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AAFPqs
AAFPqs
Pregnancy Considerations
o Preeclampsia
Severe if epigastric pain and HA (indicates that convulsions are
imminent)
Severe if BP 160/110 on 2 separate occasions, 6hrs apart
Treatment is control of symptoms (hospital administration, IV mgSO4),
and planning for prompt delivery (vaginally or via C-section)
o HTN during pregnancy: IV hydralazine, IV labetalol, or oral nifedipine can be
used. Sublingual
o nifedipine can cause severe hypotension
Lower-extremity edema is common in the last trimester of normal pregnancies and
can be treated symptomatically with compression stockings.
o
Hypertension
o MCC in children under 6 is renal parenchymal disease
o MCC adults and adolescents is essential HTN
o Goal BP in patients with CKD is 140/90
o Monotherapy for HTN in African Americans is either a diuretic or a CCB
o Metoprolol and Carvedilol are eliminated by the liver
o BP increases with normal aging
o Isolated Systolic Hypertension in elderly responds best to diuretics, and to a
lesser degree, B-Blockers
o B-blockers can worsen depression
o ACEi are preferred drugs for HTN treatment in diabetic patients
ACEi cause impaired autoregulation of glomerular blood flow
A history of angioneurotic edema is an absolute contraindication to use
of an ACEi
Congestive Heart Failure
o TZDs are associated with fluid retention and can worsen CHF
o Medically refractory CHF is treated with Cardiac Resynchronization therapy
o Echo with Doppler is best tool to evaluate HF
o NSAIDS and ASA should be avoided in patients with CHF because they cause
fluid retention and an increase in SVR, which can lead to decompensation
o B-blockers should not be used to treat CHF when patient has symptomatic
heart block.
Aorta and considerations
o Acute dissection of ascending aorta is A surgical emergency
o Dissections confined to descending aorta are managed medically unless
patient demonstrates progression of disease or continued hemorrhage into
retroperitoneal space or pleura. B-Blocker is 1st line therapy to reduce SBP to
100-120. IV nitroprusside can be added if BP cant be controlled by B-blocker
alone.
o AAA screen should be done in men age 65-75 who have ever smoked
AAA: surgical intervention when size reaches 5.5 cm
Abnormal Heart Rhythms
o Refractory or recurrent SVT (narrow complex QRS, no apparent P waves)
should be controlled with Verapamil or B-blocker. If that is insufficient,
propafenone or flecainiede may be necessary.
o Palpitations should be evaluated with EKG. 50% of palpitations are
diagnosable heart conditions.
ENDOCRINE
Thyroid
o Subclinical hypothyroidism (TSH >10 U/mL) is likely to progress to overt
hypothyroidism, and is associated with increased LDL cholesterol.
o Subclinical hyperthyroidism (TSH <0.1 U/mL) is associated with the
development of atrial fibrillation, decreased bone density, and cardiac
dysfunction
o Secondary hypothyroidism
Low free T4, low TSH
Treatment is replacement therapy.
Only free T4 levels can evaluate the proper dose. TSH is not
useful since the pituitary is malfunctioning.
Integumentary
REPRODUCTIVE
Vulvar cancer: associated with HPV 16,18 in youger women, and Lichens sclerosis
in older women
Fine needle aspirations of breast nodules
o Simple cyst: straw or green fluid with dissapearnce of cyst after drainage
o Bloody or unusual fluid cytological examination (~7% of blood stained
aspirates are associated with cancer)
US to evaluate possibility of multiple gestation
o Uterine size larger than expected
o Excessive pregnancy-associated symptoms
o Women who received fertility treatments
Fetal fibronectin (in cervical or vaginal secretions ) is the most clinically useful test
to differentiate women who are at high risk for impending preterm delivery
Endocervical curettage is contraindicated in pregnancy
Post-term (postdate) pregnancy: one that reaches 42 weeks of amenorrhea.
Perinatal mortality doubles at 42 weeks of gestational age.
