line nicotine replacement therapy (NRT) pharmacotherapies. No adjustments are necessary when using varenicline or bupropion SR. Clonidine and nortriptyline. Consider prescribing second-line agents for patients unable to use first-line medications because of contraindications or for patients for whom first-line medications are not helpful. Monitor patients for the known side effects of second-line agents. Bupropion SR and nicotine replacement therapies, in particular nicotine gum, have been shown to delay, but not prevent, weight gain.
Bupropion SR and nortriptyline appear to be effective with this population.
No. The nicotine patch in particular is safe and has been shown not to cause adverse cardiovascular effects. Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of pharmacotherapy or who desire long-term therapy. A minority of individuals who successfully quit smoking use ad libitum NRT medications (gum, nasal spray, inhaler) long term. The use of these medications long term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication. However, varenicline is not indicated for use beyond 24 weeks. Yes. There is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increases long-term abstinence rates over those produced by a single form of NRT.
May tobacco dependence pharmacotherapies be used longterm (e.g., 6 months or more)?
May pharmacotherapies ever be combined?
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Suggestions for the clinical use of pharmacotherapies for smoking cessation:

First-line Pharmacotherapies (Approved for use for smoking cessation by the FDA) Precautions/ Pharmacotherapy ContraSide Effects Dosage Duration Availability indications 150 mg QAM History of 7-12 weeks for 3 days, then Generic Insomnia seizure maintenance 150 mg BID (prescription Bupropion SR up to 6 History of Dry mouth (Start 1-2 wks only) months eating disorder before quitting) 1-24 cigs/day-2 Mouth soreness mg gum (up to 24 pieces/day) Up to 12 Generic Dyspepsia Nicotine Gum weeks (+?) (OTC only) 25+ cigs/day-4 Nausea mg gum (up to 24 pieces/day) Local irritation Nicotrol Inhaler 6-16 Up to 6 of mouth and (prescription Nicotine Inhaler cartridges/day months (+?) throat only) 1st cigarette <30min in AM: 4 mg PO Q1-2 hr x 6 wks, Q 2-4 hr x 3 wks, Mouth soreness Q 4-8 hr x 3 wks; use >8 Dyspepsia pieces/day 12 weeks (+?) Generic Nicotine Lozenge during initial Nausea 6wks 1st cigarette >30min in AM: Same schedule, using 2 mg dose Nicotrol NS 3-6 months Nicotine Nasal Nasal irritation 8-80 doses/day (prescription (+?) Spray only) 21 mg/24 hrs x 4 weeks then Local skin 14 mg/24 hrs x reaction 8 weeks (+?) Generic Nicotine Patch 2 weeks Insomnia then 7 mg/24 hrs x 2 weeks Nausea (30%) Days 1-3: 12 wks 0.5 mg QD Chantix weekly Preexisting Agitation Days 4-7: An additional dose packs and behavioral 0.5 mg BID 12 wks may Varenicline continuing disorders Depression Remainder of be prescribed monthly packs Suicidal 12 wks: 1 mg to maintain ideation BID abstinence University of South Alabama, Department of Family Medicine June 30, 2008
Cost/day
$1.99
$2.06 for 10, 2-mg pieces $2.35 for 10, 4-mg pieces $10.57 for 10 cartridges
$4.44 for 8 pieces
$37.58 for 20 doses
$2.57
$4.46
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Second-line Pharmacotherapies (Not approved for use for smoking cessation by the FDA) Pharmacotherapy Precautions/ ContraSide Effects Dosage Duration Availability Cost/day indications Oral generic Dry mouth Clonidine $0.50 Rebound hypertension Drowsiness 0.2-2.4 mg/day 3-10 weeks Transdermal (as BP allows) Dizziness Postural Catapres-TTS hypotension (prescription $3.07 Sedation only) Nortriptyline Nortriptyline Sedation Risk of HCI-generic $0.43 for 75-100 mg/day 12 weeks arrhythmias (prescription 75 mg Dry mouth only) a. The information contained within this table is not comprehensive. Please see package insert for additional information. b. Prices based on least expensive option at Drugstore.com March 2008. c. OTC = Over the Counter.
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Proposed smoking cessation algorithm from Okuyemi et al.
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Summary of Recommendations: The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Rating: Level A recommendation. Rationale: The USPSTF found good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. Although most smoking cessation trials do not provide direct evidence of health benefits, the USPSTF found good evidence that smoking cessation lowers the risk for heart disease, stroke, and lung disease. The USPSTF concluded that there is good indirect evidence that even small increases in the quit rates from tobacco cessation counseling would produce important health benefits, and that the benefits of counseling interventions substantially outweigh any potential harms. The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke. Rating: Level A recommendation. Rationale: The USPSTF found good evidence that extended or augmented smoking cessation counseling (5-15 minutes) using messages and self-help materials tailored for pregnant smokers, compared with brief generic counseling interventions alone, substantially increases abstinence rates during pregnancy, and leads to increased birth weights. Although relapse rates are high in the post-partum period, the USPSTF concluded that reducing smoking during pregnancy is likely to have substantial health benefits for both the baby and the expectant mother. The USPSTF concluded that the benefits of smoking cessation counseling outweigh any potential harms. The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents. Rating: Level I recommendation. Rationale: The USPSTF found limited evidence that screening and counseling children and adolescents in the primary care setting are effective in either preventing initiation or promoting cessation of tobacco use. As a result, the USPSTF could not determine the balance of benefits and harms of tobacco prevention or cessation interventions in the clinical setting for children or adolescents.
Resources for patients:

Smoking, steps to help you break the habit http://familydoctor.org/161.xml ACS: Guide to quitting smoking http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp Online smoking cessation support http://www.dartmouth.edu/~nobacco/LFSF/smokersmain.htm Smoking cessation and abstinence resource for teens http://www.mededu.miami.edu/Tobacco/main
References used for preparation of this chapter that also offer additional resources: Okuyemi KS, Nollen NL, Ashluwalia JS. Interventions To Facilitate Smoking Cessation. Am Fam Physician 2006;74:262-71, 276. U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Related Diseases: Recommendation Statement. November 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm CDC National Center For Chronic Disease Prevention and Health Promotion Tobacco Information and Prevention Source. http://www.cdc.gov/tobacco/data.htm U.S. Public Health Service Treating Tobacco Use and Dependence. Summary, June 2000. http://www.surgeongeneral.gov/tobacco/smokesum.htm American Academy of Pediatrics. Tobaccos Toll: Implications for the Pediatrician. Pediatrics 2001. 107 (4), 794-798, accessed at http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b107/4/794
Additional Reading: Rustin T. Assessing Nicotine Dependence. Am Fam Phys 2000 62(3) 585-590, accessed at http://www.aafp.org/afp/20000801/579.html Appendixes from U.S. Public Health Service Treating Tobacco Use and Dependence. Summary, June 2000.
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Upper Respiratory Infection