2nd stage of labor starts when the uterine cervix is completely dilated
Diagraphm use and maintenance:
o weight change of more than 15 lb, pregnancy, or pelvic surgery may
necessitate refitting
o increase risk of HIV transmission if used with nonoxynol-9
o made of latex or silicone
o contraindicated in Women with history of TSS
Adnexal cyst
o Thin walled, less than 8cm, usually in a younger patient.
o Will spontaneously resolve
o US should be done after 2-3 months to confirm resolution of cyst
Uterine rupture is a potential complication of attempted vaginal birth after cesarean.
A reliable indicator that this occurred is fetal bradycardia
Fibro adenomas the most common breast mass in adolescent girls
Postmenopausal HRT consisting of estrogen AND progestin has increased incidence of
Breast cancer. Risk outweighs benefits
Fetal macrosomia: birthweight above 4000-4500g. US does not provide an accurate
estimate of fetal weight for large fetuses. If these mothers do not go into labor
spontaneously, they will need to be managed as a postdate pregnancy patient
Patients with PID and tube-ovarian abscess and high fever should be hospitalized and
treated for at least 24 hours with intravenous antibiotics
Outpatient treatment of PID: Cefoxitinme IM + Probenecid, or Ceftriaxone (no
probenecid requirement)
Most infants with face presentation, mentum anterior, can be delivered vaginally,
either spontaneously or with low forceps
Cesarean section is indicated for fetal distress and failure to progress
All patients with AGUS should be evaluated by colposcopy and endocervical
curettage.
o Recommendation for endometrial sampling
Age 35 or older
AGUS favoring neoplasia or suggestive of an endometrial source.
o Cervical intraepithelial neoplasia is most common histologic diagnosis found in
patients evaluated for AGUS
Primary Dysmenorrhea: severe cramping pain in the lower abdomen that occurs
during menses or prior to onset of menses in the absence of associated pelvic
pathology
All combination OCPs raise levels of SHBG and decrease free Testosterone,
which can lead to improvements in acne
Cigarette smoking is the only nonsexual behaver that is consistently and strongly
correlated with cervical dysplasia
Leaving diagraphs in place for more than 24 hrs. increases the risk of TSS
ASC-US of undetermined significance management
o Repeat cytology after 4-6 months, immediate colposcopy, or reflex DNA
testing for oncogenic HPV
o If 2 repeat test are negative after 4-6 months duration, return to routine
cytological screenings
o If any repeat test determines more ASC-US, Colposcopy is indicated.
In a viable pregnancy, serum HCG doubles every 2-4 days
Combining serial hCG levels with transvaginal ultrasonography is the best
combination for evaluation of first-trimester problems, as HCG levels correlate with
sonographic landmarks
Medications that can cause galactorrhea
o OCPS that contain estrogen
o Metoclopramide, verapamil, SSRIs, bytrophenones, dopamine receptor
blockers, TCAs, phenothiazine, and thioxanthenes
MCC acute vaginitis (abnormal vaginal discharge) is bacterial vaginosis
Fibroid tumor tx: myomectomy
The finding of a red, raised, friable lesion on the cervix, or a well-demarcated cervical
lesion, mandates a biopsy to exclude cervical carcinoma, and treatment for chronic
cervicitis should not be started until the biopsy results are available
o PAP test is not sufficient is there is a grossly visible lesion, as false-negative
occur in 10-50% of tests
Most reliable predictor of survival in a patient with breast cancer is the cancer stage
at the time of diagnosis
Late decelerations are thought to be associated with uteroplacental insufficiency and
fetal hypoxia due to decreased blood flow in the placenta.
Amenorrhea is an indicator of inadequate calorie intake, which may be related to
either reduced food consumption or increased energy use
o
GASTROINTESTINAL
Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for
homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if
neuroblastoma or pheochromocytoma is suspected; both should be collected
before surgical intervention.
Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present
with anemia or osteoporosis, without gastrointestinal symptoms
o Individuals with more significant mucosal involvement present with watery
diarrhea, weight loss, and vitamin and mineral deficiencies
A patient with a past history of postoperative venous thromboembolism is at risk for
similar events with subsequent major operations.
o The most appropriate treatment of the choices listed would be subcutaneous
enoxaparin.
Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a
higher rate of postoperative hemorrhage
Aspirin is ineffective for prophylaxis of venous thromboembolism
Zenker Diverticulum: halitosis, late regurgitation of undigested food, and choking.
Dysphagia and weight loss are also present.
o Diagnosis is made with barium swallow, and treatment is surgical.
RESPIRATORY
Patients with chronic illness, diabetes mellitus, cerebrospinal fluid leaks, chronic
bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants
should receive one dose of pneumococcal polysaccharide vaccine after 2 years of
age, and at least 2 months after the last dose of pneumococcal conjugate vaccine
(Prevnar 13).
o
Revaccination with polysaccharide vaccine is not recommended for these
patients.
Individuals with sickle cell disease, those with anatomic or functional asplenia,
immunocompromised persons with renal failure or leukemia, and HIV-infected
persons should receive polysaccharide vaccine on this schedule and should be
revaccinated at least 5 years after the first dose
The live, attenuated influenza vaccine (intranasal) is an option for vaccinating
healthy, nonpregnant individuals age 5-49 years.
o It is not indicated in patients with underlying medical conditions, such as
chronic pulmonary or cardiovascular disease, or in patients with a history of
Guillain-Barr syndrome, pregnant patients, or children and adolescents who
receive long-term aspirin or salicylate therapy.
o
Patients with a history of hypersensitivity to eggs should not receive this
vaccine.
Obstructive sleep apnea-hypopnea syndrome is defined as the presence of at
least five obstructive events per hour with associated daytime sleepiness.
o
The prevalence in men is almost three times that seen in premenopausal
women and twice that of postmenopausal women.
o Other factors associated with an increased prevalence are obesity, older age,
and systemic hypertension
Macrolides are considered first-line therapy for Bordetella pertussis infection.
o Trimethoprim/sulfamethoxazole is considered second-line therapy.
A recently hospitalized patient has a significant pneumonia that requires the initiation
of empiric antibiotics.
o It is important to remember that because this patient was recently in the
hospital, the usual coverage for community-acquired pneumonia is not
adequate.
o Health care-associated pneumonia is more likely to involve severe pathogens
such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter
species.
o Methicillin-resistant Staphylococcus aureus also is a consideration, depending
on local prevalence.
o ceftazidime and gentamicin is a possible treatment for HAP
Exercise-induced bronchoconstriction (EIB) is a very common and
underdiagnosed condition in athletes.
o It is defined as a 10% lowering of FEV1 when challenged with exercise.
o The exercise required to cause bronchoconstriction is 5-8 minutes at 80% of
maximal oxygen consumption.
o A physical examination, as well as pulmonary function tests at rest and before
and after bronchodilators, will be normal unless there is underlying asthma.
Among athletes with EIB, 10% will not have asthma.
o Bronchoprovocative testing can be ordered, but if it is not available a trial with
an albuterol inhaler is reasonable.
small spontaneous pneumothorax: (involves less than 15%-20% of lung volume)
o manage by administering oxygen and observing the patient.
The pneumothorax will usually resorb in about 10 days if no ongoing air leak is
present. Oxygen lowers the pressure gradient for nitrogen and favors transfer
of gas from the pleural space to the capillaries.
o Decompression with anterior placement of an intravenous catheter is usually
reserved for tension pneumothorax.
o Chest tube placement is used if observation is not successful or for larger
pneumothoraces.
acute sinusitis.
o Failure to respond to adequate antibiotic therapy suggests either a
complication, progression to chronic sinusitis, or a different, confounding
diagnosis.
o The diagnostic procedure of choice in this situation is coronal CT of the
sinuses, due to its increased sensitivity and competitive cost when compared
with standard radiographs.
o Cultures of the nasal discharge give unreliable results because of bacterial
contamination from the resident flora of the nose.