465.9 Definition Upper respiratory infection or common cold is a self-limited illness usually lasting less than two weeks. Associated symptoms include cough, rhinorrhea and low grade fever. Goals: 1. 2. 3. 4. Determine whether symptoms of serious illness are present. Determine whether complicating factors exist. Determine whether symptoms or illnesses other than then URI are present. Provide patient education about the prevention and treatment of URI.
Overview URI is the most frequent acute illness in the United States. It is the leading cause of morbidity and doctor visits with a total economic burden close to $40 billion per year. School-age children average 5 7 episodes per year, adults 2 3 per year. Viruses are the pathogens most frequently associated with URI. Transmission is by direct contact, aerosols and fomites.
Chief complaint: Typically the complaint is I have a cold. General approach to history The history is focused on assessing symptoms and determining the presence of serious illness, complicating factors or illness other than viral URI. Age Note the patients age. Seriousness of symptoms is often dependent on the patients age. Temperature Have you had a fever? Where was the temperature taken? (Orally, rectally, axillary) Symptoms of serious illness Symptoms of respiratory distress retractions, dyspnea, rapid breathing Decrease in activity inconsolable, excessive sleeping, refusal to eat Ask about vomiting and urination See table below for age related symptoms
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Symptoms of Serious Illness by age group < 3 months 3 months 3 years 4 years - adult Respiratory distress Respiratory distress Respiratory distress - grunting - retractions - retractions - retractions - cyanosis - cyanosis - cyanosis - marked dyspnea - moderate to severe - stridor with croup - rapid respirations dyspnea symptoms not relieved - shallow respirations - rapid respiratory rate by conservative - difficulty swallowing - shallow respirations measures - choking - difficulty swallowing - stridor with croup - choking symptoms not relieved - drooling by conservative - dysphonia measures - feeling that throat is closing Responsiveness, activity Responsiveness, activity Responsiveness, activity - flaccid - unresponsive - altered mental status - lethargic - decreased level of - decreased level of - difficult to awake or consciousness consciousness keep awake - difficult to awaken or - markedly decreased - weak cry, weak suck keep awake activity - inconsolable - markedly decreased - refusing to eat - poor feeding activity - very lethargic - very lethargic - excessive sleepiness - excessive sleepiness - difficult to awaken or - inconsolable keep awake - weak suck, weak cry - unresponsive (infants) - poor feeding Dehydration, vomiting Dehydration, vomiting Dehydration, vomiting - > 8 hrs without wet - no urine >8 hrs if <1yr - no urine >12 hrs diapers - no urine >12 hrs if >1yr Meningeal signs Meningeal signs - stiff neck - stiff neck - persistent vomitting - persistent vomiting - severe headache Other Other Other - petechial or purpuric - petechial or purpuric - increased urinaton rash rash with decreased intake - petechial or purpuric rash
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Symptoms of illness other than viral URI Lower respiratory tract infection barky cough, fever >72 hrs, wheezing) Sinusitis nasal discharge > 2 weeks, facial pain Pharyngitis sorethroat, fever with exposure to strep. Pharyngitis Epiglotitis hoarsness, stridor, drooling Influenza cough, fever, myalgia Illnesses to be Differentiated from URI Diagnosis Strep. Pharyngitis Symptoms - sudden onset of sore throat - exudative tonsils - fever - hoarseness - otalgia - otorrhea - hearing loss - ear popping or fullness - dizziness - URI symptoms > 7 days - 2 or more of the following present > 7 days after onset: - sinus tenderness - facial pain - fever > 102 - past history of sinusitis - tooth pain - ear pressure - known anatomical nasal blockage - deep cough - deep mucous - fever - pleuritic chest pain - wheezing - rhonchi - mild dyspnea - chest tightness - hoarseness - severe sore throat - severe dysphagia - stridor - drooling Caution Severe dysphagia, drooling
Otitis media
Sinusitis
Pneumonia / Bronchitis
If person has asthma, lung disease or is a smoker
Epiglottitis
Needs immediate evaluation
Continued
Illnesses to be Differentiated from URI (continued) Diagnosis Mononucleosis Symptoms - severe sore throat - many enlarged lymph nodes - fatigue - prolonged fever - fever - myalgia - headache - sore throat - cough, chest tightness - EENT pruritis - watery rhinorrhea - sneezing - seasonal changes - FHx of allergies - sensitivities to specific allergens - atopy - cough - wheezing - dyspnea - chest tightness - bronchitis - prodrome typical of URI for several days - severe cough follows prodromal period - (children) whoop after paroxysm of severe cough - (adolescents/adults) cough without whoop but with gagging or vomiting. - culture or DFA positive Caution If symptoms severe, treat for mono.
Influenza
May be at risk for pneumonia
Allergic Rhinitis
Asthma
Patients may not know they have asthma. Viral URI may be a trigger. Excessive use of inhaler may indicate that further evaluation is needed.
Pertussis
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Are complicating factors present? Elderly or newborn Pregnancy Immunocompromised Chronic illnesses (ie. Asthma, COPD, sickle cell disease, renal failure) Physical Exam The physical exam is primarily to identify signs of serious illness or illnesses other than URI. Vitals Note patients age, temperature, change in weight by reviewing chart prior to entering the room. General Observe responsiveness. Is the child consoleable? HEENT Observe the conjunctiva for erythema. Inspect the tempanic membranes (erythema, drainage, effusion). Inspect the nasal passages for congestion and discharge. Inspect the posterior pharynx (erythema, exudates, tonsillar hypertrophy). Neck - Assess suppleness and note any lymphadenopathy Lungs Observe breathing effort (respiratory rate, grunting, retractions, dyspnea), cyanosis and drooling. Auscultate for wheezing or stridor. Heart heart rate, capillary refill Abdomen n/c Extremities - n/c Diagnostic Studies No diagnostic studies are needed in absence of signs and symptoms of serious illness or illnesses other than URI.
Management Prevention Hand washing is the most effective way to prevent the spread of URI. There is no medical literature to support Echinacea in the prevention of URI. Non-pharmacologic Maintain adequate rest, nutrition and hydration. Warm humidified air (vaporizer) may decrease nasal stuffiness and loosen nasal discharge. Salt water gargles sooth sore throats. (homemade: tsp salt dissolved in 8oz water). Pharmacologic Because colds are viral infections, antibiotics will not cure or shorten their course. Antibiotics are only effective in the treatment of bacterial infections. Unnecessary use of antibiotics can lead to development of antibiotic-resistant bacterial strains. Do not use aspirin containing products in children under age 21. Zinc gluconate (not acetate) may decrease the duration of URI if taken within the first 24hrs of symptoms. It has no effect on the severity of symptoms. There are no consistent studies to advocate the use of vitamins C and E in the therapy of URI. Cough and cold preparations do not change the course or duration of URI, they only help to lessen symptoms.
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Cough antitussives (dextromethorphan, codeine, Tessalon), expectorants (guaifenesin) Nasal congestion decongestants (pseudoephedrine/phenylephrine) Sneezing/rhinorrhea antihistamines (dyphenhydramine, loratadine) Sore throat lozenges, Chloraseptic spray Fever, muscle aches acetaminophen or ibuprofen The Food and Drug Administration (FDA) has recommended that over- the-counter cough and cold medicines not be used in infants and children < 2 y.o.
Suggested for further reading Chapter 26. Upper Respiratory Infections in Current Diagnosis & Treatment in Family Medicine. Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis. Lange Medical Books/McGraw-Hill publishing. 2004. Ressel, Genevieve., Practice Guidelines. Principles of Appropriate antibiotic use: Part II. Nonspecific Upper Respiratory Infection. Am Fam Physician. 2001 Aug 1; 64(3). Accessed online at http://www.aafp.org/afp/20010801/practice.html August 1, 2001. Del Mar, Chris and Paul Glasziou. Upper Respiratory Infection. Am Fam Physician. 2002 Dec 1 66(11). Accessed online at http://www.aafp.org/afp/980800ap/dick.html December 1, 2002. References Viral Upper Respiratory Infection in Adults and Children. Institute for Clinical Systems Improvement. Ninth Edition. May 2004.
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Urinary Tract Infection

Acute cystitis 595.0 Pyelonephritis 590.80 Definition:
599.0
A urinary tract infection is infection of the lower urinary system (cystitis) or upper urinary system (pyelonephritis). The term UTI is often used in reference to cystitis/stricty lower urinary tract infection. This will be the focus of this chapter. Overview: UTIs are categorized as complicated or uncomplicated based on certain criteria, this then dictates management of the infection. Both will be discussed in more detail in this chapter. Characteristics of both types are listed below: Uncomplicated UTI Normal genitourinary tract Unobstructed No recent instrumentation Symptoms confined to lower genitourinary tract Adult Female Acute cystitis in well controlled diabetic female having no complications of DM Complicated UTI EVERYTHING not listed above Including, but not limited to: o Male o Age (children, elderly) o Pregnancy o Abnormality of urinary tract (functional or anatomical) o Urolithiasis o Indwelling catheters or recent catheterization o Recent surgery involving GU tract o Diabetes mellitus o Renal insufficiency o Immunosuppression o Nosocomial infection o Recent antibiotic use
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Uncomplicated UTI Uncomplicated UTI is one of the most common diagnoses in the USA. 10% of women per year will experience a UTI, and 60% of women experience at least 1 episode during their lifetime. The peak incidence is in sexually active women between the ages of 18 and 24 years old. In this population 75-90% of infections are related to sexual intercourse with the frequency of infection directly correlating to frequency of intercourse. There has also been shown a correlation with spermicide use for birth control and UTIs. The frequency of spermicide use has been shown to correlate with infection frequency independent of intercourse frequency. Postmenopausal women experiencing acute cystitis likely had frequent infections when younger, however a complicated UTI must be ruled out in this population. Repeated epidemiologic studies have shown there is no evidence that any of the following behaviors create increased or decreased risk for development of acute cystitis. These include oral contraceptive use, condom use, post-coital voiding, type of underwear, personal hygiene after voiding or bowel movement, or bath vs. shower. The natural history of uncomplicated urinary tract infections has been shown through multiple placebo controlled trials. Spontaneous clinical and microbiologic resolution occurs in about half of patients by 3 days 6 weeks. Untreated acute uncomplicated UTIs do not have any long-term sequellae. However, they cause significant life disruption, therefore leading patients to seek medical care for faster resolution of the infection and relief of symptoms. Approach to Patient History This is the most important part of diagnosing an acute uncomplicated UTI. The following elements in the history have been shown to have a 90% positive predictive value in diagnosing acute cystitis: dysuria, urinary frequency, urinary urgency, new onset, absence of vaginal diacharge. Other common findings in the history may include suprapubic pain, hematuria, new urinary incontinence. Physical Exam This is usually unremarkable. The patient may have some suprapubic tenderness to palpation in the abdominal exam. Look for fever or CVA tenderness as these would indicate likely pyelonephritis. Also, if any vaginal complaints, a pelvic exam should be included in the exam. Laboratory Studies These studies should be used to reinforce a clinical diagnosis. Laboratory studies have failed to predict clinical outcomes in uncomplicated UTIs. Urinalysis dipstick may have positive either nitrite, leukocyte esterase, or both; may have protein or blood present *The sensitivity and specificity of the urine dipstick varies somewhat with the setting and population, as does its recommended interpretation. Women with classic urinary tract infection (UTI) symptoms have a high pretest probability of infection, and use of the dipstick adds little to the diagnosis. In women with nonspecific urogenital symptoms, positive or negative dipstick results may require a backup urine culture depending on the
clinical situation. In low-risk patients with a low pretest probability of UTI, the urine dipstick alone is useful to exclude infection if both nitrites and leukocyte esterase are negative. [Strength of recommendations: C, all recommendations based on meta-analyses of cohort studies not addressing patient-oriented outcomes]1 Urinalysis microscopic this evaluation for the presence of WBCs or bacteria is not needed or recommended. Urine culture routine culture in uncomplicated UTI is not needed or recommended, it is negative in 10-20% of cases. Culture is appropriate and recommended with initial treatment failure, early recurrence, pyelonephritis, or an atypical presentation. In these cases, the infection would then qualify as complicated UTI.
Management Studies have shown that women having experienced previous UTIs are >90% accurate in selfdiagnosis of a UTI. These plus other studies have led to recommendations and guidelines that empiric antibiotic therapy can and should be initiated in cases of acute uncomplicated cystitis. This can even be implemented by phone triage in patients that have experienced previous UTIs. Symptom resolution occurs in 6 hours in over 50% of patients and by 48 hours in greater than 90% of patients. Empiric antibiotic choice should be guided by local resistance patterns and patient allergy, however general guidelines are published. Infectious Diseases Society of America current guidelines for empiric antibiotic therapy: Drug Dose Frequency Duration** TMP/SMX 160/800mg BID 3 days Trimethoprim 160mg BID 3 days Fluroquinolones varies varies 3 days Fosfomycin 3 grams QD 1 day Other Nitrofurantoin 100mg BID 7 days **Note: postmenopausal women with no other complicating factors should have 7 days of therapy. First Line Alternatives Bacteria associated with uncomplicated UTIs: Escherichia coli (Gram neg bacilli) 75-95%; 80-85% Staphylococcus saprophyticus (Gram pos cocci) 5-10% Other Enterobacteriaceae (Klebsiella, Proteus) (Gram neg bacilli) occasional Group B streptococcus (Gram pos cocci) pregnant, diabetic Proteus mirabilis (Gram neg anaerobe) postmenopausal
Diagnosis and Management of Uncomplicated Urinary Tract Infections SUSAN A. MEHNERT-KAY, M.D.,
American Family Physician August 1, 2005 Volume 72, Number 3
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation A three-day course of trimethoprim-sulfamethoxazole (TMP/SMX; Bactrim, Septra) is recommended as empiric therapy of uncomplicated urinary tract infections (UTIs) in women, in areas where the rate of resistance Escherichia coli are less than 20 percent. Fluoroquinolones are not recommended as first-line treatment of uncomplicated UTIs in order to preserve their effectiveness for complicated UTIs. Use of beta-lactam antibiotics is not recommended for the routine treatment of uncomplicated UTIs because of limited effectiveness. For treatment of uncomplicated urinary tract infections in older women, consider short or longer (three to 10 days) courses of antibiotics.
Evidence rating C
References 24
24
C B
24 25
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For more information about the SORT evidence rating system, see page 363 or http://www.aafp.org/afpsort.xml.
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Diagnosis and Management of Uncomplicated Urinary Tract Infections SUSAN A. MEHNERT-KAY, M.D.,
American Family Physician August 1, 2005 Volume 72, Number 3
Non-Pharmocologic Management Cranberry Juice: A recent Cochrane review showed insufficient evidence to recommend cranberry juice to treat/manage UTIs. Increase Fluid Intake: there is no evidence of benefit, and speculations of negative effect due to decreased antimicrobial concentrations. Prevention Modifiable behavior i.e. discontinue spermicide use Antimicrobial prophylaxis (95-100% efficacy) Long-term low dose continuous daily or every-other-day (at bedtime); 6 mos or 1-2 years Postcoital First line nitrofurantoin or TMP/SMX Fluroquinolones RESERVED first line intolerable or resistant organisms while using first line
Nonantimicrobial strategies Cranberry or lingonberry juice or products (20-30% efficacy) Cochrane Database some evidence may decrease incidence over 12 month period in recurrent UTIs Efficacy in other groups unclear Dose and method of administration (juice, tablets, capsules) unclear Topical estrogen in postmenopausal women (0-30% efficacy) Probiotics (investigational) Vaccination (investigational)
Complicated UTI Complicated UTIs areeverything that does not qualify as an uncomplicated UTI. This can be based on age, gender, urinary tract abnormalities, of co-morbid disease states. See the list of characteristics/risk factors below. Usually these are ascending infections moving up the urinary tract. The exceptions are hematogenous spread seen in IV drug abusers where skin flora such as Staph aureus is the most common pathogen. Other hematogenous spread is found in military infections such as TB. Drug resistance is very common, and indwelling catheters significantly increase the risk of multi-organism infection, thus necessitating urine culture with sensitivities. Overall a wider variety of organisms are seen. E. Coli is still often the initiating infection, but involvement of other gram negative and (to a greater extent than uncomplicated infections) gram positive organisms are often seen. Fungal infections, especially Candida species, are also commonly seen. When Pseudomonas aeruginosa is involved it creates a biofilm that lends a survival advantage and high antibiotic resistance. Complicated UTIs require prolonged therapy (longer than uncomplicated UTI) and are at greater risk of complication. Risk Factors / Characteristics: Indwelling catheters Obstruction Male gender Age Diabetes mellitus Renal insufficiency Immunosuppression Urolithiasis Surgery Voiding dysfunction Valves Reflux Pregnancy Nosocomial Nursing home patients
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Complications: Urosepsis More likely in immunocompromised, but ALL complicated UTIs carry this risk More commonly seen with Gram negative organisms, which carry a greater risk of fatality as they cause profound hemodynamic changes, multiple organ failure, and death Renal failure May be acute or chronic, permanent or self-limited Greater risk with pre-existing renal insufficiency and obstruction Approach to Patient: At-risk populations need expedited evaluation and treatment to limit short and long-term morbidity and mortality. The first step in this is correctly identifying these patients. Your suspicion should start with the above risk factors and characteristics. Several basic principles will aid in managing these patients: 1. Accurate H&P 2. Urine culture is MANDATORY 3. CBC, chemistries 4. Imaging study CT scan preferred 5. Minimize any obstruction identified 6. Aggressive use of antibiotics a. Broad-spectrum for gram-negatives and positives b. Empiric and/or prophylactic yeast coverage, esp. in catheter and diabetic patients c. Use C&S information and adjust accordingly d. Older agents should remain as first line to minimize antimicrobial resistance e. Consider combination therapy for additive and synergistic effects
Overview of UTI in children Children are considered complicated UTI. They are more prevalent in females. By the age of 6 years old, 7% of females will have a UTI where only 2% of males. Newborns can have UTI with this accounting for 7% of diagnosed infections in febrile newborns. As with adults, they are usually ascending infections, except in infants <12 weeks old hematogenous infection is more common. E. coli accounts for 60-80% of UTIs in children, with other organisms including Proteus, Klebsiella, Enterococcus, and coagulase negative staphylococci. Evidence of risk factors is very limited. Two studies have shown an association with constipation, encopresis, bladder instability, and infrequent voiding, but this did not hold true for febrile children less than 2yo. Bathing and back-to-front wiping have not been shown to be risk factors. Symptoms of UTI in older children are the same as seen in adults. In infants symptoms include fever, irritability, jaundice, vomiting, and failure to thrive. Urine odor is not predictive of infection. Other conditions may mimic a UTI in children such as acute urethritis or vulvovaginitis caused by various irritants (bubble baths, soaps, self-exploration, pinworms). Clinical Signs and Symptoms of UTI in Children:
Newborns Jaundice Infants/preschoolers Diarrhea School age children Vomiting
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Sepsis Failure to thrive Vomiting Fever
Failure to thrive Vomiting Abdominal or flank pain New urinary incontinence Dysuria (preschoolers) Urgency (preschoolers)
Fever Strong-smelling urine Abdominal or flank pain New urinary incontinence Dysuria Urgency Frequency
In evaluating UTIs in children, urine culture and sensitivities are required in all cases prior to initiating antibiotics. A urine dipstick can rule out UTI if it is negative, but can not rule in infection if positive due to high false positive rates. Blood cultures are unnecessary in most cases. Imaging Imaging in pediatric UTIs can be a confusing topic. Below are the Clinical Practice Guidelines published by the American Academy of Pediatrics: Infants and young children 2 months to 2 years of age with UTI who do not demonstrate the expected clinical response within 2 days of antimicrobial therapy should undergo ultrasonography promptly, and either voiding cystourethrography (VCUG) or radionuclide cystography (RNC) should be performed at the earliest convenient time. Infants and young children who have the expected response to antimicrobials should have a sonogram and either VCUG or RNC performed at the earliest convenient time (strength of evidence: fair). UTI in young children serve as a marker for abnormalities of the urinary tract. Imaging of the urinary tract is recommended in every febrile infant or young child with a first UTI to identify those with abnormalities that predispose to renal damage. Imaging should consist of urinary tract ultrasonography to detect dilatation secondary to obstruction and a study to detect VUR. Ultrasonography Urinary tract ultrasonography consists of examination of the kidneys to identify hydronephrosis and examination of the bladder to identify dilatation of the distal ureters, hypertrophy of the bladder wall, and the presence of ureteroceles. Previously, excretory urography (commonly called intravenous pyelography) was used to reveal these abnormalities, but now ultrasonography shows them more safely, less invasively, and often less expensively. Ultrasonography does have limitations, however. A normal ultrasound does not exclude VUR. Ultrasonography may show signs of acute renal inflammation and established renal scars, but it is not as sensitive as other renal imaging techniques. Usually the timing of the ultrasound is not crucial, but when the rate of clinical improvement is slower than anticipated during treatment, ultrasonography should be performed promptly to look for a cause such as obstruction or abscess. VUR The most common abnormality detected in imaging studies is VUR. The rate of VUR among children younger than 1 year of age with UTI exceeds 50%. VUR is not an all-or-none phenomenon; grades of severity are recognized, designated I to V in the International Study Classification (International Reflux Study Committee, 1981), based on the extent of the reflux and associated dilatation of the ureter and pelvis. The grading of VUR is important because the natural history differs by grade, as does the risk of renal damage. Patients with high-grade VUR
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are 4 to 6 times more likely to have scarring than those with low-grade VUR and 8 to 10 times more likely than those without VUR. VCUG; RNC Either traditional contrast VCUG or RNC is recommended for detecting reflux. Although children may have pyelonephritis without reflux, the child with reflux is at increased risk of pyelonephritis and of scarring from UTI. With VCUG and RNC, a voiding phase is important because some reflux occurs only during voiding. If the predicted bladder capacity is not reached, the study may underestimate the presence or degree of reflux. VCUG with fluoroscopy characterizes reflux better than does RNC. In addition, RNC does not show urethral or bladder abnormalities; for this reason, boys, whose urethra must be examined for posterior urethral valves, or girls, who have symptoms of voiding dysfunction when not infected, should have a standard fluoroscopic contrast VCUG as part of their initial studies. RNC has a lower radiation dose and therefore may be preferred in follow-up examinations of children with reflux. However, the introduction of low-dose radiographic equipment has narrowed the gap in radiation between the VCUG and RNC. There is no benefit in delaying performance of these studies as long as the child is free of infection and bladder irritability is absent. While waiting for reflux study results, the child should be receiving an antimicrobial, either as part of the initial treatment or as posttreatment prophylaxis. Radionuclide Renal Scans Renal cortical scintigraphy (with 99 m Tc-DMSA or 99 m Tcglucoheptonate) and enhanced computed tomography are very sensitive means of identifying acute changes from pyelonephritis or renal scarring. However, the role of these imaging modalities in the clinical management of the child with UTI still is unclear. Recommendation 11
PEDIATRICS Vol. 103 No. 4 April 1999, pp. 843-852 AMERICAN ACADEMY OF PEDIATRICS: Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children Committee on Quality Improvement, Subcommittee on Urinary Tract Infection
Pharmacologic Therapy
TABLE 2
Empiric Oral Antibiotic Therapy for UTI in Children