Pleural effusions may be exudates or transudates.
o Lights criteria use ratios of fluid/serum values for protein and LDH.
Pleural fluid/serum ratios greater than 0.6 for LDH and 0.5 for protein
are indicative of exudates.
o The vast majority of transudates are due to heart failure, with cirrhosis being
the next most common cause.
o Once there is reasonable certainty that the fluid is a transudate, additional
studies usually are not necessary
Use of an incentive spirometer and similar lung expansion techniques such as chest
physiotherapy have been shown to have significant benefit for reducing
postoperative complications.
o A course of preoperative corticosteroids has been shown to be beneficial for
patients with COPD. Prolonged antibiotic prophylaxis and postoperative total
parenteral nutrition have not been shown to have any benefit
rotavirus vaccine is an oral vaccine recommended for infants in a 3-dose schedule
at ages 2, 4, and 6 months.
o The first dose should be given between 6 and 12 weeks of age, with additional
doses given at 4 to 10-week intervals.
o The vaccine cannot be initiated after 12 weeks of age and should not
be administered after 32 weeks of age.
No medication available in the United States has been shown to effectively treat
cough or cold symptoms in children younger than 2 years of age.
o Nasal saline and bulb suction is the only recommendation for treatment of
cough and cold symptoms in children younger than 2
moderate to severe COPD
o Smoking cessation is the single most important therapeutic intervention in
patients with this condition and should be the priority of care.
o No existing medications have been shown to modify the long-term decline in
lung function that is typical of COPD, but smoking cessation does prevent this
decline.
o Long-term use of oxygen in COPD patients who also have chronic, severe
hypoxia (<88% saturation) can improve quality of life and prolong survival;
however, oxygen cannot prevent further decline in lung function.
o Long-term use of oral corticosteroids is discouraged because of an
unfavorable risk-to-benefit ratio
o
If the child can take in fluids by mouth and tolerate room air, outpatient
management with close physician contact as needed is reasonable, especially
in the absence of significant underlying risk factors.
o Routine use of corticosteroids is not recommended (SOR B)
Palivizumab is a preventive measure, and is not used for treatment of
the active disease.
It may be considered in select infants and children with
prematurity, chronic lung disease of prematurity, or congenital
heart disease
If used, it should be administered intramuscularly in five
monthly doses of 15 mg/kg,
Although oral antibiotics are overwhelmingly prescribed as initial treatment in acute
sinusitis, it has been shown that the majority of acute illnesses are viral in origin
and that 98% of cases will resolve spontaneously.
o Analgesics are considered the mainstay of therapy for acute sinusitis,
according to evidence-based recommendations.
o There is little evidence of effectiveness for antihistamines, oral decongestants,
or vasoconstrictor sprays.
o There is also little evidence of effectiveness for nasal lavage in acute sinusitis,
although it has an emerging role in chronic sinusitis.
previously healthy patients with CAP and no risk factors for drug resistance:
o a macrolide such as azithromycin is the preferred treatment.
o Doxycycline is also acceptable
Patients who have been treated with antibiotics within the previous 3
months
o treat with a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or
levofloxacin)
o A -lactam plus a macrolide is also an alternative
o The antibiotic chosen should be from a different class than the one
used for the previous infection.
o A respiratory fluoroquinolone or Macrolide + B-Lactamase are also
recommended for those with comorbidities (chronic heart, lung, liver, or renal
disease; diabetes mellitus; alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of immunosuppressing drugs); or other
risk factors for drug-resistant Streptococcus pneumoniae infection
Hemothorax: bleeding into pleural space, often due to rib fracture
o treatment is to remove bloody fluid and expand the lung.
o This therapy is felt to decrease any ongoing blood loss by having the lung
pleura put a direct barrier over the site that is bleeding. It also prevents the
development of empyema or fibrosis, which could occur if the blood were to
remain.
MCC nasal obstruction in all age groups is the common cold, which is classified as
mucosal disease.