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Antibiotic Amoxicillin Cefixime (Suprax) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cephalexin (Keflex) Loracarbef (Lorabid) Sulfisoxazole (Gantrisin) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Daily dosage 20 to 40 mg per kg in three doses* 8 mg per kg in two doses 10 mg per kg in two doses 30 mg per kg in two doses 50 to 100 mg per kg in four doses 15 to 30 mg per kg in two doses 120 to 150 mg per kg in four doses 6 to 12 mg per kg/30 to 60 mg per kg in two doses
UTI = urinary tract infection. *-Amoxicillin is the first choice for infants younger than two months. Adapted with permission from Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children [published corrections appear in Pediatrics 2000;105:141, 1999;103:1052, and 1999;104:118]. Pediatrics 1999;103:848.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation Urine culture should be obtained for diagnosis of UTI in children if there is high clinical suspicion, cloudy urine, or positive urine dipstick. Routine imaging studies (e.g., ultrasonography, VCUG, renal scans) do not appear to improve outcomes in children with a first uncomplicated UTI, but the evidence is weak. Oral antibiotics should be used (when tolerated) instead of parenteral antibiotics to manage UTI in children. One-day courses of antibiotics should not be used to manage UTI in children. Consider that short courses of antibiotics (two to five days) may be as effective as longer courses (seven to 14 days). Prophylactic antibiotics may be used to reduce the risk of recurrent UTI.
Evidence rating C B
References 13-16 24, 26, 27
A A B B
35, 36 37 37-39 42, 43
UTI = urinary tract infection; VCUG = voiding cystourethrography. A = consistent, good quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For more information about the SORT evidence rating system, see page 2416 or http://www.aafp.org/afpsort.xml.
References: 1. Brian S. Alper, M.D., M.S.P.H., AND Sarah H. Curry, M.D. Urinary Tract Infection in Children. American Family Physician. Volume 72, Number 12. December 15, 2005.
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2. Susan A. Mehnert-Kay, M.D. Diagnosis and Management of Uncomplicated Urinary Tract Infections. American Family Physician. Volume 72, Number 3, August 1, 2005. 3. Urinary Tract Infection. DynaMed accessed through USA Biomedical Library online. 4. American Academy Of Pediatrics Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Committee on Quality Improvement, Subcommittee on Urinary Tract Infection Pediatrics Vol. 103 No. 4 April 1999, pp. 843-852. 5. University of Michigan Health System. Guidelines for Care of Urinary Tract Infection. Ann Arbor (MI): University of Michigan Health System; 2005 May.
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Pharmacotherapy
Understanding Pregnancy Categories1,2 Category A: controlled studies in women fail to demonstrate a risk to fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. Category B: either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse event (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of risk in later trimesters) Category C: either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if potential benefit justifies the potential risk to the fetus. Category D: there is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective.) Category X: studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. Principles of Drug Interactions (CYP 450 system, p-glycoprotein, and protein binding):3,4,5 CYP 450 system: o CYP 450 system is a phase I metabolism system o >200 P450 enzymes exist in nature; six enzymes are responsible for 90% of all metabolic activity of P450 enzymes: 1A2, 3A4, 2C9, 2C19, 2D6, 2E1 2A6, 2B6, 2C8: minor but clinically relevant enzymes Enzymes are located on smooth endoplasmic reticulum of hepatocytes and luminal epithelium of small intestine Associated with NADPH CYP450 reductase, which donates or is source of electrons needed for oxidation Major reactions involved in phase I metabolism o N-dealkylation o O-dealkylation o Aliphatic hydroxylation o Aromatic hydroxylation o N-oxidation o S-oxidation o Deamination o Hydrolysis reactions Drugs can inhibit or induce these enzymes Inhibition: o Drugs can be metabolized at a common enzyme and compete or share metabolic sites within the ER in the liver and get o Drugs with higher affinity for the enzyme will inhibit another drug from binding thus decreasing its metabolism; this will result in increased levels of any drug dependent on that enzyme o Inhibition is immediate in effect; enzyme returns to normal function once offending agent is removed Induction: Page 217
o o o
Drugs can increase synthesis of P450 proteins and increase number of sites available for metabolism May lead to decreases in amount of parent drug administered and increases in amounts of metabolites produced An inducer may decrease levels of coadministered drug and result in loss of efficacy
Polymorphisms: Poor metabolizers: slower metabolism or less able to biotransform a compound at a specific site compared to rest of population Ultraextensive metabolizers: require more drug than expected to achieve therapeutic effect because their enzymes rapidly and extensively metabolize compounds Extensive metabolizers: average metabolizers; may be converted to PMs by P450 inhibitors o not genetically determined to metabolize poorly, but they mimic genetic PMs Hydroxylates, demethylates, dealkylates compounds through oxidative metabolism Polymorphic enzyme; EMs, PMs, and UEMs will experience differences in metabolism of drugs primarily metabolized by 2D6 E.g.; PMs will have a delayed metabolism and accumulate the parent drug which could increase risk of side effects Low -capacity, high- affinity enzyme; makes up only 1.5% of total CYP450 content in liver Found primarily in liver; also in brain, prostate, bone marrow and heart Potent Inhibitors: Fluoxetine, bupropion, norfluoxetine, paroxetine, cimetidine, metoclopramide, quindine, ritonavir Other inhibitors: Antidepressants: Amitriptyline, fluvoxamine, desipramine, imipramine, sertraline, venlafaxine Antipsychotics: Chlorpromazine, clozapine, fluphenazine, haloperidol, perphenazine, risperidone, thioridazine Others: amiodarone, chlorpheniramine, celecoxib, clomipramine, diphenhydramine, doxorubicin, lansoprazole, loratadine, methadone, methylphenidate, pimozide, terbinafine, ticlodipine, valproic acid, yohimbine Inducers: unclear whether 2D6 is inducible Substrates: TCAs SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline Other antidepressants: trazodone, venlafaxine, nefazodone, mirtazapine Antipsychotics: chlorpromazine, clozapine, fluphenazine, haloperidol, perphenazine, quetiapine, risperidone, thioridazine, aripiprazole, atomoxetine Analgesics: codeine, hydrocodone, lidocaine, methadone, oxycodone, tramadol Cardiovascular drugs: carvedilol, diltiazem, flecainide, metoprolol, nifedipine, nisoldipine, propafenone, propanolol, timolol High capacity/low affinity enzyme Potent Inhibitors: Norfluoxetine, nefazodone, ciprofloxacin, norfloxacin, quinupristin/dalfopristin, itraconazole, ketoconazole, clarithromycin, erythromycin, telithromycin, efavirenz, indinavir, ritonavir, diltiazem, grapefruit juice Potent Inducers: Carbamazepine, Phenobarbital, phenytoin, rifabutin, rifampin, ritonavir Substrates (drug classes) Page 218
2D6:
3A4:
Antidepressants: TCAs, SSRIs, mirtazapine, nefazadone, trazodone, venlafaxine Antipsychotics: aripiprazole, chlorpromazine, clozapine, haloperidol, perphenazine, quetiapine, risperidone, ziprasidone Sedative-hypnotics: o Benzos: clonazepam, diazepam, alprazolam, midazolam o Zolpidem, zopiclone, o Buspirone, donepezil, galantamine Analgesics: codeine, fentanyl, hydrocodone, meperidine, methadone, propoxyphene, tramadol Antiarrythmics: Amiodarone, lidocaine, propafenone, quinidine Antibiotics: ciprofloxacin, rifabutin, rifampin Antiepileptics: carbamazepine, valproic acid, zonisamide Antihistamines: chlorpheniramine, ebastine, loratadine, terfenadine Antimalarials: choloquine, halofantrine, primaquine Antineoplastics: cyclophosphamide, docetaxel, doxorubicin, etoposide, paclitaxel, tamoxifen, vinblastine, vincristine, vinorelbine, etc. Antiparkinsonian drugs: bromocriptine, pergolide, ropinirole, selegiline Antiprogesterone drugs: mifepristone, etc Antirejection agents: cyclosporine, sirolimus, tacrolimus Beta-blockers: metoprolol, propanolol, timolol o 1A2: Found exclusively in the liver 10-15% of P450 activity in liver Low affinity/high capacity Potent inhibitors: Ciprofloxacine, enoxacin, lomefloxacin, norfloxacin, fluvoxamine, flutamide, propafenone Other inhibitors: cimetidine, grapefruit juice, lidocaine, oral contraceptives, ranitidine, rifampin, ropinirole, ticlodipine, verapamil Inducers: caffeine, carbamazepine, esomeprazole, lansoprazole, omeprazole, rifampin, ritonavir Foods: broccoli, brussel sprouts, cabbage, cauliflower, charbroiled foods Chronic smoking Substrates: Imipramine, mirtazapine, clozapine, caffeine, cyclobenzaprine, flutamide, provatriptan, melatonin, ropinirole, theophylline, zolmitriptan Located in kidney, testes, adrenal gland, prostate, ovary, duodenum; 18% of P450 content in liver Potent Inhibitors: Fluconazole, ritonavir, sulfaphenazole Other inhibitors: SSRIs, amiodarone, cimetidine, clopidogrel, efavirenz, fluvastatin, isoniazid, ranitidine, valproic acid Inducers: carbamazepine, cyclophosphamide, ethanol, Phenobarbital, phenytoin, rifabutin, rifampin, ritonavir, valproic acid Substrates: Irbesartan, losartan, valsartan Fluoxetine, sertraline Glipizide, glimepiride, glyburide, tolbutamide NSAIDs Fluvastatin, phenytoin, tamoxifen, S-warfarin, zafirlukast, torsemide Responsible for 20% of P450 activity along with 2C9 in liver Page 219
2C9:
2C19:
Potent Inhibitors Fluoxetine, fluvoxamine, norfluoxetine, paroxetine Esomeprazole, omeprazole, ritonavir, ticlodipine Other Inhibitors: Amitriptyline, cimetidine, efavirenz, fluconazole, indomethacin, lansoprazole, oral contraceptives, ranitidine, topiramate Inducers Carbamazepine, Phenobarbital, phenytoin, prednisone, rifabutin, rifampin, ritonavir, valproic acid Substrates Antidepressants: TCAs, SSRIs, venlafaxine PPIs Alprazolam, diazepam, indomethacin, phenytoin, propanolol, tolbutamide
P-glycoprotein o Membrane-based glycoproteins that transport substances such as steroids, cytokines, and glucuronate and sulfate conjugates o Present on villi in jejunum (the primary site of absorption of oral drugs), colon, gonads, renal proximal tubules, placenta, and biliary system; and in capillary endothelial cells of blood brain barrier o Transport hydrophobic substances across cells in the gut, into bile and urine and out of gonads and brain o Drugs can be P-glycoprotein substrates, inhibitors, and/or inducers o if p-glycoprotein function is inhibited or induced, absorption of drug substrates is altered p-glycoprotein inhibitors increase drug levels of substrates p-glycoprotein inducers decrease drug levels of substrates Nonsubstrates Amantadine Chlorpheniramine Citalopram Clozapine Fentanyl Fluconazole Flunitrazepam Fluoxetine Haloperidol Itraconazole Ketoconazole Lidocaine Methotrexate Midazolam Sumatriptan Yohimbine Substrates Aldosterone Amitriptyline Amoxicillin Carbamazepine Chloroquine CImetidine Ciprofloxacin Colchicine Corticosteroids Cyclosporine Digitoxine Digoxin Diltiazem Docetaxel L-Dopa Doxorubicin Enoxacin Erythromycin Estradiol Fexofenadine Indinavir Irinotecan Lansoprazole Loperamide Losartan Lovastatin Mibefradil Morphine Inhibitors Amiodarone Amitriptyline Atorvastatin Bromocriptine Chloroquine Chlorpromazine Clarithromycin Cyclosporine Cyproheptadine Desipramine Diltiazem Erythromycin Felodipine Fentanyl Fluphenazine Garlic Grapefruit juice Green tea (catechins) Haloperidol Hydrocortisone Hydroxyzine Imipramine Iraconazole Ketoconazole Lansoprazole Lidocaine Lovastatin Maprotiline Inducers Dexamethasone Doxorubicin Nefazadone (chronic) Phenobarbital Prazosin Rifampin Ritonavir (chronic) St. Johns wort Trazodone Venlafaxine ?
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Nelfinavir Nortriptylne Ondansetron Phenytoin Quetiapine Quinidine Ranitidine Rifampin Ritonavir SAquinavir Tacrolimus Talinolol Teniposide Terfenadine Vinblastine Vincristine
Methadone Mibefradil Nefazadone (acute) Nelfinavir Ofloxacin Orange Juice Pantoprazole Phenothiazines Pimozide Piperine Probenecid Progesterone Propafenone Propanolol Quinidineng Ritonavir (initial) Saquinavir Simvastatin Spironolactone Tamoxifen Terfenadine Trifluoperazine Valspodar Verapamil Vinblastine Vitamin E
Protein binding o Plasma protein binding plays a role in pharmacokinetics, pharmacodynamics and drug interactions o drug concentrations in plasma represent drug that is bound to plasma protein plus unbound drug unbound drug is the pharmacologically active moiety o any factor that alters protein binding becomes clinically important when a drug is highly protein bound o fu value: represents fraction of unbound drug fu <0.1 or 10%= highly protein bound o Albumin: Number of protein binding sites exceeds number of drug molecules available for binding in most cases When plasma concentrations for drugs bound to albumin >25-50 mg/L, albumin binding sites can become saturated; fraction of drug that is free will change with plasma concentration E.g.; salicylates and valproic acid can saturate plasma protein binding sites These drugs exhibit concentration-dependent plasma protein binding o Low plasma protein concentrations decrease plasma concentration of bound drug; however, unbound drug is usually not affected o Acidic drugs bind primarily to albumin (e.g.; phenytoin and most of anti-epileptic drugs) o Basic drugs bind to globulin (e.g; lidocaine, quinidine o Alpha1-acid glycoprotein (AAG) is an acute phase reactive protein Can be significantly decreased and increased under certain clinical conditions AAG concentrations are difficult to assay in clinical settings o Binding affinity: Binding affinity of plasma protein for a drug can alter fraction of drug that is free Ex: uremic patients exhibit plasma proteins that have less affinity for phenytoin than proteins present in nonuremic patients
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o fu values for plasma protein binding Drug fu value Drug fu value Amitriptyline 0.04 Phenobarbital 0.5 Carbamazepine 0.2 Phenytoin 0.10 Cyclosporine <0.1 Procainamide 0.84 Digoxin 0.70 Propanolol 0.06 Gabapentin 0.97 Quindine 0.20 Lidocaine 0.30 Salicyclic acid 0.16 Lithium 1.0 Valproic acid 0.15 Methotrexate 0.5 Vancomycin 0.9 Nafcillin 0.10 warfarin 0.03 o If a drug is displaced from plasma proteins it would increase the unbound drug concentration and increase the drug effects and could potentially produce toxicity o An increase in unbound drug in body produces % increase in pharmacologically active unbound drug at the site of action o When amount of unbound drug increases, rate of elimination will increase o When drug interactions associated with protein binding have been studied, it has been shown that the displacing drug is also an inhibitor of clearance The change in clearance of the unbound drug is the relevant mechanism explaining the interaction o Drugs can exhibit high or low protein binding; binding to plasma proteins can affect drug concentrations o Binding of drugs to plasma proteins is capacity-limited o Unbound drug concentration is determined by dosing rate and clearance; therefore increases in dosing rate will cause corresponding changes in unbound concentration Dosage Adjustments in Renal Disease:6 Renal Excretion: o Depends on both glomerular filtration and renal tubular secretion and absorption Glomerular elimination also depends on molecular size and protein binding of drug When glomerular filtration is impaired by renal disease, the clearance of drugs that are primarily eliminated by this mechanism will be decreased and plasma half-life of the drugs will be prolonged o Secretion of drugs can also be affected by renal disease Drugs dependent on renal tubular secretion will be excreted more slowly as creatinine clearance decreases Drugs are adjusted based on estimated creatinine clearance o CrCl= (140 age) x ideal body weight in kg/72 x serum creatinine mg/dL x 0.85 (women) o For men, ideal body weight= 50.0kg + 2.3kg/in over 5 ft tall o For women, ideal body weight= 45.5kg + 2.3kg/in over 5 ft tall Loading dose should be considered when half-life of a drug is long in patients with impaired renal function o Loading dose given to renally impaired patient is same as initial dose given to patient with normal renal function if the extracellular fluid volume is normal in patient with impaired renal function o Loading dose calculation: Loading Dose= Vd (L/kg) x Wt (kg) x Cp (mg/L) Vd= volume of distribution; Wt= patients ideal body weight; Cp= desired plasma drug level o Patients with edema or ascites may require larger loading doses; those who are dehydrated or debilitated should receive smaller initial doses o To adjust maintenance dose in renally impaired patients, the intervals between individual doses can be lengthened and the dose can be kept normal Page 222
Increasing the dosing interval is useful for drugs with wide therapeutic ranges and long half-lives in patients with renal insufficiency
Can also reduce the size of individual doses and keep the interval the same Decreasing the dose reduces differences between peak and trough plasma concentrations Important for drugs with narrow therapeutic ranges and short half-lives in patients with renal insufficiency Combination of interval prolongation and dose-size reduction is often effective and convenient
Black Box Warnings:7 Black Box Warnings appear in package inserts for certain drugs that have potential to cause serious adverse effects in patients These warnings mean that studies have indicated a drug carries significant risk of potentially serious or lifethreatening adverse effects Strongest warning FDA requires 5HT3 antagonists (Alosetron): ischemic colitis, serious complications of constipation; prescribing program implemented Protease Inhibitors: o Abacavir: lactic acidosis and severe hepatomegaly with steatosis, hypersensitivity reactions, hepatitis B exacerbations o Entecavir: lactic acidosis and severe hepatomegaly with steatosis, hepatitis B exacerbations o Ritonavir: Coadministration with certain nonsedating antihistamines, sedative hypnotics, antiarrhythmics, ergot alkaloids may cause serious adverse reactions o Indinavir o Saquinavir: different forms are not bioequivalent TNF- inhibitors (adalimumab, infliximab, etanercept): Tuberculosis, invasive fungal infections, other opportunistic infections may occur; test for tuberculosis before initiating therapy o Infliximab: Hepatosplenic T-cell lymphomas Aminoglycosides: Nephrotoxicity, ototoxicity, monitor renal and eighth cranial nerve function at initiation Antiarrythmics o Amiodarone: life-threatening arrhythmias; potentially fatal toxicities (arrhythmias, pulmonary, liver), high-risk patients o Flecainide: have not been shown to enhance survival in nonlife-threatening ventricular arrhythmias and may increase mortality, ventricular proarrhythmic effects in patients with atrial flutter o Procainamide: have not been shown to enhance survival in nonlife-threatening ventricular arrhythmias and may increase mortality, blood dyscrasias o Propafenone: have not been shown to enhance survival in nonlife-threatening ventricular arrhythmias and may increase mortality o Quinidine: have not been shown to enhance survival in nonlife-threatening ventricular arrhythmias and may increase mortality; may increase mortality is atrial fibrillation/flutter ACE inhibitors: can cause injury or death to the fetus in the second and third trimesters Angiotensin II receptor blockers: can cause injury or death to the fetus in the second and third trimesters Amphotericin B: only use for the treatment of progressive and potentially life-threatening fungal infections Amphetamines: high potential for abuse Antipsychotic agents o Clozapine: agranulosytosis, seizures, myocarditis, orthostatic hypotension, collapse, respiratory arrest, cardiac arrest, elderly patients with dementia-related psychosis are at an increased risk of death Antidepressants: increased risk of suicidal thinking and behavior in children, adolescents, and young adults at the beginning of therapy Beta-blockers: may cause an increase in ischemic symptoms after abrupt cessation of therapy Azathioprine: increased risk of neoplasia; possible hematologic toxicities Page 223
Carbamazepine: aplastic anemia and agranulocytosis; transient or persistent decrease in platelets or WBCs NSAIDs o Celecoxib: increased risk for CV thrombotic events, MI, and stroke; do not use for perioperative pain after a CABG; increased risk of GI bleed, ulceration, and perforation of stomach or intestines Cyclosporin should be managed by facilities properly equipped and staffed for immunosuppressive therapy; can cause systemic hypertension and nephrotoxicity; Sandimmune cannot be interchanged with Neoral and Gengraf o Sandimmune: administer with adrenal corticosteroids but not with other immunosuppressive agents; increased susceptibility to infection and lymphoma; absorption is erratic, so monitor drug levels and possible organ rejection o Neoral and Gengraf: increased susceptibility to infection, lymphoma and other neoplasia; monitor drug concentration levels; psoriasis patients previously on PUVA or other immunosuppressants have an increased risk for skin malignancies Corticosteroids NNRTIs o Efavirenz o Nevirapine: Severe hepatotoxicity (especially in the first 18 weeks), severe skin rashes (hypersensistivity, Stevens-Johnson syndrome, toxic epidermal necrolysis); monitor patient closely during the first 18 weeks (fist 6 weeks are most important) NRTI o Emtricitabine: lactic acidosis and severe hepatomegaly with steatosis; not indicted for hepatitis B; exacerbations of hepatitis B have been reported after discontinuing this drug o Tenofovir: lactic acidosis and severe hepatomegaly with steatosis; not indicted for hepatitis B; exacerbations of hepatitis B have been reported after discontinuing this drug o Lamivudine: lactic acidosis and severe hepatomegaly with steatosis; HIV and hepatitis B doses are different, so make sure patient is getting the correct dosage; exacerbations of hepatitis B have occurred after discontinueing the medication o Stavudine: lactic acidosis and severe hepatomegaly with steatosis; pancreatitis o Zidovudine: hematologic toxicity (neutropenia and severe anemia), myopathy, lactic acidosis and severe hepatomegaly with steatosis Low Molecular weight heparins: spinal/epidural hematomas may occur in patients who have epidural/spinal anesthesia or spinal puncture, which can result in paralysis; risk is increased with indwelling epidural catheters or with other anticoagulant use; monitor for neurologic impairment Estrogens: endometrial cancer, stroke, DVT, should not be used to prevent CV disease or dementia Gold compounds: physician she familiarize themselves with signs and symptoms of toxicity and warn patients about toxicity; review lab work before each gold injection Hydroxycloroquine: o Physicians should completely familiarize themselves with the complete contents of the package insert before prescribing HCQ Interferon o Can cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders o Monitor patients closely with periodic clinical and laboratory evalutations o Patients with persistently severe or worsening symptoms of these conditions should be withdrawn from therapy Iron-containing products: o Accidental overdose is leading cause of fatal poisoning in children younger than 6 years of age; keep products out of reach of children Isotretinoin: o Must not be used by women and adolescents who are pregnant or who may become pregnant; high risk of birth defects o Special prescribing requirements: approved for marketing only under special restricted distribution program approved by FDA due to its teratogeniticty and to minimize fetal exposure; can only be prescribed by physicians registered with iPLEDGE program, only registered pharmacies can dispense the drug, patients must also be registered with the program Page 224