MCC unilateral nasal obstruction are anatomical abnormalities (septal deviation is the
most common)
Asthma treatment is based on classification.
o mild persistent asthma: symptoms more than 2 times per week but less
than once a day, symptoms less than 2 nights per month, peak expiratory flow
(PEF) or FEV1 >80% of predicted, and a PEF variability of 20%30%.
o
MUSCULOSKELETAL
Surgery should be reserved for children 8-10 years of age who still have
cosmetically unacceptable, dysfunctional gaits.
o Major complications of surgery occur in approximately 15% of cases, and can
include residual in-toeing, out-toeing, avascular necrosis of the femoral head,
osteomyelitis, fracture, valgus deformity, and loss of position.
o Thus, observation alone is appropriate treatment for a 5-year-old with
uncomplicated anteversion.
Hydroxychloroquine, is a well-known disease-modifying agent that can slow
the progression of rheumatoid arthritis.
Osteoarthritis causes changes predominantly in the proximal interphalangeal (PIP)
and distal interphalangeal (DIP) joints of the hands known as Bouchards and
Heberdens nodes respectively, and the carpometacarpal joints of the thumbs.
rheumatoid arthritis commonly causes subluxations in the metacarpophalangeal
joints,
Allopurinol can cause temporary wasting of acute gout
A therapeutic exercise program will reduce both pain and disability in patients with
osteoarthritis of the knee.
o There is no evidence to support the use of capsaicin cream, but NSAIDs will
reduce pain and there are proven therapies that will improve function of the
patients knee. While intra-articular corticosteroids are effective in relieving
pain in the short term (up to 4 weeks), there is no evidence for long-term
efficacy. There is not good evidence to support the use of glucosamine for
treating osteoarthritis of the knee.
Acute monoarthritis in adults is most commonly caused by infection, trauma, or
crystal deposition.
o Rheumatoid arthritis seldom presents as monoarthritis, and more often has a
subacute course with multiple, symmetric joints involved. Having a normal
uric acid level suggests against gout, but does not rule it out. Also, gout is
seven times more likely to be seen in males, whereas pseudogout is 1.5 times
more frequent in females. Pseudogout most often affects the elderly, and
usually affects the knee, wrist, and ankle. Gout presents most commonly in
the first metatarsophalangeal joint and insteps of the feet, but also can occur
in the knee, wrist, finger, and olecranon bursa. Differentiating between gout
and pseudogout can be difficult and is best done by analysis of joint fluid.
uncomplicated lateral ankle sprains require minimal intervention.
o The Ottawa ankle rules were developed to determine when radiographs are
needed for ankle sprains.
The highest risk for falling occurs immediately after hospital stays and lasts
for about a month. Ambulatory blood pressure monitoring is associated with
so many false-negative and false-positive results that it cannot be
recommended for all patients who fall.
Arthritis and vision problems are both strongly associated with an increased
risk of falls
SPECIAL SENSORY
Uncomplicated Acute Otitis Media: treat with Amoxicillin
About 3% of persons over age 55 have glaucoma, making it a leading cause of vision
impairment. Although it is usually asymptomatic, the most common presenting symptom is tunnel
vision, a gradual loss of peripheral vision.
Macular degeneration: MCC cause of blindness in individuals over 65
Penicillin can be used to treat dental infections
prescribe oral fluoride supplementation at currently recommended dosages to preschool-aged
children older than 6 months of age whose primary water source is deficient in fluoride
CMV is the most common congenital infection and occurs in up to 2.2% of newborns.
o It is the leading cause of congenital hearing loss.
Vitreous detachment is very common after age 60 and occurs frequently in younger persons
with myopia.
o The separation of the posterior aspect of the vitreous from the retina exerts traction on
the retina, with the attendant risks of a retinal tear and detachment.
Dental infections complicated by the development of cellulitis should be treated with oral
antibiotic therapy. The antibiotic of choice is penicillin. Clindamycin should be used if a patient is
allergic to penicillin.