Isoniazid: o Hepatitis: risk increases with daily consumption of alcohol o Carefully monitor patients and interview at monthly intervals o Patients >35yo: monthly symptom reviews, AST/ALT prior to starting therapy and periodically throughout treatment Azole antifungals: o Ketoconazole Hepatotoxicity Drug interactions: Terfenadine- contraindicated; rare cases of serious cardiovascular adverse events including death, ventricular tachycardia and torsades de pointes Astemizole- contraindicated; ketoconazole inhibits metabolism of astemizole resuling in elevated levels of its active metabolite which may prolong QT intervals Cisapride: contraindicated; serious cardiovascular adverse events including ventricular tachycardia, ventricular fibrillation and torsades de pointes have occurred with coadministration o Itraconazole CHF: discontinue of signs or symptoms of CHF develop; do not administer to patients with evidence of ventricular dysfunction such as CHF or history of CHF Coadministration of cisapride, pimozide, quinidine or dofetilide is contraindicated; may inrease concentrations of these drugs and cause serious cardiovascular adverse events Leflunomide: o Pregnancy must be excluded before start of treatment; contraindicated in pregnant women or women of childbearing potential who are not using reliable contraception o Pregnancy must be avoided during leflunomide treatment or prior to completion of drug elimination procedure after treatment lithium: o lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels o facilities for prompt and accurate serum lithium determinations should be available before initiating therapy loop diuretics: o potent diuretics; excess amounts can lead to profound diuresis with water and electrolyte depletion; careful medical supervision is required and dosage must be individualized Metformin: o Lactic acidosis: rare but serious metabolic complication that can occur due to accumulation of metformin o Do not use in patients who have conditions associated with hypoxemia, dehydration or sepsis; do not use in patients with significant renal impairment o Monitor for signs and symptoms of lactic acidosis including decreased blood pH, electrolyte disturbances with increased anion gap, increased lactate/pyruvate ratio, and elevated blood lactate levels (5mmol/L or more) o Monitor renal function closely and temporarily discontinue prior to any intravascular radiocontrast study and for any surgical procedure Mercaptopurine: o Potent drug and should not be used unless a diagnosis of acute lymphatic leukemia has been adequately established and responsible physician is knowledgeable in assessing response to chemotherapy Methotrexate: o Deaths: use only in life-threatening neoplastic diseases or in patients with psoriasis or rheumatoid arthritis with severe, disabling disease that is not adequately responsive to other forms of therapy o Bone marrow suppression: may occur with resultant anemia, leucopenia, or thrombocytopenia Severe, sometimes fatal, bone marrow suppression, aplastic anemia, and GI toxicity has occurred Page 225
Monitor: CBC with differential and platelet counts, liver function tests Periodic liver biopsies Patients with renal dysfunction, pleural effusions, ascites are at increased risk for impaired elimination and should be monitored more frequently o Liver: hepatotoxicity, fibrosis, cirrhosis after prolonged use o Methotrexate-induced lung disease: Potentially dangerous lesions may occur at any time during therapy at doses as low as 7.5mg/week Monitor for pulmonary symptoms (dry, nonproductive cough) o Pregnancy: fatal death and/or congenital anomalies have occurred; do not use in women of childbearing potential unless benefits outweigh risks Contraindicated in pregnant women with RA or psoriasis o Renal use: use extreme caution in patients with renal dysfunction and use at reduced dosages; renal dysfunction will prolong elimination o GI: diarrhea and ulcerative stomatitis require interruption of therapy; hemorrhagic enteritis and death from intestinal perforation may occur o Diluents: do not use formulations and diluents containing preservatives for intrathecal or experimental high dose MTX therapy o Malignant lymphomas: may occur in patients receiving low-dose MTX and may regress following withdrawal of drug o Tumor lysis syndrome: may induce tumor lysis syndrome in patients with rapidly growing tumors o Skin reactions: severe, occasionally fatal, skin reactions may occur following single or multiple doses of MTX o Potentially fatal opportunistic infections: especially Pneumocystis carinii o Radiotherapy: given concomitantly with radiotherapy may increase risk of soft tissue necrosis and osteonecrosis o Severe reactions: because of possibility of severe toxic reaction which can be fatal, fully inform patients of the risks involved and assure constant supervision Metronidazole: o Shown to be carcinogenic in mice and rats; unnecessary use of drug should be avoided and reserved for conditions for which it is indicated Midazolam: o Syrup has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical care settings o Continuously monitor respiratory and cardiac function Misoprostol: o Can cause abortion, premature birth or birth defects when administered to pregnant women o Women of child-bearing potential should not be prescribed this drug for reducing risk of NSAIDinduced ulcer unless patient is at high risk of complications from gastric ulcers or at high risk of developing gastric ulcers; prescribe to patient if: Negative serum pregnancy test 2 weeks prior to beginning therapy Capable of complying with effective contraception measures Received both oral and written warnings of hazards of this drug, risk of possible contraception failure, and danger to other women of childbearing potential should the drug be taken by mistake Will begin misoprostol only on second or third day of next normal menstrual period Mycophenolate: o increased susceptibility to infection and possible development of lymphoma o Female users of childbearing potential must use contraception; increased risk of miscarriage and congenital malformations Naltrexone: o Hepatotoxicity: when given in excessive doses, can cause heptocellular injury o Contraindicated in acute hepatitis or liver failure Nitroprusside: Page 226
Not suitable for direct injection after reconstitution; must be diluted further in 5% Dextrose injection before infusion o Can cause precipitous decreases in blood pressure; can lead to irreversible ischemic injuries or death in patients not properly monitored; monitor blood pressure continuously o Causes rise in cyanide ion to potentially lethal levels if used at rates >2mcg/kg/min Usual dose rate is 0.5 to 10mcg/kg/min and should not last longer than 10 minutes o Monitor acid-base balance and venous oxygen concentration which may indicate cyanide toxicity Opioid Analgesics: o Fentanyl transmucosal: indicated only for management of breakthrough cancer pain in patients with malignancies already receiving and tolerant of opioid therapy for underlying persistent cancer pain Contraindicated in management of acute or postoperative pain Do not use in opioid nontolerant patients due to life-threatening hypoventilation o Fentanyl transdermal system: schedule II substance and has high potential for abuse and fatal overdose due to respiratory depression Indicated for management of persistent, moderate to severe chronic pain that requires continuous, around-the-clock opiod administration for an extended period of time, and cannot be managed by other means such as nonsteroidal analgesics, opioid combination products or IR opioids Should only be used in patients already tolerant to opioid therapy of comparable potency due to risk of respiratory depression in nontolerant patients Only intended for transdermal use on intact skin o Hydromorphone High potency injection: highly concentrated solution intended for use in opioid tolerant patients Extended-release capsules: indicated for management of persistent moderate to severe chronic pain in opioid tolerant patients Use in patients already receiving opioid therapy, have demonstrated tolerance, and require minimum total daily dose of opiate medication equivalent to oral hydromorphone 12mg. o Methadone: Should be dispensed only by hospitals, community pharmacies, and maintenance programs approved by FDA and designated state authorities Used to treat narcotic addiction in detoxification or maintenance programs Cardiac conduction effects: inhibits cardiac potassium channels and prolongs QT interval o Morphine: Avinza: modified-release formulation intended for once-daily dosing Astromorph PF, Duramorph, Infumorph: because of risk of severe adverse effects when epidural or intrathecal route of administration is employed, patients must be monitored in fully equipped and staffed environment for at least 24 hours after initial dose Infumorph: not recommended for single-dose IV, IM or SC administration because of very large amount of morphine in ampul and risk of overdose o Oxycodone: CR is a schedule II substance with abuse potential similar to morphine Indicated for management of moderate to severe pain when continuous, around-the-clock analgesic is needed for an extended period of time Not intended for as needed use; to be used only in opioid tolerant patients o Propoxyphene: Do not prescribe for patients who are suicidal or addiction-prone Prescribe with caution for patients taking tranquilizers or antidepressants Tell patients not to exceed recommended dose and to limit alcohol intake Excessive doses of propoxyphene either alone or in combination with other CNS depressants including alcohol are major cause of drug-related deaths Oral contraceptives: o Smoking: cigarette smoking increases risk of serious cardiovascular side effects from OCs o Risk increases with age (>35yo) and heavy smoking (at least 15 cigarettes a day) Page 227
Penicillamine: o Physicians should be thoroughly familiar with drugs toxicity, special dosage considerations, and therapeutic benefits o Never use casually Pentazocine combinations: o Potentially lethal reaction including pulmonary emboli, vascular occlusion, ulceration and abscesses, withdrawal symptoms in narcotic dependent patients if used by injection or in combination with other substances o Talwin Nx is intended for oral use only Phenytoin: o Administer slowly; do not exceed 50mg/minute IV in adults o Do not exceed 1 to 3 mg/kg/min in neonates Thiazolidinediones (pioglitazone, rosiglitazone) o Cause or exacerbate CHF in some patients o Observe for signs and symptoms of heart failure including excessive, rapid weight gain, dyspnea, and/or edema o Do not use in patients with established NYHA class III or IV heart failure Pramlintide acetate injection: o Increased risk of insulin-induced severe hypoglycemia, especially in type 1 diabetes Polymixin B: o Nephrotoxicity: monitor for albuminuria, cellular casts, azotemia; monitor for decreased urine output or increased BUN o Neurotoxicity: monitor for signs and symptoms of irritability, weakness, drowsiness, ataxia, perioral parathesia, numbness of extremities, blurred vision o Concurrent therapy with other neurotoxic or nephrotoxic drugs o Neuromuscular blockade o Use in pregnancy: safety has not been established Progestins: o Should not be used for prevention of cardiovascular disease o Should be prescribed at lowest effective doses and for shortest duration Promethazine: o Do not use in children <2yo because of potential for fatal respiratory depression Quetiapine: o Increased mortality in elderly patients with dementia-related psychosis o Extended-release form is not approved for treatment of elderly patients o Suicidality in children and adolescents (immediate-release form) Ribavirin: o Ineffective as monotherapy for chronic hepatitis C infection and should not be used alone for this indication o Hemolytic anemia; may worsen cardiac disease and lead to MI Do not use in patients with history of significant or unstable cardiac disease o Teratogenic and/or embryocidal effects Rituximab injection: o Fatal infusion reactions Deaths within 24 hours; monitor for signs and symptoms of hypoxia, pulmonary infiltrates, acute respiratory distress syndrome, MI, ventricular fibrillation or cardiogenic shock o Tumor lysis syndrome Acute renal failure requiring dialysis following treatment of non-Hodgkin lymphoma o Severe mucocutaneous reactions Salicylates: o Reyes syndrome in children and teenagers with chickenpox or flu virus Long-acting beta- 2 agonist: salmeterol/formoterol o May increase risk of asthma-related death Sirolimus: Page 228
Increased susceptibility to infection and possible development of lymphoma Liver transplantation Excess mortality, graft loss, and hepatic artery thrombosis (HAT) When used in combination with tacrolimus Use not recommended in liver transplant patients o Lung transplantation Bronchial anastomotic dehiscence Not recommended for use in these patients Tacrolimus: o Increased susceptibility to infection and possible development of lymphoma may result from immunosuppression Streptomycin injection: o Risk of neurotoxic reactions in patients with impaired renal function or prerenal azotemia Disturbances of vestibular and cochlear function, optic nerve dysfunction, peripheral neuritis, arachnoiditis, encephalopathy o Monitor renal function; peak serum concentrations should not exceed 20-25mcg/mL o Avoid use of concurrent nephrotoxic drugs Succinylcholine injection: o Acute rhabdomyolysis with hyperkalemia followed by ventricular death in children o Reserve for emergency intubation or immediate securing of airway is necessary Tamoxifen: o For women with ductal carcinoma in situ (DCIS) and women at high risk of breast cancer Can cause uterine malignancies, stroke, pulmonary embolism Thyroid hormones: o Do not use thyroid hormones either alone or in combination with other therapeutic agents for the treatment of obesity or for weight loss o In euthyroid patients, doses within range of daily hormonal requirements are ineffective for weight reduction o Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects Trastuzumab: o Cardiomyopathy: can result in left ventricular dysfunction and CHF o Infusion reactions and pulmonary toxicity: symptoms can occur within 24 hours; monitor for dyspnea or significant hypotension Urokinase injection: o Risk of potentially serious hemorrhage o Use in hospitals where recommended diagnostic and monitoring techniques are available Valganciclovir/ganciclovir: o Granulocytopenia, anemia, thrombocytopenia; carcinogenic, teratogenic and caused aspermatogenesis in animal studies Valproic acid: o Hepatotoxicity: children <2yo are at increased risk; monitor for symptoms such as anorexia, facial edema, lethargy, malaise, vomiting and weakness o Teratogenicity: information sheet describing teratogenic potential should be given to patients o Pancreatitis: monitor for symptoms of abdominal pain, nausea, vomiting, and/or anorexia Warfarin o Bleeding risk; can cause major or fatal bleeding o Regular monitoring of INR is recommended; report signs/symptoms of bleeding immediately
o o
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Dangerous Abbreviations:8,9 Dangerous Term O.D. for once daily q.o.d. for every other day q.d. for once daily q.n. for every night q hs for once daily at bedtime, each day TIW for three times a week U for unit O.J. for orange juice g (microgram) sq or sub q for subcutaneous Reason for Danger Interpreted as right eye Interpreted as every once a day or read as q.i.d or q.d. Read as q.i.d. Read as every hour Read as every hour Interpreted as T/W (Tuesday and Wednesday), twice a week, or TID Read as 0, 4, 6, or cc Read as OD or OS Misread as mg when written The q could be read as every; may be misread as SL (sublingual) if written poorly Misread as IV; the I could be misread as a 1; could be read as 10 Read as OU Read as 55 Not understood or misunderstood Read as U for unit Not understood or misunderstood Appropriate Term Write out once daily Write out every other day Write out once daily Write out every night, HS, or nightly Use HS or at bedtime Write out three times a week Write out unit Write out orange juice Write mcg Write out subcut Write out units or international units with a lowercase i Write out each year Write out sliding scale or 1/2 Write out the full name of the chemical Write mL Write out generic or brand names or use facilitys protocol procedure
IU for International units AU for each year ss for sliding scale or half (Apothecary system) Chemical symbols cc Lettered abbreviations for drug names Examples: MS or MS04 for morphine sulfate DPH, ASA, APAP, AZT, CPZ, etc. Apothecary symbols/terms per os for by mouth D/C for discharge T/d for one per day / use for with, and, or per Roman numerals > and < Drug name and dosage not separated by a space Trailing zeros (after a decimal point 1.0) Naked decimal point (no number before the decimal point .5) HS written for half strength AU, AS, AD written for both ears, left ear, right ear
Not understood or misunderstood OS read as left eye Interpreted as discontinue Read as TID Read as a 1 Not understood or misinterpreted Not understood or the meaning is reversed Last letter (such as an l) could be misread as part of the dose (140 mg instead of 40 mg) Decimal point may be missed, causing a tenfold overdose Decimal point may be missed, causing a tenfold overdose Interpreted as HS meaning hour of sleep Misinterpreted as OU, OS, OD (both eyes, left eye, right eye)
Use the metric system Write by mouth, orally, or PO Write out discharge Write out once daily Write out and with, or per Use Arabic numerals Write or greater than or less than Leave a space between the drug name, dose, and unit Omit the zero after the decimal point Add a zero before the decimal point Write out half strength Write out instructions clearly
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Narrow Therapeutic Index Drugs:10 Definition: Drugs where increasing the dose only slightly may cause a large increase in serum drug levels and clinical effect and could also cause a toxic effect. A small decrease in the dose may cause plasma levels to drop, resulting in a loss of therapeutic effect. The clinical implication of recognizing and monitoring these medications is to avoid possible toxicities (with supratherapeutic levels) and ineffectiveness (with subtherapeutic levels). 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Aminoglycoside Antibiotics Warfarin, heparin Aspirin Carbamazepine Conjugated estrogens Cyclosporine Digoxin Esterified Estrogens Hypoglycemic agents Levothyroxine sodium Lithium Phenytoin Procainamide Quinidine sulfate/gluconate Theophylline Tricyclic antidepressants Valproic Acid
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Therapeutic drug level monitoring11 TABLE KEY: RIA Monoclonal radioimmunoassay; FPIA Fluorescence polarization immunoassay; HPLC High-performance liquid chromatography Drug Goal Levels Timing of Level Frequency of Level Aminoglycosides Gentamicin, Tobramycin: Peak level: 1 hour after Some institutions wait until after Conventional dosing maintenance dose is given steady state is reached (after 3-4 Peak: 5-8 mg/L, Trough: to avoid distribution phase doses) but this is not necessary <2 mg/L. Once daily Trough level: within dosing Peak: 20 mg/L, hour before next Trough: undetectable maintenance dose is given Amikacin: Conventional dosing Peak: 20-30 mg/L, Trough: < 10 mg/L. Once daily dosing Peak: 60 mg/L, Trough: undetectable. Carbamazepine Plasma Concentration: 4Take samples at the same Obtain plasma samples within the 12 mg/L (some physicians time of the day each time a first few weeks of therapy to prefer 4-8 mg/L because sample is drawn to compare compare level with clinical toxicity can develop) serum levels (example response and periodically always in the morning thereafter before dose is given) Digoxin Concentrations: 0.8-2 Trough level: Once steady Within 24 hours of loading dose g/L state reached: draw level to confirm relationship between just before next dose given; dose and response; routine levels any sample time can be once steady state has been used that is 4 hours after an reached (7-14 days after IV dose or 6 hours after an maintenance regimen is initiated oral dose or changed and 15-20 days in end stage renal disease); Ethosuximide Plasma Concentrations: Long t1/2 so not critical; Monitor after patient has reached 40-100 mg/L trough levels preferred steady state (7-14 days in children, longer in adults) Cyclosporine Serum/Plasma (g/L): Troughs are most RIA: 5-125 commonly used (draw FPIA polyclonal: 150-400 directly before next dose is FPIA monoclonal: 50-125 given) HPLC: 50-125 Whole Blood (g/L): RIA: 150-400 FPIA polyclonal: 200-800 FPIA monoclonal: 150400 HPLC: 150-400 Tacrolimus Therapeutic Wait 24-36 hours after Concentration: 5-20 initiating or altering dose ng/mL and draw a trough level (right before next dose is given) Sirolimus Therapeutic Wait 1 week and draw a Concentration: 5-15 blood sample to look at ng/mL trough levels (draw directly before next dose is given) University of South Alabama, Department of Family Medicine June 30, 2008 232
Lidocaine
Therapeutic Plasma Concentrations: 1-5 mg/L
Lithium
Therapeutic Range: 0.60.8 mEq/L
Methotrexate
Therapeutic Plasma Concentration: variable
Phenobarbital
Therapeutic Concentrations: 15-40 mg/L
Phenytoin
Just before the first a.m. dose of lithium; at least 12 hours after the last evening dose Checking leucovorin regimen: 24-48 hours after leucovorin initiation to see if another dose is needed Not critical; can be taken anytime, but troughs are recommended for consistency (draw level directly before next dose is given); when IV, draw at least one hour after end of infusion Oral extended absorption: time of sample isnt critical, but troughs are preferred IV form: measure troughs; avoid taking a sample 1-2 hours after infusion is over
Do not monitor until 4-8 hours after initiating therapy; not used to adjust therapy; used to relate clinical impressions with plasma levels Steady state occurs in 3-5 days; draw levels when needed to adjust dose Check levels when infusing to make adjustments, when patients are taking multiple doses, and when testing leucovorin regimen 2-3 weeks after initiation or dosage change
Procainamide
Theophylline
Therapeutic Plasma Concentration: 5-20 mg/L
Tricyclic Antidepressants
Therapeutic Range (g/L): Amitriptyline: 120-250 Desipramine: 100-250
Immediate release: Trough levels preferred Sustained Release: Sample times less important, but trough preferred (draw sample directly before next dose is given) Nonsustained Release or liquid: Troughs (draw sample directly before next dose is given) Sustained Release: Time less crutial, troughs recommended 12 hours after a dose, which is usually in the morning (Peaks unpredictable Troughs hard because
Tests plasma levels before reaching steady state to monitor for low and high concentrations, but adjust cautiously based on these levels; Varies with disease Need rapid therapeutic concentrations, monitor 2-3 days after initiation and get a second level in another 3-5 days; if level hasnt changed in 3-5 days, monitor weekly Stable patient on long-term therapy, monitor every 3-12 months Within the first 24-48 hours and when patients clinical status changes
Begin 24 hours after initiation or change
At the beginning of therapy: Without signs of toxicity, wait 1 week after initiation; after adjusting based on levels, June 30, 2008 233
Imipramine: 180-350 Nortriptyline: 50-150 Valproic Acid Therapeutic Plasma Concentration: 50-100 mg/L
dosed at bedtime)
Troughs (draw sample directly before next dose is given)
monitor signs and symptoms; test if suspect noncompliance or side effects caused by concentration 2-4 days following initiation, change in regimen, addition of other antiepileptic drugs; measure when seizure control changes or suspect toxicity
Vancomycin
Therapeutic Plasma Concentartion: Peak: < 40-50 mg/L Trough: ~ 10 5 mg/L
Troughs, but can monitor peaks as well; troughs should be obtained within 1 hour before the next dose; if peaks are measured, draw levels 1-2 hours after end of infusion
REFERENCES Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation. 7 th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2005. xxvi p. 2. Billups NF, Billups SM, editors. American Drug Index. 47 th ed. St. Louis: Facts and Comparisons; 2002. 1022 p. 3. Cozza KL, Armstrong SC, Oesterheld JR. Drug Interaction Principles for Medical Practice: Cyctochrome P450s, UGTs, P-glycoproteins. 2nd ed. Washington, DC: American Psychiatric Publishing, Inc; 2003. 4. Katzung BG, editor. Basic and Clinical Pharmacology. 7 th ed. Stanford, CT: Appleton & Lange; 1998. 47-48 p. 5. Winter ME. Basic Clinical Pharmacokinetics. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 10-18 p. 6. Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th ed. Philadelphia: American College of Physicians; 2007. 1-16p. 7. Black Box Warnings from Drug Facts and Comparisons. In: Facts and Comparisons 4.0. [Internet database]. Wolters Kluwer Health, Inc. 2008- [cited 2008 Jul 1]. Available from: http://online.factsandcomparisons.com 8. Davis NM. Medical Abbreviations: 26,000 Conveniences at the Expense of Communication and Safety. 12th ed. Warminster (PA): Neil M Davis Associates; 2005. 6-7 p. 9. About Medication Errors: Dangerous Abbreviations [Internet]. National Coordinating Council for Medication Error Reporting and Prevention; [cited 2008 Jul 1]. Available from http://www.nccmerp.org/dangerousAbbrev.html 10. Brown CH. Overview of Drug Interactions. U.S. Pharmacist [Internet]; [cited 2008 Jul 1]. Available from: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/mar00druginteractions.htmd 11. Winter, ME. Basic Clinical Pharmacokinetics. 4th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2004. 130-476 p. 1.
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Common Illnesses in Family Practice

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Abdominal Pain Asthma Chest Pain Cough Depression Diabetes Hyperlipidemia Hypertension Joint Pain Low Back Pain

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

Right Upper Quadrant

Left Upper Quadrant

Right Lower Quadrant

Left Lower Quadrant

University of South Alabama, Department of Family Medicine

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

Toxins Infection Miscellaneous

University of South Alabama, Department of Family Medicine

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

FLOW CHARTS Initial Approach to Abdominal Pain

History Physical exam Initial lab tests Radiographs

Patient hemodynamically stable

Rigid (surgical) abdomen? YES

Non-rigid abdomen algorithm

CBC, lytes CT if available or abd films & CXR Surgery consult

Limited resuscitation/ urgent CT/surgery

Consider unusual causes of rigid abdomen

University of South Alabama, Department of Family Medicine

June 30, 2008

See pain location table above

Signs & Symptoms Acute Localized?

CT scan Consider GI and/or surgery consult Confirmed

Limited resuscitation/ surgery

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

University of South Alabama, Department of Family Medicine

June 30, 2008

Minor Limitation None

University of South Alabama, Department of Family Medicine

June 30, 2008

L O N G - T E R M C O N T R O L M E D I C AT I O N S Name/Products Indications Potential Adverse Effects

Systemic Corticosteroids: Methylprednisolone Prednisolone Prednisone

Cromolyn Sodium and Nedocromil

-15 to 20 percent of patients complain of an unpleasant taste from nedocromil.

-Tachycardia, skeletal muscle tremor, hypokalemia, prolongation of QTc interval in overdose.

- Long-term control and prevention of symptoms, especially nocturnal symptoms.

Leukotriene Modifiers Zafirlukast tablets Zileuton tablets